Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Botulinum Toxin (Botox) Type A injections you received on August 31, 2020.
You asked the Plan to waive the coinsurance for the Botox injections. You say that you cannot afford the cost of these injections. The Plan denied your request. The Plan says you were charged this coinsurance correctly. The Plan has indicating that the surgery copayment that was charged for this date of service has been waived, so you're only responsible for the coinsurance for the Botox.
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 20% coinsurance for Medicare Part B drugs obtained in a provider's office or outpatient setting. You have been asked to pay 20% coinsurance for the Botox injections. The Botox injections fall within the Medicare Part B drugs obtained in a provider's office or outpatient setting 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 coinsurance for the Botulinum Toxin (Botox) Type A injections you received on August 31, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine mileage, per trip (A0170).

You asked the Plan to pre-approve the additional mileage. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says your request exceeds the allowable transportation benefit.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Specifically, your request submitted to the Plan was for a total of 93 miles for each trip. However, the Plan contract provides coverage for 50 miles of driving distance only for each trip. Your request exceeds the allowable transportation benefit. Therefore, we decided that the Plan does not have to pre-approve additional routine mileage, per trip (A0170).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda (J9271).
You asked the Plan to pre-approve Keytruda. The Plan denied your request. The Plan says you do not meet criteria for approval for Keytruda.
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 Keytruda (J9271) is not medically reasonable and necessary for you. Our physician reviewer found the requested use of Keytruda (J9271) is not FDA-approved for your diagnosis. Our reviewer also found that the use of Keytruda in this case is not supported by one of the major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services (CMS) approved medical journal. 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 (J9271).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional resin-based composite.

You asked the Plan to pay for the additional resin-based composite. You say that the Plan's website does not list any limitations for fillings. The Plan denied your request. The Plan says your benefits for this service have been satisfied and the frequency limitation has been exceeded.

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, two fillings are covered at 50% per calendar year when services are rendered by an in-network provider. The record shows that you received three resin-based composites, two of which were covered by the Plan at 50%, and your restorations benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the additional resin-based composite.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion device (CPT code 22869), for the enrollee.
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the services are considered experimental and investigational.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer is experimental. More research is needed to show safety and efficacy of the Vertiflex spacer. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion device (CPT code 22869), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a radiation oncology consultation to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve a radiation oncology consultation to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The provider at issue in this case is not a network provider with the Plan. 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 a radiation oncology consultation to be provided by an OON provider. Our reviewer says that the services are not medically necessary. Our physician reviewer found there are no compelling medical reasons offered in the case file to support the medical necessity of this enrollee receiving treatment out of network. There is no evidence in the case file that the out of network provider would provide a service that an in-network provider cannot. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a radiation oncology consultation to be provided by an OON provider have not been met. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve a radiation oncology consultation to be provided by an OON provider. Therefore, we decided that the Plan does not have to pre-approve a radiation oncology consultation to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of the lumbar spine you had on December 1, 2020.
You asked the Plan to waive the copayment for the MRI. You say that you cannot afford this copayment. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this MRI ($254.27) is less than your copayment obligation, you are responsible for the full allowed 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 $325 copayment for diagnostic radiology services. You have been asked to pay a $325 copayment for the MRI. The MRI falls within the diagnostic radiology services 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 magnetic resonance imaging (MRI) of the lumbar spine you had on December 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on November 13, 2020.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the laboratory services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for laboratory services provided on November 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.
You asked the Plan to pre-approve a ventilator. You say that this therapy is effective for the enrollee. The Plan denied your request. The Plan says there is no evidence of chronic hypercapnia.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 a ventilator. Our physician reviewer found that the enrollee has moderate COPD and severe obstructive sleep apnea (OSA). It appears the Trilogy ventilator was initiated as treatment for the OSA. It is unclear from the medical records whether the enrollee ever tried a continuous positive airway pressure (CPAP) device. There is no documentation of carbon dioxide retention. A CPAP is considered first-line therapy for OSA. Those who fail CPAP may benefit from BiPAP. However, Medicare does not cover a home ventilator for the treatment of OSA, or when used as CPAP or BiPAP. Therefore, a home ventilator is not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion Device for the enrollee.
You asked the Plan to pre-approve these services. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that experimental and investigational procedures are not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The spacer device is experimental. More research is needed to show safety and efficacy of the vertiflex device. Open laminectomy is the gold standard. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion Device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular services provided on December 3, 2020 by an out of network (OON) provider.
You asked the Plan to pay for cardiovascular services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that there are in-network providers available for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for cardiovascular services provided on December 3, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aid services provided out of network on October 1, 2020.
You asked the Plan to pay for these services. You say that the Plan should pay for these services. The Plan denied your request. The Plan says the Plan contract is clear about the rules that need to be followed for hearing services and hearing aids.
Medicare does not cover hearing aids or hearing aid services. However, the Plan offers a hearing benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract is clear that hearing services and hearing aids and services must be rendered by a contracted provider. Therefore, we decided that the Plan does not have to pay for hearing aid services provided out of network on October 1, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the services (CPT 93226) provided on August 31, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that this is not a covered service.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan says that this is not a covered service. However, CPT 93226 is covered by Medicare. The Plan has not provided documentation to support that this is a non-covered service. Without supporting documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the services (CPT 93226) provided on August 31, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Testosterone gel.
You asked the Plan to pre-approve Testosterone gel. You say that the enrollee has been on this medication
since 2015. You also say that this medication has helped improve the enrollee's quality of life. The Plan denied
your request. The Plan says this medication does not fall under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Testosterone gel.
Benefits for Testosterone gel 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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) services you
received from November 5, 2020, to November 7, 2020.
You asked the Plan to waive the copayment for the ER services. You say that this claim should be paid in full
because you thought you were having a stroke. The Plan denied your request. The Plan says you were charged
this copayment 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 $90
copayment for emergency room visits.
You have been asked to pay a $90 copayment for the ER services. 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 emergency room (ER) services you received from November 5, 2020, to November 7, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for hospital discharge day management services (99238) provided on November 7, 2020.
You asked the Plan to pay for the hospital discharge day management services. You say that you would like reconsideration because this claim was billed appropriately. The Plan denied your request. The Plan says that this claim was not billed with a CPT/Revenue code or a description of service.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan has not included any supporting documentation to indicate why this claim was not billed appropriately. It is the burden of the Health Plan to substantiate their denial with evidence. The denial is not substantiated and we must find in your favor. Therefore, we decided that the Plan has to pay for hospital discharge day management services (99238) provided on November 7, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), Prophylaxis - adult (D1110), and Intraoral- complete series of radiographic images (D0210) provided on July 22, 2020.
You asked the Plan to pay for the comprehensive oral evaluation, dental cleaning and complete series of x-rays. You say that you called and were told the services would be covered. The Plan denied your request. The Plan says they do not have a record of a call for prior authorization and the services were provided by a non-contracted provider. Therefore, the services are not covered by the Plan.
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 may cover the comprehensive oral evaluation, dental cleaning and complete series of x-rays when they are provided by a provider contracted with the Plan's third party dental administrator. We looked at the Plan's list of contracted dental providers, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the comprehensive oral evaluation, dental cleaning and complete series of x-rays have not been met. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), Prophylaxis - adult (D1110), and Intraoral- complete series of radiographic images (D0210) provided on July 22, 2020.
Your complaint about potentially being provided misinformation by a Plan representative is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services that you provided on August 31, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says prior
authorization was not obtained by the provider or facility. The provider should have verified the member's
eligibility, health benefits and obtained authorization prior to the member s visit before providing services to
the member as outlined on the member's ID card.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
physician's services. We found no exception that would require the Plan to pay for these services. Therefore,
we decided that the Plan does not have to pay for physician's services that you provided on August 31, 2020.