Persius/hicric huggingface dataset:
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hearing aids.
You asked the Plan to pre-approve these services. You say that the provider is closer to the enrollee's home and
easily accessible. The Plan denied your request. The Plan says the services are not covered.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for
hearing aids only when obtained from their provider.
We looked at the file and the Plan's rules. The file shows that the hearing aids are being requested from another provider.  The Plan covers hearing aids only from their provider. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve hearing aids.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for a Zoster vaccine provided on December 10, 2019.
You asked the Plan to pay for this vaccine. You say that this claim should be paid. The Plan denied your request. The Plan says the Zoster vaccine must be submitted to your Medicare Part D benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide this vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to this vaccine. Therefore, we decided that the Plan does not have to pay for a Zoster vaccine provided on December 10, 2019.
Benefits for this vaccine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided from December 1, 2017 through December 2, 2017.
You asked the Plan to pay for the medical services. You say that you are retired and on a fixed income. The Plan denied your request. The Plan says you must submit your claim to us within one year of the date you received the service, item, or drug.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that a claim for the medical services was not filed until November 15, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the medical services provided from December 1, 2017 through December 2, 2017.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox injections.
You asked the Plan to pre-approve the Botox. You say that you would like reconsideration because this is the primary treatment for the member's condition. The Plan denied your request. The Plan says this medicine is not being furnished by the physician, but rather is being furnished by a specialty pharmacy that bills the member's pharmacy benefit.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Botox injections.
Benefits for the Botox may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on December 3, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on December 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397)
provided to the enrollee on November 22, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your
request. The Plan says the documentation does not indicate services are necessary for treatment of the
enrollee's condition.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical
record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the
type and quantity of items ordered and for the frequency of use.
The record shows that documentation submitted did not indicate the provider discussed the need for the billed
supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to
pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on November 22, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zolpidem tartrate 5mg tablet for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says drug coverage is limited to Medicare Part B covered drugs.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Zolpidem tartrate 5mg tablet for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2750) for tooth # 28.
You asked the Plan to pre-approve the dental service. You say that tooth # 28 has buccal restoration. You say that the sensitive filling keeps falling out. You also say that tooth # 28 needs a crown. The Plan denied your request. The Plan says the tooth does not appear to have significant breakdown due to decay or trauma. The Plan also says the crown is not medically necessary.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the dental service when the services are medically necessary and reasonable. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the dental service. Our reviewer says that the service is not medically necessary. Our physician reviewer found the documentation provided did not show significant coronal breakdown of tooth # 28. Therefore, the reviewer found that the criteria for coverage for a crown for tooth # 28 have not been met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental service have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown (D2750) for tooth # 28.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on August 14, 2019.
You asked the Plan to waive the copayment for the CT scan. You say that if you were allowed to take your medicine you would not have had to get a CT scan. You say that it is not fair that you have to pay the copayment. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $180 copayment for advanced imaging services at an in-network specialist's office. You have been asked to pay a $180 copayment for the CT scan. The CT scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the CT scan provided on August 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on October 16, 2019.
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because Per CMS, CPT code S9328 is a valid code. The Plan denied your request. The Plan says CPT code S9328 has a status code of I which is not valid for Medicare purposes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code S9328 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S9328 has a status code of I. This means that CPT code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided on October 16, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda (J9277).
You asked the Plan to pre-approve Keytruda. You say that this is an approved use. The Plan denied your request. The Plan says this would be an experimental use.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Keytruda. Our reviewer says that the requested use of Keytruda does not meet the Medicare criteria for coverage. Our physician reviewer found the requested use of Keytruda is not FDA-approved for the enrollee's diagnosis, nor is it supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal after progression on prior PD-L1 inhibitor (nivolumab). We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda (J9277).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided on January 8, 2020.
You asked the Plan to waive the copayment for an MRI. You say that you disagree with the $100 copayment because the plan paid much less. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 copayment for diagnostic radiology. You have been asked to pay a $100 copayment for an MRI. An MRI falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an MRI provided on January 8, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says that the enrollee could have the care needed at home with help, or at an alternative level of care within the nursing home.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for continued SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the complete upper denture (D5120) and the complete lower denture (D5110) provided on January 28, 2020.
You asked the Plan to reimburse you for the dental items. You say that your dentures broke. You say that you received new ones through emergency dental prostheses. You say that you never received the medical plan summary of new benefits for 2020 and was not aware of what you were supposed to do before this emergency. You also say that the provider does not accept medical plans. The Plan denied your request. The Plan says that the provider in this case is not a network provider. The Plan also says that authorization was not obtained before you received the services.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This provider has opted out of the Medicare program. The file shows that the provider entered into a private contract with you regarding payment. The records shows that the dental provider is not eligible to participate in Medicare. Therefore, we decided that the Plan does not have to reimburse you for the complete upper denture (D5120) and the complete lower denture (D5110) provided on January 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
You asked the Plan to pre-approve the compression stockings. You say that you need these stockings to aid in treatment for your lymphedema. The Plan denied your request. The Plan says the compression stockings are noncovered.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shoulder-hand-wrist orthosis (L3960) provided to the enrollee on December 19, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for a shoulder-hand-wrist orthosis (L3960) provided to the enrollee on December 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0673).
You asked the Plan to pay for a pneumatic compression device. You say that the device is necessary to prevent deep vein thrombosis. The Plan denied your request. The Plan says this pneumatic compression device is not covered by Medicare.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism is a preventive service. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0673).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services provided from July 3 to July 9, 2019.
You asked the Plan to pre-approve the SNF services. You say that the services in dispute were medically necessary. The Plan denied your request. The Plan says the documentation does not demonstrate that the enrollee met the criteria for coverage of SNF care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you received oral medications, had stable vital signs, had clear lungs, and was treated for pain. You received physical therapy in the acute hospital. By the dates in question, you were at a modified independent to supervision/set-up level of functional mobility, including gait to 250 feet with a rolling walker. There were no identifiable skilled nursing service needs. There were no identifiable skilled therapy service needs. You did not meet the severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services provided from July 3 to July 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the laboratory services on April 2, 2019 and December 11, 2019.
You asked the Plan to waive the deductible for the laboratory services. You say that you do not agree with your deductible amount. You say do not understand who would meet the deductible amount for laboratory work. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $300 deductible that applies towards in-network laboratory services.
The laboratory services you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $300 deductible that applies towards in-network laboratory services.
The allowed amount for the laboratory services on April 2, 2019 is $89.81. Therefore, $89.81 is the amount that is applied to your deductible. The allowed amount for the laboratory services on December 11, 2019 is $18.67. Therefore, $18.67 is the amount that is applied to your deductible.
This cost sharing is a contractual obligation that had not been met at the time the laboratory services were received on April 2, 2019 and December 11, 2019. Therefore, we decided that the Plan does not have to waive the deductible for the laboratory services provided on April 2, 2019 and December 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the initial periapical x-ray (D0220), the root canal (D3310), the re-bonding indirectly fabricated or prefabricated posts and cores (D2915 x 2), and the crowns (D2750 x 2) provided from August 1, 2018 to September 17, 2019.
You asked the Plan to reimburse you for the dental services. You say that all of the dental services that you received from August 1, 2018 to September 17, 2019 were either medical emergencies or medically necessary. You also say that you were advised that the services would be covered. The Plan denied your request. The Plan says that the yearly allowances for 2018 and 2019 have been exhausted.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the yearly allowances for 2018 and 2019 were exhausted prior to receiving the services. The record shows that you have been reimbursed the maximum allowance for both 2018 and 2019.
Date of Service
Plan Paid
7/3/2018
$112
8/1/2018
$38
2018 TOTAL:
$150
9/6/2019
$79
9/17/2019
$171
2019 TOTAL:
$250
The 2018 and 2019 Evidence of Coverage clearly state that anything over the yearly allowance is the enrollee's responsibility. Therefore, we decided that the Plan does not have to reimburse you for the initial periapical x-ray (D0220), the root canal (D3310), the re-bonding indirectly fabricated or prefabricated posts and cores (D2915 x 2), and the crowns (D2750 x 2) provided from August 1, 2018 to September 17, 2019.