Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oncology services from an out-of-network (OON) provider.
You asked the Plan to pre-approve these services. You say that you would like to continue seeing this provider. The Plan denied your request. The Plan says the services are available from network providers.
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 oncology services from an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the chemotherapy infusion provided on January 14, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the chemotherapy infusion. You say that the service was medically necessary. 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 chemotherapy infusion provided on January 14, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fluoride application provided on June 7, 2021.
You asked the Plan to pay for the fluoride application. You say that payment of $40 will not exceed the amount of $2,000 intended for dental care. You say that the $40 that was not covered should be paid. 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 fluoride application provided on June 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) provided on June 17, 2021.
You asked the Plan to pay for the complete series of intraoral x-rays. You say that you did not ask for the complete x-rays, and the person who provided them said they were certain the Plan would cover this service. You also say that you should not be held responsible and cannot pay for this service. The Plan denied your request. The Plan says this service is not covered. The Plan also says that you did not contact the Plan prior to this date of service to verify benefits and provider eligibility.
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 complete series of intraoral x-rays (D0210) provided on June 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the implant (D6010) provided on June 7, 2021.
You asked the Plan to pay for the dental service. You say that your book says the dental plan will pay $1,000
per benefit period. You also say that this amount should be paid. The Plan denied your request. The Plan says
implants are not listed as a covered dental 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 implant is not among those covered
under this benefit. Therefore, we decided that the Plan does not have to pay for the implant (D6010) provided
on June 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chemotherapy therapy administration (96413, 96415) provided on April 30, 2021.
You asked the Plan to pay for chemotherapy therapy administration. You say that similar services were previously paid. The Plan denied your request. The Plan says these codes are not supported.
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 96413 is chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug. The definition of 96415 is chemotherapy administration, intravenous infusion technique; each additional hour (List separately in addition to code for primary procedure).
We find that CPT codes 96413 and 96415 are not supported in the medical record. Specifically, the time spent on chemotherapy administration is not documented in the records. Based on this information, we decided that Medicare rules for coverage of chemotherapy therapy administration have not been met. Therefore, we decided that the Plan does not have to pay for chemotherapy therapy administration (96413, 96415) provided on April 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99204) and the electrocardiogram (93000) rendered by the out-of-network (OON) provider on April 6, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. The Plan did not pre-approve the services at issue.

We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the office visit (99204) and the electrocardiogram (93000) rendered by the out-of-network (OON) provider on April 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for cleaning (D1110), oral evaluation (D0120), and bitewing xrays
(D0274) provided on May 12, 2021.
You asked the Plan to pay for the dental services. You say that you are not comfortable seeking out a new
dentist during the coronavirus. You also say that you would rather just not go. The Plan denied your request.
The Plan says the provider in this case does not participate with the Dental Plan. The Plan also says that if you
receive services from a dentist that does not participate in the dental plan's network you will be responsible for
the full cost of those services and no payment will be made.
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 dental services you received are not
among those covered under this benefit when they are performed by a non-participating dental provider.
Therefore, we decided that the Plan does not have to pay for cleaning (D1110), oral evaluation (D0120), and
bitewing x-rays (D0274) provided on May 12, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the emergency room visit provided on April 16, 2021.
You asked the Plan to reduce the copayment for the emergency room visit. You say that according to your benefits, x-rays have a $20 copayment. The Plan denied your request. The Plan says you have been asked to pay 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 $90 copayment per visit for emergency care.
You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The record shows the x-rays were received during your emergency room visit. 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 copayment for the emergency room visit provided on April 16, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency care provided on June 12, 
2021. 
 
You asked the Plan to waive the copayment for the emergency care. You say that you have other coverage. The 
Plan denied your request. The Plan says you were charged the copayment correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for Emergency Care.  
 
You have been asked to pay a $90 copayment for the emergency care. 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 emergency care provided on June 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and interpretation (D0364) and consultation (D9310), or pay more for the first intraoral periapical x-ray (D0220) provided on June 1, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the cone beam CT capture and interpretation and consultation, and to pay more for the first intraoral periapical x-ray. You say that you believe that the consultation should have been covered. The Plan denied your request. The Plan says the cone beam CT capture and interpretation and consultation are not covered. The Plan also says that the first intraoral periapical x-ray is partially covered, and you must pay the outstanding amount because this was provided by an OON dentist.
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 cone beam CT capture and interpretation (D0364) and consultation (D9310) are not among those covered under this benefit. You are also responsible for the difference between the billed amount and allowed amount for covered dental services that are received OON. Therefore, we decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and interpretation (D0364) and consultation (D9310), or pay more for the first intraoral periapical x-ray (D0220) provided on June 1, 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 the anesthesia for corneal transplant (00144) provided on December 8, 2020.
You asked the Plan to pay for the anesthesia for corneal transplant. You say that this service was medically necessary. The Plan denied your request. The Plan says this service is excluded as experimental/investigational or not generally recognized according to professional standards of safety and effectiveness
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 pay for the anesthesia for corneal transplant. 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 underwent eye surgery under block anesthesia. The provided records do not support the medical necessity and reasonableness, as defined by Medicare rules, of the requested service for the enrollee's condition. The elements of the coverage criteria were not satisfied. 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 anesthesia for corneal transplant have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia for corneal transplant (00144) provided on December 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.
You asked the Plan to pre-approve Vertiflex. You say that the enrollee meets all indications for this procedure. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because Vertiflex is experimental/investigational.
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 Vertiflex. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental, more research is needed to show its safety and efficacy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trulance.
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 self-administered drugs are not covered.
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 Trulance.
Benefits for these services 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 Venofer.
You asked the Plan to pre-approve Venofer. You say that this drug is medically necessary for the enrollee's
condition. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage.
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 Venofer. Our reviewer says that the
requested drug is not medically reasonable and necessary. Our physician reviewer found that the enrollee is a
60-year-old male with diagnosis of hypertension, dyslipidemia, class II obesity, degenerative joint disease, and
mild macrocytic anemia. The member does not have end stage renal disease and is not under treatment with
erythropoietin. His Hgb has dropped 7% since February 2019 despite oral iron and a negative GI work up. The
last problem-oriented blood tests revealed a normal Iron level (86 mcg/dl), normal Ferritin (156 ng/ml), and
normal Transferrin saturation (31%). The member has macrocytic anemia without evidence of iron deficiency.
The review has determined that the documentation does not support that Venofer is medically reasonable and
necessary for the patient. The documentation does not support that Venofer is safe and effective for the patient.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Venofer have not been met. Therefore, we decided that the Plan does not have
to pre-approve Venofer.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Opdivo.
You asked the Plan to pre-approve Opdivo. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says medical studies have not proven that the requested drug is helpful for treatment of the enrollee's condition.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Opdivo. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found the enrollee has been diagnosed with angiosarcoma of the breast. In this case, the requested drug is not FDA-approved for the enrollee's condition. Furthermore, Opdivo has no compendia support for angiosarcoma. There is no phase II/III literature to support the requested drug. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to pre-approve Opdivo.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) services you received on April 24, 2021, to April 25, 2021.
You asked the Plan to waive the copayment for the ER services. You say that this copayment should be waived because you were kept overnight. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that you were not admitted into the hospital but were kept in the ER under observation.
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 $90 copayment for emergency room visits.
You have been asked to pay a $90 copayment for the ER services. Records show that you were not formally admitted to the hospital, so you do not meet criteria to have this copayment waived. 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 emergency room (ER) services you received on April 24, 2021, to April 25, 2021.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the enrollee is below his prior level of function. You say that the enrollee needs assistance with activities of daily living, walking, and transfers. You say that you cannot care for the enrollee at home. The Plan denied your request. The Plan says that the enrollee's current needs can be safely managed with an alternate level of care. The Plan says that SNF care is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the criteria for coverage have been met. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does have documented skilled therapy needs. While the enrollee is ambulatory, he is doing so with multiple rest breaks and safety supervision. Given his age and diagnosis, a period of skilled therapy is medically necessary and reasonable to establish a maintenance program and/or prevent deterioration of the enrollee's condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
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.