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

 We decided that the Plan has to pay for the extraction (D7140), bone graft at time of implant (D6104), and the implant placement (D6010) provided on February 8, 2021.  You asked the Plan to pay for the dental services. You say that the implant was paid for. You say that your plan requested the payment be returned. You say that this dentist is in network as they were listed on the website. You also say that you called to verify he was in network and he was. The Plan denied your request. The Plan says that there is an annual maximum benefit of $4,000 for dental services. The Plan also says that the annual maximum benefit has been exhausted.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan has denied these services stating the annual limit for dental services has been reached. The documentation submitted does not include any evidence that the Plan has paid the annual limit. It is the burden of the Health Plan to substantiate their denial with evidence. This denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for the extraction (D7140), bone graft at time of implant (D6104), and the implant placement (D6010) provided on February 8, 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist visit provided on April 22, 2021.  You asked the Plan to waive the copayment for a specialist visit. You say that you do not understand why you keep receiving bills and cannot afford them. The Plan denied your request. The Plan says the claims were processed correctly, and you are being charged the correct 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 $40 copayment for each specialist visit.     You have been asked to pay a $40 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 a specialist visit provided on April 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Vertiflex Superion.  You asked the Plan to pre-approve a Vertiflex Superion. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 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 a Vertiflex Superion. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has moderate to severe spinal stenosis at L3-L4 as well as evidence of a vertebral compression fracture at L3-L4, the levels requested for treatment. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended.  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 Superion have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion.
Appeal type: Inpatient Hospital
Decision: Favorable

 We decided that the Plan has to pre-approve services.  You asked the Plan to pre-approve the requested services. You say that the services are medically necessary. You also say that the enrollee is ready for discharge. The Plan denied your request. The Plan says that the services are not medically necessary.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan has not forwarded sufficient information to determine what services are at issue or why they were denied. The case file includes an approved authorization for inpatient services, an appeal for Skilled Nursing Facility Services and a denial of payment for an undisclosed service. The Plan has not forwarded any evidence of a denial for authorization for Skilled Nursing Facility services. It is the burden of the Health Plan to substantiate their denial with evidence. There is no evidence of what service has been denied or why so we must find in your favor. Please note, we requested this information from the Plan and did not receive a reasonable response. Therefore, we decided that the Plan has to pre-approve services.   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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Keytruda.  You asked the Plan to pre-approve Keytruda. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  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 Keytruda. Our reviewer says that the medication is not medically necessary. Our physician reviewer found this enrollee does not have PD-L1 testing on her tumor. The service is not reasonable or medically necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for outpatient surgeries you had at an ambulatory surgical center on March 8, 2021, and March 22, 2021.  You asked the Plan to waive the copayments for the outpatient surgeries. You say that you were told that you didn't owe anything for these procedures. 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 $325 copayment for outpatient surgery at an ambulatory surgery center.   You have been asked to pay a $325 copayment for the outpatient surgeries. 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 outpatient surgeries you had at an ambulatory surgical center on March 8, 2021, and March 22, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a repeat diagnostic polysomnography (95810).  You asked the Plan to pre-approve a repeat sleep study. You say that your specialist recommended an observation sleep study would be more conclusive than an in home sleep study. The Plan denied your request. The Plan says a repeat diagnostic polysomnography is not medically necessary.  The Plan follows Medicare rules. Medicare rules say that repeat polysomnography is indicated when the enrollee's symptoms has been inadequately treated for obstructive sleep apnea (OSA).  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 repeat sleep study. Our reviewer says that repeat sleep study is not medically necessary. Our physician reviewer found a diagnostic polysomnography (PSG) is not medically necessary. The reviewer found that the enrollee's problem is with the continuous positive airway pressure (CPAP) interface. The reviewer found there does not seem to be any question about the diagnosis of obstructive sleep apnea (OSA). The reviewer found that the enrollee's CPAP appears to be working well, because the apnea-hypopnea index (AHI) on CPAP is normal. The reviewer found that the records do not indicate that the enrollee is having symptoms of inadequately treated OSA. The record shows that the enrollee needs assistance with mask fit. Therefore, the reviewer found that the requested repeat sleep study is not medically necessary or reasonable.  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 repeat sleep study have not been met. Specifically, the file does not show that the request is for inadequate treatment, but for adjustments with the mask fit. Therefore, we decided that the Plan does not have to pre-approve a repeat diagnostic polysomnography (95810).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an additional injection of diagnostic or therapeutic substance.  You asked the Plan to pre-approve an additional injection of diagnostic or therapeutic substance. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 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 additional injection of diagnostic or therapeutic substance. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no role for a series of injections. Only one injection is medically reasonable and necessary. After the duration and effectiveness of the epidural steroid injection is assessed, another injection maybe considered if effectiveness criteria were met.  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 additional injection of diagnostic or therapeutic substance have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional injection of diagnostic or therapeutic substance.
Appeal type: Supplemental Benefit
Decision: Favorable

 We decided that the Plan has to pre-approve dental services.  You asked the Plan to pre-approve dental services. The Plan denied your request. The Plan says that if Original Medicare does not cover an item or service, the Plan also does not cover the item or 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.   We looked at the file, and the rules. The file shows that an oral exam, cleaning, and dental x-rays were requested. The Plan offers a dental benefit in excess of Medicare coverage. The requested services are among those covered under this benefit. The case file does not indicate you have met the maximum allowance of $325 for preventive dental services. Based on this information, we decided that the Plan's rules for coverage of dental services have been met. Therefore, we decided that the Plan has to pre-approve dental services.   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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Keytruda.  You asked the Plan to pre-approve Keytruda. The Plan denied your request. The Plan says the drug is not recommended for the requested use.  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 stage IV non-small cell lung cancer (NSCLC). The requested use of Keytruda is not FDA-approved for the enrollee's diagnosis. The drug is for first-line, single-agent treatment of NSCLC in those with stage III NSCLC who are not candidates for surgical resection or definitive chemoradiation, or in those with metastatic NSCLC with tumors with PD-L1 expression, as determined by an approved test, with no epidermal growth factor receptor (EGFR) or anaplastic lymphoma kinase (ALK) genomic tumor aberrations. The PD-L1 for this enrollee is 0 and no ALK or EGFR reported.  The requested use of the drug is not  supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The requested use is not indicated, not supported or not recommended in any of the compendia. The documentation does not 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 not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda.
Appeal type: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Xgeva.  You asked the Plan to pre-approve Xgeva. The Plan denied your request. The Plan says the enrollee has not tried and failed Zometa.   Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  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 Xgeva. Our physician reviewer found that the enrollee has metastatic prostate cancer. The Plan requires a trial of Zometa before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drug. There is no documentation provided indicating that the Plan's required drug would likely be less effective 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 Xgeva have not been met. Therefore, we decided that the Plan does not have to pre-approve Xgeva.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve dialysis services (90937, 90999) to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve the dialysis services. You say that the services are medically necessary. The Plan denied your request. The Plan says there are network providers available.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve dialysis services (90937, 90999) 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 pre-approve out of network Otolaryngologist services.  You asked the Plan to pre-approve out of network providers. You say that you prefer to see the requested provider. The Plan denied your request. The Plan says this treat treatment can be provided in network.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve out of network Otolaryngologist services.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for a whole-body scan (code 78306) and a computed tomography (CT) scan of the abdomen/pelvis (code 74176) provided on May 12, 2021.  You asked the Plan to waive the copayments for the radiological services. 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 $225 copayment for diagnostic and nuclear medicine radiological services. If multiple test types are performed in the same day, multiple copayments will apply.  You have been asked to pay a $225 copayment for the whole-body bone scan. You have also been asked to pay $207.75, which is less than the $225 copayment for the CT scan of the abdomen. Radiological services fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 a whole-body bone scan and a computed tomography (CT) scan of the abdomen/pelvis provided on May 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Eylea.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has not tried and failed the Plan's required drugs, Avastin, Mvasi, or Zirabev. The records do not show that the required drugs would be contraindicated or less effective; therefore, the Eylea is not reasonable or medically necessary at this time.  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 Eylea.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the negative pressure wound therapy pump (wound vac) you received on July 17, 2021.  You asked the Plan to waive the coinsurance for the wound vac. You say that you took the wound vac to the wound clinic and they told you that you did not need to use it.  You said that you returned the wound vac, so you should not have to pay for it. The Plan denied your request. The Plan says you were charged this coinsurance correctly.  The Plan says that you received this item on July 17, 2021, and did not return it to the provider until July 26, 2021.  Because you had the device in your possession for  9 days, you are responsible for the month's rental of this item.  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.   You have been asked to pay 20% coinsurance for the wound vac. The wound vac falls within the durable medical equipment benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. Rentals of durable medical equipment occur on a monthly basis.  Therefore, if you have the item for the month or any portion thereof, you are responsible for the coinsurance for the monthly rental. 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 negative pressure wound therapy pump (wound vac) you received on July 17, 2021.