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

 
We decided that the Plan does not have to waive the copayment for the ambulance services. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that the facility ordered this 
trip, therefore, you should not have to pay this copayment. The Plan denied your request. The Plan says you 
were charged this cost sharing 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 $325 
copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $293.90 for these 
services. You have been asked to pay the allowed amount of $293.90, which is less than the $325 copayment. 
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 ambulance services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the acute inpatient rehabilitation facility 
(IRF) services provided from January 7, 2022, through January 20, 2022. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the services provided. 
 
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 $200 
copayment per day, for days 1-5 and $0 after day 5 for up to 90 days in a benefit period for Medicare-covered 
services received in an acute rehabilitation or long-term acute care hospital.   
 
You have been asked to pay $1000 ($200 copayment x 5 days) for the acute inpatient rehabilitation facility 
services provided. 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 acute inpatient rehabilitation 
facility (IRF) services provided from January 7, 2022, through January 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three (3) office consultations and treatment with a 
specialist to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve office consultations and treatment with a specialist. You say that the 
enrollee is requesting to see the requested provider after reviewing the surgical approach offered by the in-
network provider. The Plan denied your request. The Plan says a network provider can help evaluate the 
enrollee for possible surgery. A second opinion could also be obtained with an in-network provider. 
 
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 requested provider in this case is not a network provider with the Plan. 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 these items/services. Therefore, we decided that the Plan does not have to pre-approve 
three (3) office consultations and treatment with a specialist to be provided by an out-of-network (OON) 
provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Gene Panel testing provided on February 15, 2022. 
 
You asked the Plan to pay for the laboratory testing. You say that the services provided were medically 
necessary. You say that they were a valuable tool to determine treatment for the enrollee. You also say that the 
services should be paid at the in-network level. The Plan denied your request. The Plan says the enrollees 
claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on 
the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the 
providers responsibility to verify the enrollees coverage before rendering services and to know proper billing 
procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the Gene Panel testing provided on February 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bi-ventricular defibrillator (CRT-D). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that an implantable defibrillator is covered when 
specific criteria are met. 
 
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 services are not medically necessary. Our physician reviewer found the enrollee has atrial fibrillation and 
cardiomyopathy with severe left ventricular dysfunction. He is described as having controlled ventricular rate 
and narrow QRS complex without left bundle branch clock. Thus, rationale for atrioventricular node ablation is 
not clear. As such, guidelines would not support implant of a CRT-D, only a non-CRT defibrillator. There is 
insufficient documentation to support the medical necessity for implantation of a CRT-D for this enrollee. 
 
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 bi-ventricular defibrillator (CRT-D).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oversized lens (V2780) and polarized lens (V2762) 
provided on April 29, 2022. 
 
You asked the Plan to pay for the lens enhancements. You say that the provider contacted the Plan regarding 
your coverage before you ordered the glasses. The Plan denied your request. The Plan says these services are 
not covered benefits. The Plan also says that while these services are not covered, they are available at a 
discounted rate to members. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when they are single vision or lined multi-focal lens. 
 
 
  We looked at the file and the Plan's rules. The contract states that lens enhancements are not covered through 
the allowance. Based on this information, we decided that the Plan's rules for coverage of the lens 
enhancements have not been met. Therefore, we decided that the Plan does not have to pay for the oversized 
lens (V2780) and polarized lens (V2762) provided on April 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network inpatient hospital stay 
provided on November 10, 2021, to November 25, 2021. 
 
You asked the Plan to waive the copayment for an in-network inpatient stay. You say that you should not have 
to pay such a high copayment. The Plan denied your request. The Plan says the copayment applied was correct. 
 
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 $275 
copayment per day for in-network, inpatient hospital care.  
 
You have been asked to pay the allowed amount of $1580, which is less than the $1650 copayment for an in-
network inpatient stay. An in-network inpatient stay falls within the In-Network, Inpatient Hospital Care 
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 in-network inpatient hospital 
stay provided on November 10, 2021, to November 25, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve 10 additional PT visits. You say that you are making progress with your 
strength and mobility. The Plan denied your request. The Plan says 10 additional PT visits are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 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 10 additional PT visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found that the additional therapy services are not an appropriate 
duration and frequency for treatment of your medical condition and therefore 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 10 additional PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 10 additional physical therapy (PT) visits.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extra ambulance mileage provided on January 25, 2022. 
 
You asked the Plan to pay for the extra ambulance mileage. You say that you were transported to the further 
hospital because it was the only one with available beds for patients with COVID-19. You also say that you are 
on a limited income and cannot afford to pay for this service. The Plan denied your request. The Plan says the 
requested service of extra mileage for the ambulance trip to the hospital is upheld based on the Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare law contains a restriction that miles 
beyond the closest available facility cannot be billed to Medicare. 
 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the extra ambulance mileage have not been met. Therefore, we decided that the Plan does not have 
to pay for the extra ambulance mileage provided on January 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and prophylaxis (D1110) 
provided on April 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says the dental services were received from an out-of-network provider 
and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a periodic oral evaluation (D0120) and prophylaxis (D1110) provided on April 12, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ProText. 
 
You asked the Plan to pre-approve ProText. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
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 ProText. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a diagnosis of enthesopathy of bilateral feet and ankle. The Food and Drug 
Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare 
approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's 
clinical situation.  There is insufficient literature to establish that the requested service is safe and effective for the enrollee's 
condition.  Therefore, the enrollee does not meet criteria for the requested 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 ProText have not been met. Therefore, we decided that the Plan does not have 
to pre-approve ProText.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine PCR testing provided on July 21, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that urine PCR amplification techniques raise considerable concerns regarding contamination from one 
specimen to another, creating the potential for false-positive results. Amplification of organisms representing 
latent infection or colonization cannot be distinguished from active, clinically significant infections. 
Additionally, PCR may amplify fragments of nucleic acids, representing dead microorganisms, thus further clouding the clinical interpretation. Finally, specificities, sensitivities, and positive and negative predictive 
values of PCR have not been reported in large groups of patients for many of the microorganisms. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the urine PCR testing provided on July 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with irinotecan, panitumamab, ondasetron, 
atropine, dexamethasone, and diphenhydramine. 
 
You asked the Plan to pre-approve treatment with irinotecan, panitumamab, ondasetron, atropine, 
dexamethasone, and diphenhydramine. You say that this is medically necessary. The Plan denied your request. 
The Plan says this medication combination is not supported. 
 
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 treatment with irinotecan, 
panitumamab, ondasetron, atropine, dexamethasone, and diphenhydramine. Our reviewer says that the 
requested treatment is not supported. Our physician reviewer found the record indicates that you have a 
diagnosis of recurrent descending colon adenocarcinoma.  
 The Food and Drug Administration has not stated that the requested drug combination is indicated for your 
condition. It is also not supported for your clinical situation in the Medicare-approved cancer drug compendia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of treatment with irinotecan, panitumamab, ondasetron, atropine, dexamethasone, 
and diphenhydramine have not been met. Therefore, we decided that the Plan does not have to pre-approve 
treatment with irinotecan, panitumamab, ondasetron, atropine, dexamethasone, and diphenhydramine.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pharmacogenetics testing services provided on April 5, 
2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says one code must 
be submitted for the panel. 
 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 the pharmacogenetics testing was billed with CPT code 81238. This code is not included for the 
testing services. If no CPT code is available for the gene(s) being tested, the unlisted molecular pathology 
procedure code 81479 should be used. Based on this information, we decided that Medicare rules for coverage 
of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the 
pharmacogenetics testing services provided on April 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 2, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the referring provider sends the specimens 
to your laboratory to process, and you would like the claim to be paid. The Plan denied your request. The Plan 
says the rendering and referring providers are both OON providers and there was no approved authorization. 
Also, the service rendered was not urgent or emergent. 
 
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 the laboratory services provided on March 2, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dialysis services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the dialysis services. You say that you would like to continue using the 
same dialysis provided. The Plan denied your request. The Plan says there are network providers available. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve dialysis 
services to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug 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 Keytruda. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has a diagnosis of adenocarcinoma of the lung with unknown PD-L1 status, and 
EGFR/ALK status whose disease has progressed during previous treatment with the requested drug. The Food 
and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The 
Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested 
drug in the enrollee's clinical situation. Therefore, the enrollee does not meet criteria for the requested drug. 
 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.