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

We decided that the Plan has to waive the copayment for the office visit provided on January 28, 2021.
You asked the Plan to waive the copayment for the office visit. You say that you were never examined by the provider and was only asked pre-screening questions prior to the vaccine injection. You say that the copayment is not warranted. The Plan denied your request. The Plan says that 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). The enrollee's contract with the Plan says that enrollees pay a $0 copayment for PCP visits. The Plan says the enrollee must pay a $40 copayment for a specialist visit. Based on the plan contract, however, the enrollee cannot be asked to pay more than a $0 copayment for a PCP visit. The records show the rendering provider is a family medicine provider. Therefore, we decided that the Plan has to waive the copayment for the office visit provided on January 28, 2021.
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: Home Health
Decision: Favorable

We decided that the Plan has to pay for the home therapy services provided from September 6, 2019, to October 17, 2019.

You asked the Plan to pay for the home therapy services. You say that the claim was submitted to the local plan. The Plan denied your request. The Plan says that the claim must be submitted to the local plan for processing.

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 claim is to be submitted to the local plan. We found that there is no evidence provided to support that this claim is not payable as billed. Therefore, we decided that the Plan has to pay for the home therapy services provided from September 6, 2019, to October 17, 2019.

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: Lab
Decision: Favorable

We decided that the Plan has to pay for laboratory testing provided on July 30, 2020.

You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because Medicare denies coverage for all cardiovascular risk assessment panels - except the basic lipid panel - for symptomatic patients with suspected or documented cardiovascular disease.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. 

This testing was ordered by an in-network provider. The file does not show that the plan provided notice that lab tests would not be covered. Under Medicare rules, this means lab tests is considered approved by the plan. Therefore, we decided that the Plan has to pay for laboratory testing provided on July 30, 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 crown and core buildup, including any pins when
required provided on November 16, 2020, and November 24, 2020.
You asked the Plan to pay for the crown and core buildup. You say that you enrolled in the additional dental
plan to get better coverage. The Plan denied your request. The Plan says you are responsible for 100% of the
cost for Class 3 Major Services. The Plan also says that you upgraded your dental coverage to the dental
option, which did not go into effect until January 1, 2021.
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, you are responsible for 100% of the
cost for Class 3 Major Services, including the initial placement of crowns and onlays, and post and core, or
crown buildup. Therefore, we decided that the Plan does not have to pay for the crown and core buildup,
including any pins when required provided on November 16, 2020, and November 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown provided on February 5, 2021.
You asked the Plan to pay for the crown. You say that your tooth was broken and could not be extracted
because it is part of your partial. The Plan denied your request. The Plan says this service is not a covered
benefit.
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 requested items or services are not
among those covered under this benefit. The annual $175 allowance you have is for fillings and simple tooth
extractions. Therefore, we decided that the Plan does not have to pay for the crown provided on February 5,
2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Opdivo.
You asked the Plan to pre-approve Opdivo. You say that the requested Opdivo is medically necessary. The
Plan denied your request. The Plan says the requested Opdivo is not medically necessary.
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 Opdivo. Our reviewer says that the
requested Opdivo is not medically necessary. Our physician reviewer found the enrollee is diagnosed with non-
Hodgkin lymphoma. Opdivo is not FDA-approved for the enrollee's diagnosis. The use of Opdivo is not
supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical
journal. Phase II trials showed poor response rates to single agent in refractory patients.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to
pre-approve Opdivo.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician service provided on January 29, 2020.
You asked the Plan to pay for the physician service. You say that you did not have the Plan provider directory
and this provider gave you a very good service. The Plan denied your request. The Plan says payment for the
privately contracted provider is denied.
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 who
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the
physician service provided on January 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Acetaminophen with Codeine, 300-30 mg tablet.
You asked the Plan to pre-approve Acetaminophen with Codeine. You say that this drug is necessary. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.
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 Acetaminophen with Codeine, 300-30 mg tablet.
Benefits for Acetaminophen with Codeine 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two crowns and core buildup, including any pins when
required provided on January 26, 2021.
You asked the Plan to pay for the crowns and core buildup. You say that you believe you have an annual dental
allowance of $1,000, with $250 of the allowance remaining to be paid to you. The Plan denied your request.
The Plan says the maximum dental allowance of $750 has been reimbursed to you, and no further
reimbursement can be issued.
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 Plan offers a $750 allowance every
year for non-Medicare covered preventive and comprehensive dental services combined. The contract says that
you are responsible for any amount above the dental coverage limit. The record shows that you met the annual
maximum benefit on January 19, 2021 and your annual maximum benefit has been exhausted. Therefore, we
decided that the Plan does not have to pay for the two crowns and core buildup, including any pins when
required provided on January 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on July 30, 2020 by a Medicare opt out provider.
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you believe these services should be covered because the Summary of Benefits does not state that services rendered by a dentist who does not accept Medicare are not covered. The Plan denied your request. The Plan says the treating provider has formally opted out of Medicare participation. The Plan also says that your pan does not allow payment to providers that have opted out of Medicare.
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 requested items or services are not
covered when they are rendered by a provider who has opted out of Medicare. Therefore, we decided that the
Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on July 30, 2020 by a
Medicare opt out provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex Superion device placement surgery for the
enrollee.
You asked the Plan to pre-approve these services. You say that the enrollee needs this to treat lumbar spinal
stenosis with neurogenic claudication. 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 Vertiflex device
is experimental, and more research is needed to show safety and efficacy of the device. Our physician reviewer
found that the enrollee's condition does not meet 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 Vertiflex Superion device placement surgery for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee requires intensive inpatient rehab with daily physician management. The Plan denied your request. The Plan says the enrollee's skilled therapy and nursing needs can be provided at a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our physician reviewer found that the enrollee was admitted to the acute care hospital for seizures. She was discharged to a skilled nursing facility and then discharged home. There is ongoing weakness. Her medical conditions are stable. There are no complex nursing needs. She does not require treatment by multiple therapies in an intensive rehabilitation therapy program. She does require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Stelara injection, 90 mg/ml.
You asked the Plan to pre-approve a Stelara injection. You say that the injection is necessary. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.
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 Stelara injection, 90 mg/ml.
Benefits for a Stelara injection 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and copayment for the ambulance
transportation (A0428) received March 19, 2021.
You asked the Plan to waive the deductible and copayment for the ambulance transportation. You say that you
had a lot of medical bills in 2020 and would like this deductible and copayment waived. The Plan denied your
request. The Plan says the correct cost share has applied to the claim.
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 $250 deductible and a $50 copayment for Ambulance Services.
The item or service you asked the Plan to waive the deductible and copayment for falls within the benefit
category the Ambulance Services benefit category. The Plan has followed Medicare rules by clearly disclosing
in the contract that there is a $250 deductible and a $50 copayment for Ambulance Services. Your claim for the
ambulance transportation fell partially in the deductible and partially in normal coverage. You have been asked
to pay $201 in deductibles and copayments ($151 in your remaining deductible and a $50 copayment).
Therefore, we decided that the Plan does not have to waive the deductible and copayment for the ambulance
transportation (A0428) received March 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an endodontic therapy.
You asked the Plan to pre-approve the endodontic therapy. You say that it is medically necessary that you
receive a root canal. The Plan denied your request. The Plan says this service is not a covered benefit under
your 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown and core buildup, including any pins when
required provided on January 5, 2021 by a Medicare opt out provider.
You asked the Plan to pay for the crown and core buildup. You say that you were not advised by the provider
or the Plan that this provider had opted out of Medicare. The Plan denied your request. The Plan says you are
responsible for services provided by privately contracted providers. The Plan also says that charges incurred by
Medicare opt out providers will not be reimbursed.
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 requested items or services are not
covered when they are rendered by a provider who has opted out of Medicare.
Therefore, we decided that the Plan does not have to pay for the crown and core buildup, including any pins
when required provided on January 5, 2021 by a Medicare opt out provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance oxygen and oxygen supplies (A0422), ground
mileage (A0425), and emergency ambulance transport (A0427) provided on November 7, 2020.
You asked the Plan to pay for the ambulance oxygen and oxygen supplies, ground mileage, and emergency
ambulance transport. The Plan denied your request. The Plan says the enrollee's claims would be covered by
original Medicare on the date of hospice election, until the first day of the following month in which Hospice
was revoked, which would be December 01, 2020.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated.
The enrollee ended Medicare Hospice benefits on November 7, 2020. The services in question were provided
before the end of that month. Therefore, we decided that the Plan does not have to pay for the ambulance
oxygen and oxygen supplies (A0422), ground mileage (A0425), and emergency ambulance transport (A0427)
provided on November 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup, including any pins when required provided on February 25, 2021.
You asked the Plan to pay for the core buildup. You say that you contacted the Plan and were told you would be reimbursed for this service. The Plan denied your request. The Plan says this service is not covered. The Plan also says that you did not contact the Plan prior to this date of service to verify benefits and provider eligibility.
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 requested items or services are not among those covered under this benefit. The record shows that your provider contacted the Plan and was advised that your policy does not have crown coverage, including core buildups. Therefore, we decided that the Plan does not have to pay for the core buildup, including any pins when required provided on February 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Bupropion Hydrochloride, Hydrochlorothiazide, Gabapentin, Losartan Potassium, and Pramipexole Dihydrochloride provided from February 25, 2021, to February 26, 2021.
You asked the Plan to pay for the Bupropion Hydrochloride, Hydrochlorothiazide, Gabapentin, Losartan Potassium, and Pramipexole Dihydrochloride. You say that you were given these medications at the hospital because you were out of your medications at home. The Plan denied your request. The Plan says these drugs are self-administered, and are not covered in the outpatient setting under Medicare Part B.
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 pay for the Bupropion Hydrochloride, Hydrochlorothiazide, Gabapentin, Losartan Potassium, and Pramipexole Dihydrochloride provided from February 25, 2021, to February 26, 2021.
Benefits for the Bupropion Hydrochloride, Hydrochlorothiazide, Gabapentin, Losartan Potassium, and Pramipexole Dihydrochloride may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.