Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the complete upper and lower denture.
You asked the Plan to pre-approve the complete upper and lower denture. You say that the previous surgery was inadequate, so the dentures made did not work. You say that you now need proper dentures. The Plan denied your request. The Plan says your benefit has been exhausted for the 2021 plan year.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, you also have maximum benefit of one complete upper and lower denture every five years. The Plan paid for the immediate upper and lower denture provided on August 21, 2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve the complete upper and lower denture.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87486, 87496, 87498, 87541, 87581, 87640, 87798, & 87532) provided December 11, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.
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 CPT code 87486, 87496, 87498, 87541, 87581, 87640, 87798, & 87532 is not supported in the medical record. Specifically, the place of service listed on the claim (81, laboratory) does not match the place of service detailed in the records (11, office setting). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (87486, 87496, 87498, 87541, 87581, 87640, 87798, & 87532) provided December 11, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (U0003 and U0005) provided on January 7, 2021.
You asked the Plan to pay for the infectious agent detection by nucleic acid. You say that you are an independent laboratory and do not see the enrollee directly, you only receive specimens from the enrollee's referring physician to test and report the findings. You also say that this claim is not hospice related. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
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 infectious agent detection by nucleic acid (U0003 and U0005) provided on January 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspirate for the enrollee.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the clinical value and effectiveness of bone marrow aspirate in the setting of spinal fusion surgery have not been demonstrated in the peer-reviewed literature.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Bone marrow aspirate remains experimental for use as bone graft material. More research is needed to show safety and efficacy. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspirate for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prefabricated stainless-steel crown (D2931) provided on March 18, 2021.
You asked the Plan to pay for the prefabricated stainless-steel crown (D2931). You say that you were told that you have $2,000 for dental care and you would be covered as long as the provider is in your plan. You say that you are asking for payment for the procedure. The Plan denied your request. The Plan says the service is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the prefabricated stainless-steel crown (D2931) provided on March 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for injections (J0690, J3010, J1100, J2001, J2710, J3010, J0171, J2704, J2405) provided September 15, 2020.
You asked the Plan to waive the copayment for the injections. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct cost-sharing was applied.
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 20% coinsurance for Part B drugs.
You have been asked to pay a 20% coinsurance ($312.90) for the injections. The injections fall within the Part B drugs 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 injections (J0690, J3010, J1100, J2001, J2710, J3010, J0171, J2704, J2405) provided September 15, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Keytruda.
You asked the Plan to pre-approve Keytruda. The Plan denied your request. The Plan says that the enrollee has not completed more than 2 cycles of the previous treatment.
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 physician reviewer found that the enrollee has metastatic endometrioid endometrial cancer. The requested use of Keytruda is FDA approved for the enrollee's diagnosis. Treatment, in combination with Lenvatinib, of advanced endometrial carcinoma that is not microsatellite instability-high (MSI-H) or mismatch repair deficient (dMMR) is supported in patients who have disease progression following prior systemic therapy (in any setting) and are not candidates for curative surgery or radiation. The requested use is not listed as not indicated, not supported, or not recommended in any of the compendia. The documentation does support that the requested drug is safe and effective and otherwise reasonable and necessary 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 Keytruda have been met. Therefore, we decided that the Plan has to pre-approve Keytruda.
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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies and materials provided from March 24, 2021 through April 29, 2021.
You asked the Plan to pay for the additional supplies and materials. You say that the new code was established to report additional practice expenses incurred during a public health emergency including supplies and additional clinical staff time. You say that the claims should be reprocessed for payment. The Plan denied your request. The Plan says this is a bundled code and is not eligible for separate reimbursement.
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, the CPT Code Manual definition of code 99072 is additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease.
We find that CPT code 99072 is not supported in the medical record. Specifically, CPT code 99072 has a status indicator of B. This means that CPT code 99072 is considered bundled and not separately payable. Based on this information, we decided that Medicare rules for coverage of the additional supplies and materials have not been met. Therefore, we decided that the Plan does not have to pay for the additional supplies and materials provided from March 24, 2021 through April 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement cushion cover (E2619), an adapter plate (K0108), and a footplate extension (K0108).
You asked the Plan to pre-approve a replacement cushion cover, an adapter plate, and a footplate extension. You say that these items are medically necessary. The Plan denied your request. The Plan says these items cannot be approved as requested.
The Plan must follow Medicare rules. Medicare rules say that a nonadjustable skin protection and positioning seat cushion (E2607, E2608) is a prefabricated cushion that has a removable vapor permeable or waterproof cover or it has a waterproof surface. Wheelchair seat and back cushion codes are all-inclusive. Use of code K0108 to separately bill for added components is incorrect coding. Miscellaneous options, accessories, or replacement parts for wheelchairs that do not have a specific code and are not included in another code should be coded K0108. We looked at the file and Medicare rules. The requested replacement cushion cover and adapter plate are included in the seat cushion that was approved under code E2607. The footplate extension cannot be approved because it was requested with code K0108, and there is a more appropriate code for this item. Based on this information, we decided that Medicare rules for coverage of a replacement cushion cover, an adapter plate, and a footplate extension have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement cushion cover (E2619), an adapter plate (K0108), and a footplate extension (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retainer crowns (D6740 x 3), and pontics (D6245 x 2).

You asked the Plan to pre-approve the dental services. You say that you need a bridge. You say that this would prevent your teeth from shifting. You say that you have a speech impediment due to the gap. You also say that your teeth are decaying due to not having insurance. The Plan denied your request. The Plan says retainer crowns are not listed as covered services. The Plan says that pontics are not listed as covered services either.

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 retainer crowns and pontics are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve retainer crowns (D6740 x 3), and pontics (D6245 x 2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that you had these items approved in the past. The Plan denied your request. The Plan says these items are not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records do not show that you suffer from diabetic foot disease or wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided on May 17, 2021.
You asked the Plan to pay for the dental service. You say that the enrollee's regular dentist referred you to this periodontist. You say that you do not understand why the enrollee would be referred to a provider that was out of network. You also say that the enrollee is not able to afford this payment. The Plan denied your request. The Plan says comprehensive periodontal evaluation is not listed as 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 Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the comprehensive periodontal evaluation is not among those covered under this benefit, regardless of the provider's network status. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided on May 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553, K0554).
You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553, K0554).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the abatacept injection and intravenous infusion provided on June 11, 2021.
You asked the Plan to waive the coinsurance for the abatacept injection and intravenous infusion. You say that you cannot pay over $900 every time you have an infusion. The Plan denied your request. The Plan says the claim reprocessed to apply the correct coinsurance.
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% of the total allowed amount for other Part B drugs and their administration from a network provider.
You have been asked to pay a total of $899.82 for the abatacept injection and intravenous infusion.
Service
Allowed Amount
Coinsurance
Member Liability
Abatacept Injection
$4,424
20%
$884.80
Intravenous Infusion
$75.09
20%
$15.02
TOTAL:
$899.82
The abatacept injection and intravenous infusion fall within the "Medicare Part B prescription drugs" 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 coinsurance for the abatacept injection and intravenous infusion provided on June 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an epidural injection (62321).
You asked the Plan to pre-approve an epidural injection. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for the requested treatment have not been met.
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 an epidural injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case.
Our physician reviewer found that the enrollee's symptoms do not match the provided diagnosis of C6 radiculopathy and the number of injections exceeds utilization limits. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an epidural injection have not been met. Therefore, we decided that the Plan does not have to pre-approve an epidural injection (62321).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a digital hearing aid (V5261), a hearing aid fitting (V5011), an ear mold (V5264) and a dispensing fee (V5160) provided on December 10, 2020.
You asked the Plan to pay for a hearing aid, a hearing aid fitting, an ear mold and a dispensing fee. You say that the provider is a participating provider with the Plan. You also say that you have called the Plan several times and was given misinformation. You would like the claim reprocessed and paid. The Plan denied your request. The Plan says hearing aids and supplies will only be covered when they are received by a specified network provider.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan contract says that the enrollee receives one hearing exam every year as well as two hearing aids every 2 years with a specified hearing vendor. Hearing aids ordered through providers other than the Plan's hearing vendor are not covered.
We looked at your review, the file, and the Plan's rules. The EOC confirms that hearing aids and supplies should be purchased by a specific hearing vendor. The provider in this case is not part of the Plan's hearing network. Before receiving hearing services, you must contact the hearing vendor for the Plan. Based on this information, we decided that the Plan's rules for coverage of a digital hearing aid, a hearing aid fitting, an ear mold and a dispensing fee. have not been met. Therefore, we decided that the Plan does not have to pay for a digital hearing aid (V5261), a hearing aid fitting (V5011), an ear mold (V5264) and a dispensing fee (V5160) provided on December 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Movantik.
You asked the Plan to pre-approve Movantik. You say that the enrollee has tried and failed all formulary alternatives. The Plan denied your request. The Plan says the enrollee's plan does not cover outpatient prescription drugs.
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 Movantik.
Benefits for Movantik 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vyzulta eye drops.
You asked the Plan to pre-approve Vyzulta. You say that the enrollee is stable on Vyzulta. The Plan denied your request. The Plan says the enrollee's plan does not cover outpatient prescription drugs.
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 Vyzulta eye drops.
Benefits for Vyzulta 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission provided from May 1, 2021, through May 3, 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 each time you are admitted to an acute care hospital, you pay $300. You will not pay more than $900 for inpatient hospital covered services in a calendar year.
You have been asked to pay a $300 copayment for the inpatient hospital admission 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 inpatient hospital admission provided from May 1, 2021, through
May 3, 2021.