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

 
We decided that the Plan does not have to pay for the laboratory services provided on September 24, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered.  
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services provided on September 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pembrolizumab. 
 
You asked the Plan to pre-approve pembrolizumab. You say that you agree that testing should be done but 
treatment should start. You say that the medication should be approved for at least one year given the 
likelihood of maintenance treatment with pemetrexed and pembrolizumab. The Plan denied your request. The 
Plan says there is lack of definitive staging or genetic susceptibility studies for the proposed regimen. 
 
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 pembrolizumab injections. Our 
reviewer says that the use of pembrolizumab is not FDA-approved for the enrollees diagnosis without certain 
testing. Our physician reviewer found that the use of pembrolizumab is not supported by one of the major drug 
compendia or by clinical research that appears in a CMS-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of pembrolizumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve pembrolizumab.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the custom fabricated abutment - includes placement 
(D6057) and abutment supported porcelain fused to metal crown (high noble metal) (D6059) provided October 
7, 2021. 
 
You asked the Plan to pay for the custom fabricated abutment and abutment supported crown. You say that you 
purchased additional dental coverage and would like this service covered. The Plan denied your request. The 
Plan says these services are 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 custom fabricated abutment - includes placement (D6057) and abutment supported porcelain fused to metal crown (high noble metal) (D6059) 
provided October 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the homemaker services provided on September 2, 
2021, to November 6, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to reimburse you for the homemaker services provided by an OON provider. You say that 
you would like the Plan to reconsider your request. The Plan denied your request. The Plan says the 
homemaker services you received were provided by an OON provider. The Plan says there were multiple in-
network providers available to you that could have provided the services you received. 
 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 reimburse you for care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to reimburse you for these 
items/services. Therefore, we decided that the Plan does not have to reimburse you for the homemaker services 
provided on September 2, 2021, to November 6, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Therapeutic, prophylactic, or diagnostic injection (specify
substance or drug) (96372) Vitamin B12 injection (J3420) provided January 1, 2021 to October 14, 2021.
You asked the Plan to pay for the injection services. You say that the Plan must correct the errors, contact
providers and advise that you owe no payment for services in August and beyond. The Plan denied your
request. The Plan says the claims were processed with the correct cost share applied and no further payments
are needed.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is in-network out of pocket max of $2,800 which applies to Medicare Part
B prescription drugs.
The item or service you asked the Plan to pay for falls within the benefit category Medicare Part B Prescription
Drugs. The Plan has followed Medicare rules by clearly disclosing in the contract that there is in-network out
of pocket max of $2,800 which applies to Medicare Part B prescription drugs.
If you reach the maximum out-of-pocket amount of $2,800, you will not have to pay any out-of-pocket costs
for the rest of the year for in-network covered Part A and Part B services. The records show that you were
asked to pay the correct amount of $2,800 of your out-of-pocket max for the 2021 year. This cost sharing is a
contractual obligation that had not been met at the time the injection services was received on January 1, 2021
to October 14, 2021. Therefore, we decided that the Plan does not have to pay for Therapeutic, prophylactic, or
diagnostic injection (specify substance or drug) (96372) Vitamin B12 injection (J3420) provided January 1,
2021 to October 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (99100) provided July 2, 2021. 
 
You asked the Plan to pay for the anesthesia services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says this code is not separately payable. 
 
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 99100 is not supported in the medical record. Specifically, per the National Physician 
Fee Schedule, this code has a status of "B" and payment is always bundled with the primary service. Based on 
this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. 
Therefore, we decided that the Plan does not have to pay for anesthesia services (99100) provided July 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for inpatient hospital services (99223, 99233, 
99239) rendered from August 27, 2021, to August 29, 2021. 
 
You asked the Plan to waive the deductible for inpatient hospital services. You say that your copayment, which 
includes physician services, and you should not be billed for each doctor individually as your copayment 
covers their services. The Plan denied your request. The Plan says you were charged the correct copayment 
amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $500 deductible which applies to inpatient hospital care.  
 
You have been asked to pay $500 for inpatient hospital services. Inpatient hospital services fall within the 
benefit category inpatient hospital care. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $500 deductible which applies to inpatient hospital care. This cost sharing is a 
contractual obligation that had not been met at the time inpatient hospital services was received on August 27, 2021, to August 29, 2021. Therefore, we decided that the Plan does not have to waive the deductible for 
inpatient hospital services (99223, 99233, 99239) rendered from August 27, 2021, to August 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete lower denture (D5120) provided on November 
11, 2021. 
 
You asked the Plan to pay for the denture. You say that you do not understand why the claim for your lower 
denture was denied. You say that your upper denture was paid. You also say that you have a limited income. 
The Plan denied your request. The Plan says complete lower denture is not listed as a covered dental item. 
 
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 complete lower denture not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the complete 
lower denture (D5120) provided on November 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on October 15, 2021. 
 
You asked the Plan to pay for the dental service. You say that your dentist advised the condition of your gums 
requires frequent dental cleanings. You say that failure to follow your dentist's recommendation will result in 
deterioration of your dental health. You also say that this may result in your insurance company having to pay 
more toward your dental bills. The Plan denied your request. The Plan says prophylaxis is covered twice per 
plan year. The Plan also says the frequency limit has been exceeded. 
 
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 and prophylaxis is listed as covered, the 
frequency limit has been exceeded. The record shows that the Plan paid for prophylaxis that you received on 
February 19, 2021, and June 11, 2021. Therefore, we decided that the Plan does not have to pay for the 
prophylaxis (D1110) provided on October 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the stem cell transplant. 
 
You asked the Plan to pre-approve the stem cell transplant. You say that the patient will receive tandem 
transplants with Carboplatin and Etoposide after having induction and high dose chemotherapy with stem cell 
collection. You say that this form of therapy offers the potential for cure in a situation which is otherwise fatal. 
The Plan denied your request. The Plan says Medicare doesn't cover stem cell transplant for testicular cancer. 
 
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 the stem cell transplant. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that autologous transplant after high dose chemotherapy is not supported by the NCD 
criteria. 
 
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 stem cell transplant have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the stem cell transplant.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial nursing facility care, per day (99305) rendered by 
the out-of-network (OON) provider on June 23, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the initial nursing facility care, per day (99305) rendered by the out-of-network (OON) 
provider on June 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will require an intensive team including 
a rehabilitation doctor and nurse, social worker, and therapists. The Plan denied your request. The Plan says the 
enrollee can safely receive the services in other settings. 
 
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 that the member does not require treatment by multiple therapies at an intensive 
rehabilitation therapy program. The member can receive further services at a lower 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the primary closure of a sinus perforation (D7261) provided 
September 24, 2021. 
 
You asked the Plan to pay for the primary closure of a sinus perforation. You say that this service happened as 
the result of a tooth extraction. 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 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 
primary closure of a sinus perforation (D7261) provided September 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (81479) provided on March 8, 2021. 
 
You asked the Plan to pay for code 81479. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, code 81479, was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
laboratory service (81479) provided on March 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fluid flow or fluid GF (Q4206). 
 
You asked the Plan to pre-approve fluid flow or fluid GF. You say that the enrollee has waited for a month. 
You also say that the enrollee is hurting and in pain while walking. The Plan denied your request. The Plan 
says this service is considered experimental and investigational. The Plan also says that the Medicare criteria 
for reasonable and necessary are not met, as it has not been shown to be safe and effective in long term studies, 
and there is a lack of evidence to support the clinical efficacy of this product. 
 
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 fluid flow or fluid GF. Our reviewer 
says that the fluid flow or fluid GF is not medically reasonable or necessary. Our physician reviewer found this 
patient is suffering with recalcitrant left plantar fasciitis. The patient has failed conservative treatments 
including corticosteroid injections and therapy. It has been recommended that they receive injections of fluid 
flow or fluid GF. Our reviewer found that the fluid flow or fluid GF cannot be considered safe and effective. 
Unfortunately, there are no long-term double-blind placebo-controlled studies to evaluate the effectiveness of 
fluid flow or fluid GF injections for plantar fasciitis. Our physician reviewer also found that it does not appear 
that this patient has undergone treatments including non-steroid anti-inflammatory medications, orthotic 
therapy, casting, activity modification, and non-weight bearing. 
 
 
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of fluid flow or fluid GF have not been met. Therefore, we decided that the Plan 
does not have to pre-approve fluid flow or fluid GF (Q4206).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) provided on July 15, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the unauthorized services rendered were by a non-participating provider. 
The Plan also says that it was determined that the services received were not urgent/emergent, and the member 
does not have out of network coverage for services determined to be non-urgent/emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit (99214) provided on July 15, 2021, 
by an out-of-network (OON) provider.
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 the SNF care. You say that you are concerned for your safety if you go 
home. You say going home may lead to an injury resulting with a lapse of recovery and possible hip 
replacement. The Plan denied your request. The Plan says authorization is denied because SNF care is not 
medically necessary, and your needs can be met through outpatient therapy on an intermittent basis.  
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 the SNF care. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found you do not have documented skilled 
nursing needs or skilled therapy needs. You are ambulating household distances and tending to activities of 
daily life (ADLs) with minimal supervision. Daily skilled services are not required to establish a maintenance 
program or to prevent deterioration of you condition. Your custodial and intermittent care needs can be 
provided at a lower 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 the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) care.