Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for physical therapy services provided by a physical therapist on March 17, 2020.  You asked the Plan to pay for physical therapy services. You say that plans are required to pay non-contracted providers at the preferred provider rate if services are not available from preferred providers in the service area. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. The Plan says the records do not support the code billed.  The Plan must follow Medicare rules. Medicare rules say that services of a physical therapist billed as services incident to a physician/non-physician practitioner's service must meet all incident requirements.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy services have not been met. Specifically, the billing provider is a nurse practitioner. As such, physical therapy services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided by a physical therapist on March 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve gynecology services to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve OON services. You say that the doctor's you went to are unfamiliar with the medication you need. The Plan denied your request. The Plan says the medical care you require is provided within your network.  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 OON services. Therefore, we decided that the Plan does not have to pre-approve gynecology services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the wound care services provided from July 20, 2021, through July 28, 2021.   You asked the Plan to waive the copayment for the wound care services. You say that you were never told you would have a copayment of $100. The Plan denied your request. The Plan says you have been charged 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 $100 copayment for each outpatient hospital facility visit.   You have been asked to pay only one $100 copayment for the wound care services, even though you had three separate visits. The wound care services fall within the Outpatient Hospital Services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the wound care services provided from July 20, 2021, through July 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the re-cement or re-bond implant/abutment supported crown (D6092) provided March 17, 2021.

You asked the Plan to pay for the re-cement of an implant supported crown. You say that you would like the service covered. The Plan denied your request. The Plan says this service is not covered under your 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 re-cement or re-bond implant/abutment supported crown (D6092) provided March 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a microprocessor knee and K3 foot.  You asked the Plan to pre-approve a microprocessor knee and K3 foot. You say that the requested microprocessor knee and K3 foot is medically necessary. The Plan denied your request. The Plan says the requested microprocessor knee and K3 foot 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 pre-approve a microprocessor knee and K3 foot. Our reviewer says that the requested microprocessor knee and K3 foot is not medically necessary. Our physician reviewer found the requested items exceed the enrollee's medical need. The physician documentation does not support that this enrollee is a level K3 ambulator given the documentation that the enrollee uses a walker to ambulate. The documentation does not reveal why the enrollee's function cannot be met with a mechanical knee. The requested microprocessor knee and K3 foot exceed the enrollee's medical need.  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 microprocessor knee and K3 foot have not been met. Therefore, we decided that the Plan does not have to pre-approve a microprocessor knee and K3 foot.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve tildrakizumab, 1MG injection (CPT code J3245), for the enrollee.  You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied your request. The Plan says this is a self-administered drug and not covered by Medicare.  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 tildrakizumab, 1MG injection (CPT code J3245), for the enrollee.   Benefits for the medication 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve incontinence supplies.  You asked the Plan to pre-approve incontinence supplies. You say that this is medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.  The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable.   While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Prolia 60MG/ML syringe (CPT code J0897), for the enrollee.  You asked the Plan to pre-approve the medication. You say that the enrollee has severe osteoporosis. You state Prolia was chosen because the enrollee is not a candidate of Evenity and cannot administer self-injectables. The Plan denied your request. The Plan says the request was denied due to failure to complete a three-year trial of a bisphosphonate or to indicate a contraindication or intolerance to the same. The Plan states the review on appeal has not indicated why the enrollee cannot even try oral bisphosphonates.  The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 medication. Our physician reviewer found based on the medical records provided the enrollee has not tried and failed the required drug(s). Based on the medical records provided there is no indication that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for the 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 the medication have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia 60MG/ML syringe (CPT code J0897), for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the epidural injections provided from January 7, 2021, to April 15, 2021.  You asked the Plan to waive the copayment for the epidural injections. You say that you have had these injections before and never received a bill. You say you never expected the insurance not to cover it. The Plan denied your request. The Plan says you have been charged 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 $150 copayment for each outpatient hospital service, including outpatient surgery or procedure.   You have been asked to pay a $150 copayment for each of the epidural injections. The epidural injections fall within the Outpatient Hospital Services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the epidural injections provided from January 7, 2021, to April 15, 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 stage IV pancreatic cancer recent progression with liver mets. The requested use of 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. No phase III trials supporting use as monotherapy or combination therapy.   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 waive the copayments for care management services via phone you received from a nurse at your Primary Care Physician's (PCP) office.  You asked the Plan to waive the copayments for the care management services. You say that the nurse you spoke to on these occasions was wonderful, but you were not aware that there would be any cost sharing associated with this service.  If you had known, you would not have had the services as you are on a fixed income. The Plan denied your request. The Plan says you were charged these copayments 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 $15 copayment per visit for primary care telehealth services.   You have been asked to pay a $15 copayment per visit for the care management services. the care management services fall within the primary care telehealth services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for care management services via phone you received from a nurse at your Primary Care Physician's (PCP) office.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a respiratory assist device (RAD), bi-level pressure capability, with back-up rate feature coded as E0471.  You asked the Plan to pre-approve the E0471 RAD. You say that the enrollee would benefit from this treatment. The Plan denied your request. The Plan says criteria for the requested RAD are not met.  The Plan follows Medicare rules. Medicare rules say that RADs such as E0471 are covered when medically necessary as defined 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 the E0471 RAD. Our reviewer says that the criteria for coverage of the requested RAD have not been met. Our physician reviewer found the documentation does not include sufficient evidence to support a diagnosis of CSA or CompSA as defined in the LCD.  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 E0471 RAD have not been met. Therefore, we decided that the Plan does not have to pre-approve a respiratory assist device (RAD), bi-level pressure capability, with back-up rate feature coded as E0471.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory testing provided on May 24, 2021.  You asked the Plan to pay for lab test. You say that this testing meets all of the requirements for coverage. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation submitted does not support the Place of Service (POS) code billed on this claim.  The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).        We looked at the file and Medicare rules. The documentation shows that the sample for this testing was taken in an office setting, therefore the POS code 81 - indicating an independent lab setting - is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of lab test have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on May 24, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.  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 admission 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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records show that you are medically stable for discharge from the hospital. You have no skilled nursing needs. You have skilled therapy needs but do not require skilled therapy services on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF level of care.  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 skilled nursing facility (SNF) admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a reline complete upper denture (D5730) and a reline partial lower denture (D5741) provided on April 19, 2021.  You asked the Plan to pay for a reline complete upper denture and a reline partial lower denture. You say that you had a procedure done to realign your dentures because they were not fitting properly, and you could not chew with them. This was not cosmetic but was medically necessary. You also say you were not informed that your insurance would not cover this or what the out of pocket would be. The Plan denied your request. The Plan says the services at issue are non-covered services with your health 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.   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 a reline complete upper denture (D5730) and a reline partial lower denture (D5741) provided on April 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient hospital services you received on July 20, 2021.  You asked the Plan to waive the copayment for the inpatient hospital services. You say that you went to urgent care and were incorrectly diagnosed with pneumonia.  As a result, you were taken by ambulance to the hospital and admitted.  You stated that you were in the hospital for about 14 hours and then you checked yourself out.  You stated that you should not have to pay the copayment because you were not satisfied with the care received. The Plan denied your request. The Plan says you were charged this copayment correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $175 copayment per day for days 1-7 for inpatient hospital care.   You have been asked to pay a $175 copayment for the inpatient hospital services. This copayment applies regardless of your satisfaction with the services received. 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 inpatient hospital services you received on July 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for preventive dental service (D1999) provided on August 10, 2021.  You asked the Plan to pay for preventive dental service. You say that the Plan directory says this service is covered. The Plan denied your request. The Plan says the denial of payment for this service is correct, because preventive dental service D1999 is not covered by the Plan's 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 preventive dental service (D1999) provided on August 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a complete upper denture (D5110) and a complete lower denture (D5120) provided on August 3, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for a complete upper denture and a complete lower denture. You say that the dentures you received should be covered 100% by the Plan and there should be no charge to you. The Plan denied your request. The Plan says the service is a covered benefit, but you are disputing the amount assessed by the health plan as an OON liability.

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 a complete upper denture and a complete lower denture when the services are provided by an in-network provider.

We looked at the EOC, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a complete upper denture and a complete lower denture have not been met. The records show the Plan paid the maximum allowed amount for the services at issue. Specifically, you received services from an OON provider, and you are responsible for the fees in excess of the billed amount. Therefore, we decided that the Plan does not have to pay for a complete upper denture (D5110) and a complete lower denture (D5120) provided on August 3, 2021, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) on January 20, 2021.  You asked the Plan to pay for ambulance response and treatment, no transport. The Plan denied your request. The Plan says the Medicare ambulance benefit is a transport benefit. If no transport occurs, then there is no Medicare-covered service.  The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.  The ambulance company did not provide transport services on January 20, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) on January 20, 2021.