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

We decided that the Plan does not have to pre-approve Opdivo for the enrollee.
You asked the Plan to pre-approve Opdivo. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that medical studies haven't proven that this drug is helpful when you've tried but not had a positive response to another anti-PD1 drug.
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 Opdivo is not medically reasonable and necessary for the enrollee. Opdivo is not FDA-approved for the enrollee's diagnosis with progression on prior immunotherapy. 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. Our physician reviewer found that the enrollee's condition does not meet criteria for Opdivo.
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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses provided on April 8, 2021.

You asked the Plan to pay for eyeglasses. You say that you purchased two pair of eyeglasses and you are entitled to reimbursement of $150 for the one pair or eyeglasses per your insurance benefit. The Plan denied your request. The Plan contract says that the vision care benefit for eyewear may not be combined with any other discounts or promotional offers.

Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

We looked at the file and the Plan's rules. The file shows that you purchased two pair of eyeglasses with an in- store promotional package. The Plan's eyewear benefit says that this benefit may not be combined with any other discounts or promotional offers. Based on this information, we decided that the Plan's rules for coverage of eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses provided on April 8, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that you need skilled care to safely return home. The Plan denied your request. The Plan says rules for SNF care have not been met because the requested level of care is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that you have no identifiable skilled nursing service needs. You do have identifiable skilled therapy service needs; however, you do not require skilled nursing or therapy services on a daily basis. You do not meet 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the injection(s), of diagnostic or therapeutic
substance(s), not including neurolytic substances, including needle or catheter placement, interlaminar epidural
or subarachnoid, lumbar or sacral, with imaging guidance (62323), provided on March 18, 2021.

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 service 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 $40
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory
surgical centers when conducted by a specialist.

You have been asked to pay a $40 copayment for the injection provided by a specialist at a hospital outpatient
facility. 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 injection(s), of diagnostic or therapeutic
substance(s), not including neurolytic substances, including needle or catheter placement, interlaminar epidural
or subarachnoid, lumbar or sacral, with imaging guidance (62323), provided on March 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive cardiovascular genetic panel (81286,
81404, 81405, 81406, 81407, 81408, 81479) provided on October 8, 2020.

You asked the Plan to pay for a comprehensive cardiovascular genetic panel. You say that this was medically
necessary. The Plan denied your request. The Plan says this is not covered.

The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular
(CV) risk assessment panels, except the basic lipid panel, for symptomatic and asymptomatic patients.

We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not
covered. Based on this information, we decided that Medicare rules for coverage of a comprehensive
cardiovascular genetic panel have not been met. Therefore, we decided that the Plan does not have to pay for a
comprehensive cardiovascular genetic panel (81286, 81404, 81405, 81406, 81407, 81408, 81479) provided on
October 8, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance imaging, brain (including brain stem) (70551) provided on November 25, 2019 by an out-of-network (OON) provider.
You asked the Plan to pay for the diagnostic services. You say that see attached proof of timely filing and reconsider processing the claim for payment. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 magnetic resonance imaging, brain (including brain stem) (70551) provided on November 25, 2019 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the tooth extraction (D7140) provided on July 2, 2021.

You asked the Plan to pay for the extraction. You say that this was a simple tooth extraction and should be covered by your dental benefit. The Plan denied your request. The Plan says extractions are not covered by your dental 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. The Plan covers cleanings, routine and comprehensive oral exams, and bitewing and panoramic x-rays. 

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. Therefore, we decided that the Plan does not have to pay for the tooth extraction (D7140) provided on July 2, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) stay
provided March 1, 2021 to March 9, 2021.

You asked the Plan to waive the copayment for the SNF stay. You say that the copay is way to high for you to
be able to afford. The Plan denied your request. The Plan says the claim was processed with the correct
copayment applied per the Evidence of Coverage.

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 $0
copayment for days 1-20 $184 copayment per day for days 21-100 for Skilled nursing facility (SNF) care.

You have been asked to pay $1,288.00 ($184x7 days) for the SNF stay. The SNF stay falls within the Skilled
nursing facility (SNF) 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 the skilled
nursing facility (SNF) stay provided March 1, 2021 to March 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the porcelain pontic (D6241) and retainer crown (D6740) provided on January 7, 2021.
You asked the Plan to pay for the dental services. You say that these services should be covered by your enhanced benefit. The Plan denied your request. The Plan says these services are not covered by your dental benefits.
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. Therefore, we decided that the Plan does not have to pay for the porcelain pontic (D6241) and retainer crown (D6740) provided on January 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 29, 2021.

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services billed are not a covered benefit.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.

The laboratory services at issue in this appeal were requested solely for screening purposes. Medicare does not
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the
laboratory services provided on January 29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for targeted genomic sequence panel testing (code 81455) provided on November 20, 2020.

You asked the Plan to pay for genetic testing. You say that this testing was ordered by the treating physician to help determine the course of treatment for the enrollee. The Plan denied your request. The Plan says this test is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that targeted genomic sequence analysis code 81455 will be denied automatically as not medically necessary. 

We looked at the file and Medicare rules. This test is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for targeted genomic sequence panel testing (code 81455) provided on November 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical placement of an implant (D6010 x 2) provided
on May 4, 2021.
You asked the Plan to pay for the dental services. You say that you bought dentures prior to having dental
coverage. You say that now you need implants to hold the denture in place. You also say that without the
implants, the dentures are of no use to you. The Plan denied your request. The Plan says surgical placement of
an implant body is not listed as covered services.
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, surgical placement of an implant body
are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for
the surgical placement of an implant (D6010 x 2) provided on May 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869).

You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested treatment is a medical
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met
because the requested procedure is experimental/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 a Vertiflex procedure. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found that the requested procedure is considered experimental/investigational as its role in
the management of spinal stenosis is still uncertain.

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 Vertiflex procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve a Vertiflex procedure (22869).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on November 21, 2020.

You asked the Plan to pay for the ambulance services. You say that the ambulance transport provided on November 21, 2020 was medically necessary. The Plan denied your request. The Plan says the ambulance transport provided on November 21, 2020 was not medically necessary.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 

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 ambulance services. Our reviewer says that the ambulance transport provided on November 21, 2020 was not medically necessary. Our physician reviewer found ambulance transport services were utilized on 11/21/2020 for a scheduled non-emergent transport. She was in no pain or distress and vitals were stable before and during transport. The documentation does not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for this enrollee on 11/21/2020. A stretcher van or wheelchair van would have been more appropriate. The documentation does not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport on 11/21/2020. Vitals were normal, no pain, no distress. The documentation does not support that the ambulance transport on 11/21/2020 was medically reasonable and necessary for the enrollee. It was a non-emergent transport.

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 ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on November 21, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the comprehensive oral evaluation (D0150), full mouth x-rays (D0210), and cleaning (D1110) provided on March 29, 2021, to March 31, 2021.

You asked the Plan to pay for the dental services. You say that you and your spouse called the Plan to receive information on participating dentists, and member services told you this provider was in-network. The Plan denied your request. The Plan says that this provider is not part of the Plan's network, and out-of-network dental care is not covered.

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. 

You were referred for the dental services by an agent of the Plan's Member Services department. The file does not show that the Plan provided notice that the dental services would not be covered. Documentation shows that your spouse called the Plan to find a provider for both of you and was given inaccurate information from member services. The Plan has agreed to pay for the services your spouse received from this same provider in March of 2021, because they were directed to this provider by an agent of the Plan. This same exception should be made in your case, as you were both given this same information from the Plan as spouses. Under Medicare rules, this means the dental services is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the comprehensive oral evaluation (D0150), full mouth x-rays (D0210), and cleaning (D1110) provided on March 29, 2021, to March 31, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power mobility device (PMD).

You asked the Plan to pre-approve a PMD. You say that you would like this to be covered. The Plan denied your request. The Plan says that your physician recommends you use a walker with a seat.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 

The file shows that your condition can be improved by a walker, cane or manual wheelchair. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power mobility device (PMD).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with a topical peripheral nerve stimulator.

You asked the Plan to pre-approve this procedure. You say that this treatment is medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare only covers implanted nerve stimulators. The requested procedure and topical device are not covered by Medicare for peripheral nerve treatment.

The Plan must follow Medicare rules. Medicare does not cover this treatment when provided with a topical device for stimulation. Therefore, we decided that the Plan does not have to pre-approve treatment with a topical peripheral nerve stimulator.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a nerve procedure using a topical device.
You asked the Plan to pre-approve a nerve procedure using a topical device. You say that this treatment is medically necessary. The Plan denied your request. The Plan says Medicare only covers implanted nerve stimulators. The requested procedure and topical device are not covered by Medicare.
The Plan must follow Medicare rules. Medicare does not cover this treatment when provided with a topical device for stimulation. Therefore, we decided that the Plan does not have to pre-approve a nerve procedure using a topical stimulation device.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility admission.

You asked the Plan to pre-approve skilled nursing facility admission. You say that skilled nursing facility services are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. Based on the medical records provided, this appears to be a placement more for social issues rather than for the need of daily skilled nursing or daily skilled therapy services. Medicare coverage criteria are not met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility admission.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the coronavirus testing (U0003) provided from July 14, 2020, to August 19, 2020.

You asked the Plan to pay for the laboratory testing. You say that the services are not related to the enrollee's hospice diagnosis. The Plan denied your request. The Plan says the enrollee's 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 provider's responsibility to verify the enrollee's 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 coronavirus testing (U0003) provided from July 14, 2020, to August 19, 2020.