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

 We decided that the Plan does not have to reduce the cost sharing for the stress echocardiogram and the injection of perflutren lipid microspheres you received on August 19, 2021.  You asked the Plan to reduce the cost sharing for the stress echocardiogram and the injected drug. You say that you were never told this injection would cost more money.  You stated that they only took $35 from you at the time of the service, so you don't think you should be charged anything else. The Plan denied your request. The Plan says you were charged this cost sharing 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 $55 copayment for ultrasounds and 20% coinsurance for Medicare Part B drugs.   You have been asked to pay a $55 copayment for the stress echocardiogram and 20% coinsurance for the injected drug. A stress echocardiogram is a type of ultrasound and the injection of perflutren lipid microspheres is a Medicare Part B drug. 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 reduce the cost sharing for the stress echocardiogram and the injection of perflutren lipid microspheres you received on August 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power wheelchair.  You asked the Plan to pre-approve a power wheelchair. You say that you need an electric wheelchair. The Plan denied your request. The Plan says the requested item is not a covered benefit.  The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home.   Review of the file shows that the item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a portable oxygen concentrator.  You asked the Plan to pre-approve a portable oxygen concentrator. You say that you need this device to allow you the greatest amount of mobility to continue to visit family, go shopping, attend concerts, meet friends for coffee and go on vacation. The Plan denied your request. The Plan says a portable oxygen concentrator is not covered for use outside of the home.  The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. Although this item may be helpful and give you more flexibility, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for Cinacalcet coded as J0604-AX and unlisted dialysis procedure coded as 90999-G4-V7 provided from June 1, 2021 to June 29, 2021.  You asked the Plan to pay for codes J0604-AX and 90999-G4-V7. 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 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 J0604 is Cinacalcet, oral, 1 mg, (for esrd on dialysis). The definition of code 90999 is Unlisted dialysis procedure, inpatient or outpatient.  We find that CPT codes J0604-AX and 90999-G1-V7 are not supported in the medical record. Specifically, J0604 was billed with a modifier no longer payable by Medicare as of January 1, 2021. As a result, the associated dialysis services associated with this drug administration will also be denied. Based on this information, we decided that Medicare rules for coverage of codes J0604-AX and 90999-G4-V7 have not been met. Therefore, we decided that the Plan does not have to pay for Cinacalcet coded as J0604-AX and unlisted dialysis procedure coded as 90999-G4-V7 provided from June 1, 2021 to June 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve men's orthopedic footwear.   You asked the Plan to pre-approve men's orthopedic footwear. You say that in your letter to the Plan and also to this office, that the requested orthotics are medically necessary and that you do meet the listed criteria due to the immense pain and deformity of your feet. The Plan denied your request. The Plan says this item is not a covered benefit.  Medicare rules state that supportive devices for the feet (such as orthopedic shoes) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Based on the medical records provided by your physician you have diagnoses of right bunion, right hammer toe, right metatarsalgia, exostosis of the right foot, osteoarthritis of the right and left foot, bilateral flat feet and bilateral ankle pain. However, you do not have a diagnosis of severe diabetic foot disease nor would the requested shoes be attached to and part of the original cost of a leg brace. While it is understood that the use of these shoes may be beneficial to you, your records do not reflect a diagnosis for which these shoes are covered by Medicare.  Therefore, we decided that the Plan does not have to pre-approve men's orthopedic footwear.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) provided March 16, 2021.  You asked the Plan to pay for the fluoride varnish. You say that you thought this service would be 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 topical application of fluoride varnish (D1206) provided March 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit provided on June 3, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the office visit. You say that you were never told you would need a preferred provider organization (PPO) or an additional policy to be covered. The Plan denied your request. The Plan says no prior authorization was obtained.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 the office visit provided on June 3, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 We decided that the Plan has to pay for the additional intraoral x-rays provided on August 19, 2021.  You asked the Plan to pay for the additional intraoral x-rays. You say that your benefit covers up to $2,000 in care and you don't understand why you should pay $64 out-of-pocket. The Plan denied your request. The Plan says that reimbursement for one intraoral x-ray has already been issued.  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. The Plan did not submit the correct Evidence of Coverage. Without the correct Evidence of Coverage, we cannot determine that the denial is correct or justified by the Plan. Therefore, we decided that the Plan has to pay for the additional intraoral x-rays provided on August 19, 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 pre-approve visits with an out of network cancer center.  You asked the Plan to pre-approve visits with an out of network provider. You say that you prefer to see the requested provider. The Plan denied your request. The Plan says this provider is not 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 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 has network providers available who can provide this treatment. Therefore, we decided that the Plan does not have to pre-approve visits with an  out of network cancer center.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a sinus augmentation (D7951).  You asked the Plan to pre-approve the dental service. You say that the services are necessary. The Plan denied your request. The Plan says sinus augmentation 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 requested sinus augmentation is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a sinus augmentation (D7951).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve cetuximab and cemiplimab-rwlc.  You asked the Plan to pre-approve cetuximab and cemiplimab-rwlc. You say that the requested cetuximab and cemiplimab-rwlc are medically necessary. The Plan denied your request. The Plan says the requested cetuximab and cemiplimab-rwlc are 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 cetuximab and cemiplimab-rwlc. Our reviewer says that the requested cetuximab and cemiplimab-rwlc are not medically necessary. Our physician reviewer found the record indicates that the enrollee has a diagnosis of squamous cell cancer of the skin.  The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation.  No literature from Medicare approved cancer journals were submitted for review.  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 cetuximab and cemiplimab-rwlc have not been met. Therefore, we decided that the Plan does not have to pre-approve cetuximab and cemiplimab-rwlc.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a second oxygen concentrator.  You asked the Plan to pre-approve a second oxygen concentrator. You say that you need a second unit so you can live or use both floors in your house. The Plan denied your request. The Plan says duplicate equipment is not covered.  The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.  The file shows that you have oxygen equipment for use in your home. Medicare does not pay for duplicate or extra oxygen concentrators. Therefore, we decided that the Plan does not have to pre-approve a second oxygen concentrator.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 We decided that the Plan has to pay $150 for the lenses. We decided that the Plan does not have to fully pay for the lenses.   You asked the Plan to pay for the lenses. You say that the total amount of the eyeglasses was $285 but the eyeglass department shows $387.20 because you purchased other items. The Plan says payment cannot be issued without additional information.  We decided that the Plan has to pay $150 for the lenses.   The Plan says that payment cannot be issued without additional information. The documentation submitted supports that you paid more than $150 for lenses. Therefore, we decided that the Plan has to pay $150 toward the lenses and you are responsible for any remaining amount.   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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the prefabricated abutments (D6056) for tooth #2 and #3.  You asked the Plan to pre-approve the prefabricated abutments (D6056). The Plan denied your request. The Plan says the benefit was exhausted on April 9, 2021.  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 a maximum benefit of two abutments per calendar year. The Plan paid for the custom fabricated abutment (D6057) for tooth #4 and #5 provided on April 9, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve the prefabricated abutments (D6056) for tooth #2 and #3.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the eye exam, refraction and ophthalmic diagnostic imaging provided by an out-of-network provider on April 26, 2021.  You asked the Plan to pay for the eye exam, refraction and ophthalmic diagnostic imaging. You say that you reside half the year in a different state and were never informed you needed a PPO or additional policy to be covered. You say that you were not informed you needed a referral, and the bill should be waived considering you were not properly informed. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not approved in advance.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.   The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 the eye exam, refraction and ophthalmic diagnostic imaging provided by an out-of-network provider on April 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a bone replacement graft (D4263), osseous surgery (D4260), and therapeutic parenteral drug (D9610).  You asked the Plan to pre-approve the dental services. You say that you need these services. The Plan denied your request. The Plan says the requested dental services are not listed as covered.  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 bone replacement graft, osseous surgery, and therapeutic parenteral drug are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a bone replacement graft (D4263), osseous surgery (D4260), and therapeutic parenteral drug (D9610).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for periodontal maintenance provided on August 9, 2021.  You asked the Plan to pay for the periodontal maintenance. You say that you want to appeal as this bill should be covered under your plan. 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 periodontal maintenance provided on August 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hotel accommodation and restaurant services provided on May 5, 2021.  You asked the Plan to pay for the overnight stay and meal. You say that you scheduled a ride via your transportation benefit, but they did not show up. You say that you decided to go and stay the night in a hotel and order dinner. You say that you confirmed the ride twice but when they called from an unknown number, you did not pick up the call. You say that the transportation company cancelled your ride as a result. You also say that your plan should pay for this since the facility was 33 miles from your home. The Plan denied your request. The Plan says hotel and restaurant services are not covered by the plan or Medicare.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the overnight stay and meal have not been met. Specifically, hotel and restaurant services are not covered by the Plan or Medicare. Additionally, the record shows that the transportation company called to confirm transportation the night before, however, the call was not answered. Therefore, we decided that the Plan does not have to pay for the hotel accommodation and restaurant services provided on May 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the ostomy supplies you received on July 28, 2021.  You asked the Plan to waive the coinsurance for the ostomy supplies. You say that you do not think you should have to pay for this because you had a blood vessel cut during surgery. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for ostomy supplies.   You have been asked to pay 20% coinsurance for the ostomy supplies. This coinsurance applies regardless of the reason why you need the supplies. 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 ostomy supplies you received on July 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve home infusion therapy services to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve these OON services. You say that you feel you should be allowed to continue with this out of network provider. The Plan denied your request. The Plan says the requested services can be provided by a network provider.  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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve home infusion therapy services to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on July 20, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the laboratory services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says prior authorization was not obtained prior to services being provided.  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 the laboratory services provided on July 20, 2021 by an out-of-network (OON) provider.