Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive your coinsurance for durable medical equipment.

You asked the Plan to waive your coinsurance for a humidifier and CPAP device. You say that these should be completely covered because of COVID and COVID services are covered at 100%. The Plan denied your request. The Plan says you pay a 20% coinsurance for durable medical equipment provided by an in-network durable medical equipment provider.

The Health Plan website says that for the 2022 plan year, Medicare Advantage (MA) benefits include no member cost share for COVID-19 treatment. MA medical plan members will have no copays, deductibles orcoinsurance for covered services for treatment of active, confirmed cases of COVID-19. This could include telehealth, primary care physician visits, specialty physician visits, facility visits, labs, home-health and ambulance services. 

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 Durable Medical Equipment (DME) and Related Supplies. 

You have been asked to pay a $2.66 coinsurance for a humidifier. A humidifier falls within the Durable Medical Equipment (DME) and Related Supplies benefit category. The Plan allowed $13.30 for this equipment; $13.30 x 20% = $2.66. This means that you have been asked to pay the correct amount based on your contract with the Plan.

You have also been asked to pay a $7.95 coinsurance for a CPAP device. A CPAP device falls within the Durable Medical Equipment (DME) and Related Supplies benefit category. The Plan allowed $39.75 for this equipment; $39.75 x 20% = $7.95. 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 your coinsurance for durable medical equipment.

Please note, the Health Plan states that a cost sharing exception may be applied for covered services for treatment of active, confirmed cases of COVID-19. The documentation does not support that you had an active case of COVID-19 on this date of service.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a non-preferred brand blood glucose monitor (OneTouch Ultra2).

You asked the Plan to pre-approve a non-preferred brand blood glucose monitor. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the requested items are not a covered benefit.

Medicare rules say that plans can require enrollees to get diabetic supplies from preferred providers/brands. The contract with the Plan says that only ACCU-CHEK manufactured by Roche, or Trividia products sometimes packaged under your pharmacy's name are covered by the Plan.

The requested brand in this case is not a preferred brand with the Plan. The Plan has preferred brands who can provide the items 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 a non-preferred brand blood glucose monitor (OneTouch Ultra2).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a computerized ophthalmic diagnostic
imaging provided on December 22, 2020.

You asked the Plan to waive the copayment for the computerized ophthalmic diagnostic imaging. You say that
you already paid a $45 copayment and you do not believe you should have to pay again. The Plan denied your
request. The Plan says you have been asked to pay the correct cost-sharing 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 $45
copayment for Medicare-covered vision services.

You have been asked to pay a $45 copayment for the computerized ophthalmic diagnostic imaging. The
computerized ophthalmic diagnostic imaging falls within the "Vision care" benefit category. The record shows
this was billed as a separate service. 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 computerized
ophthalmic diagnostic imaging provided on December 22, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the travel and lodging expenses provided on February 24, 2020.

You asked the Plan to reimburse you for the travel and lodging expenses. You say that you were not informed of any changes to your insurance plan regarding travel reimbursement. The Plan denied your request. The Plan says you were eligible for the travel and lodging benefit until December 24, 2019. Therefore, any reimbursement claims submitted to the plan for date of service after December 24, 2019 would not be covered.

The contract with the Plan says that the member has up to one year (365 days) from the date of transplant to send the plan travel and lodging reimbursement claims for payment consideration.

We looked at the file and the Plan's rules. The file shows that the enrollee has up to one year (365 days) from the date of transplant to send the plan travel and lodging reimbursement claims for payment consideration. You were eligible for the travel and lodging benefit until December 24, 2019. Any reimbursement claims submitted to the plan for date of service after December 24, 2019 would not be covered. Therefore, we decided that the Plan does not have to reimburse you for travel and lodging transplant expenses provided on February 24, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve stereotactic body radiation therapy (SBRT).

You asked the Plan to pre-approve the SBRT. You say that you believe that this is necessary in order to allow the enrollee to continue to receive benefit from chemotherapy. The Plan denied your request. The Plan says this is not considered necessary for this type of cancer.

The Plan follows Medicare rules. Medicare rules say that SBRT is not considered medically necessary in cases where the tumor burden cannot be completely targeted and when disease could be treated by conventional methods.

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 SBRT. Our reviewer says that the requested SBRT is not shown to be medically reasonable and necessary in this case. Our physician reviewer found for metastatic disease, SBRT is generally only indicated for patients with oligometastatic disease of for those undergoing palliation after prior radiation. Oligometastases are defined as a state of metastatic disease with metastases few in number and extent. A study specifically addressed the use of SBRT for "oligoprogression" of disease (i.e. limited growth of lesion(s) ) in patients with ALK+ or EGFR mutated NSCLC in an effort to enable the patients to continue systemic therapy and treat the disease that has progression; they demonstrated >6 months of additional tumor control with SBRT. 

The above-mentioned study in 2012, along with ongoing studies, have resulted in several review articles describing the potential of SBRT for oligoprogression. One recent review highlights that published data to date support the concept of SBRT for oligoprogression, but the toxicity of how to combine with systemic therapy, and optimal dose fractionation remain unknown. The review discusses an ongoing prospective study to evaluate SBRT for oligoprogression in patients with ALK or EGFR mutated NSCLC.

While SBRT for widespread disease (which is the case in this patient with recently treated nodal, brain and bone metastases, and progressive lung metastases) can perhaps be considered in some selected patients, there is no plausible, compelling reason for SBRT (over other forms of radiation) for this patient. According to the LCD, coverage criteria are not met because the entire tumor burden cannot (and is not planned) to be encompassed, but rather only the growing intrathoracic disease. 

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 SBRT have not been met. Therefore, we decided that the Plan does not have to pre-approve stereotactic body radiation therapy (SBRT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a walker purchased out of network on August 5, 2020.

You asked the Plan to pay for a walker. You say that you were not aware that you had to be sure the provider was a Medicare eligible provider. The Plan denied your request. The Plan says the contract is clear that durable medical equipment must be purchased from eligible providers and may require prior authorization.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided by a vendor who is not Medicare eligible. The provider from whom you purchased the walker is not a Medicare eligible provider. You did not follow your Plan contract rules prior to purchasing this equipment. Therefore, we decided that the Plan does not have to pay for a walker purchased out of network from on August 5, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99231) provided on October 5, 
2021. 
 
You asked the Plan to pay for the evaluation and management service. You say that the service was medically 
necessary. 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 date of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the subsequent hospital care (99231) provided on October 5, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fundus photography with interpretation and report 
provided on May 11, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the fundus photography with interpretation and report. You say that the provider 
is in the Plan's network. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 
fundus photography. We found no exception that would require the Plan to pay for the fundus photography. 
The record shows the provider is out-of-network. Therefore, we decided that the Plan does not have to pay for 
the fundus photography with interpretation and report provided on May 11, 2022, by an out-of-network (OON) 
provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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 reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program at least three hours a day and five days 
a week, or 15 hours over seven consecutive days. You may benefit from physical and occupational therapy 
however, it is not clear that you can participate in and benefit from the intensity of therapies provided on acute 
inpatient rehabilitation. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extraction (D7210) provided on April 12, 2022. 
 
You asked the Plan to pay for the surgical extraction. You say that you believe this service should be covered. 
The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan. The 
Plan also says that you were not enrolled in the optional dental rider on this date of service. 
 
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. 
 
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 
surgical extraction (D7210) provided on April 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for opioid treatment provided to the enrollee.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says the provider is not certified.

The Plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are
enrolled in the Medicare program.

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 services. Our physician reviewer found The rendering provider is not eligible to bill Medicare for an opioid treatment program. The Plan did not preapprove the services. We found no exception that would require the Plan to pay for these items/services. 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 pay for opioid treatment provided to the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ozempic.

You asked the Plan to pre-approve the Ozempic. You say that the records provided support the need for the requested drug. The Plan denied your request. The Plan says the drug being requested is not covered under the enrollee's contract. The Plan says that the enrollee has no Part D benefit or commercial pharmacy plan administered by the Plan.

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 Ozempic.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have the degree of medical complexity to necessitate care in skilled 
nursing facility setting. You also do not require the level of intensity of skilled therapy services provided in the 
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 skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 21, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pool lift. 
 
You asked the Plan to pre-approve a pool lift. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the requested lift is not covered by Medicare or the Plan. The Medicare definition of 
durable medical equipment is not met. A pool lift is not used to take care of a medical need. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a pool lift.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office visit (99214) provided on February 14, 2022. 
 
You asked the Plan to pay for the physician service. You say that additional payment should be made. The Plan 
denied your request. The Plan says that the claim processed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that for services paid on a fee schedule, Medicare 
secondary payment amounts are determined by a formula and are the lowest.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the physician service have been met. Therefore, we decided that the Plan has to pay for the office 
visit (99214) provided on February 14, 2022.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 1, 2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of residual tooth roots (D7250), therapeutic 
parenteral drug (D9610), and deep sedation/general anesthesia (D9222) provided on April 13, 2022. 
 
You asked the Plan to pay for the removal of residual tooth roots, therapeutic parenteral drug, and deep 
sedation/general anesthesia. You say that you are on a limited income. The Plan denied your request. The Plan 
says the removal of residual tooth roots and therapeutic parenteral drug are not covered expenses under your 
dental plan. The Plan also says that the deep sedation/general anesthesia is not covered because the removal of 
residual tooth roots is not a covered service. 
 
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. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the removal of residual tooth roots 
(D7250) and therapeutic parenteral drug (D9610) are not among those covered under this benefit. The contract 
clearly states that anesthesia is covered as needed with covered procedures. Therefore, we decided that the Plan 
does not have to pay for the removal of residual tooth roots (D7250), therapeutic parenteral drug (D9610), and 
deep sedation/general anesthesia (D9222) provided on April 13, 2022.