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

We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve routine transportation. You say that you need additional rides to get to your 
appointment. The Plan denied your request. The Plan says the denial of authorization for additional routine 
transportation is correct, because routine transportation beyond 50 one-way trips per calendar year is not 
covered by the Plan. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 50 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up (D2950) and an occlusal guard (D9944). 
 
You asked the Plan to pre-approve the dental service and item. You say that you need the device because you 
grind your teeth at night. The Plan denied your request. The Plan says core build up is not listed as a covered 
service. The Plan says that occlusal guard is not listed as a covered service either. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core 
build up (D2950) and an occlusal guard (D9944).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the physician services on July 22, 2020 and 
July 27, 2020. 
 
You asked the Plan to adjust the copayment for the physician services. You say that you paid a $143.66 
copayment. The Plan denied your request. The Plan says the Plan says you were charged $15 copayments for 
the office visits correctly, however the provider is refunding you your payment minus the copayments. 
 
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 $15 
copayment for Specialist's Office visit.  
 
You have been asked to pay a $15 copayment for each physician services. The physician services fall within 
the Specialist's Office visit 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 adjust the copayment for the 
physician services on July 22, 2020 and July 27, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interlaminar/interspinous process 
stabilization/distraction device. 
 
You asked the Plan to pre-approve the device. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this device is experimental. More research is needed to show 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 the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an interlaminar/interspinous process stabilization/distraction device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on October 17, 
2019. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you paid the office visit 
copayment of $45 at the time of this visit and do not feel that you owe this amount. The Plan denied your 
request. The Plan says the copayment amount you are being charged is correct. 
 
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 $295 
copayment for outpatient surgery at an outpatient hospital facility. This service was performed at an outpatient 
hospital facility; therefore, the outpatient hospital copayment applies to this claim and not the specialist office 
copayment.  
 
You have been asked to pay the allowed amount of $221.41, which is less than the $295 copayment for 
outpatient surgery. Outpatient surgery falls within the Outpatient Surgery and Other Medical Services Provided 
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 outpatient surgery provided on October 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network chiropractic services provided from January 
7, 2020 to July 7, 2020. 
 
You asked the Plan to pay for out of network services. You say that these services should be covered by the 
Plan. The Plan denied your request. The Plan says you did not have prior authorization or referral for out of 
network chiropractic care. 
 
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 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 out of network chiropractic 
services provided from January 7, 2020 to July 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation. 
 
You asked the Plan to pre-approve proton beam radiation. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has 
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 proton beam radiation. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found a clinically meaningful, plausible benefit from proton therapy was not shown in the 
case records, and it seems as though proton therapy is being offered for routine care, outside of a clinical trial. 
Proton therapy will always reduce normal tissue exposure to some extent, but not always in a clinically 
meaningful manner. In order to establish medical necessity, a plausible clinical benefit should be demonstrated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam radiation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam radiation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the IV hydration services provided on June 2, 2020. 
 
You asked the Plan to pay for the IV hydration services (J7030, 96360). You say that the Plan should pay this 
claim. The Plan denied your request. The Plan says the services are 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 the services performed to facilitate hydration are not separately billable.  Based on this 
information, we decided that Medicare rules for coverage of the IV hydration services have not been met. 
Therefore, we decided that the Plan does not have to pay for the IV hydration services provided on June 2, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), the extraction (D7210), 
the primary closure of a sinus perforation (D7261), and the fees for a surgical tray (D9999 x 2) provided on 
September 30, 2019. 
 
You asked the Plan to pay for the dental services. You say that you have chronic sinusitis. You also say that the 
services were necessary. The Plan denied your request. The Plan says the dental services you received are not 
listed as covered services. 
 
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. Additionally, the Evidence of Coverage clearly states that any services 
not listed are not covered. Therefore, we decided that the Plan does not have to pay for the limited oral 
evaluation (D0140), the extraction (D7210), the primary closure of a sinus perforation (D7261), and the fees 
for a surgical tray (D9999 x 2) provided on September 30, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve ten applications of Epifix skin substitute. 
You asked the Plan to pre-approve the additional applications. You say that there has been an ulcer for a few 
months, and it is painful. The Plan denied your request. The Plan says that the plan has already approved five 
applications. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 the additional applications. Our 
reviewer says that the requested additional applications are considered medically reasonable and necessary in 
this case. Our physician reviewer found this should be covered, as treatment with Epifix should be continued 
until the therapeutic goal has been reached. 
 
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 additional applications have been met. Therefore, we decided that the Plan 
has to pre-approve ten applications of Epifix skin substitute.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the radiology services provided on June 
11, 2020. 
 
You asked the Plan to reduce the copayment for the radiology services. You say that last year you paid less for 
the same radiology procedure. The Plan denied your request. The Plan says you were charged this copayment 
correctly and your 2019 copayment was $100 also. 
 
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 $100 
copayment for Outpatient Diagnostic Tests.  
 
You have been asked to pay a $100 copayment for the radiology services. The radiology services fall within the 
Outpatient Diagnostic Tests 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 reduce the copayment for the 
radiology services provided on June 11, 2020.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pay for the physical therapy services rendered from June 22, 2020 to August 
27, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that the therapy cap was met. 
 
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 states that the allowed amount has been reached for therapy. While 
there is a Medicare therapy cap, the services may be allowed if medically necessary. The Plan has not provided 
any medical records to show that the services were not medically necessary and eligible for the therapy cap. 
Therefore, we decided that the Plan has to pay for the physical therapy services rendered from June 22, 2020 to 
August 27, 2020.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient admission. 
 
You asked the Plan to pre-approve inpatient admission. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has 
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 inpatient admission. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review has determined that the requested inpatient admission for a sigmoid 
resection was not medically reasonable or 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 inpatient admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve inpatient admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for wrist hand orthosis (L3916) and shoulder elbow wrist hand 
orthosis (L3960) provided on April 10, 2020. 
 
You asked the Plan to pay for the wrist hand orthosis and shoulder elbow wrist hand orthosis. You say that you 
would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there is 
no evidence of an established relationship between the enrollee and ordering physician. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order or proof of delivery for the supplies provided in this case. 
Additionally, the record does not show any evidence of an established relationship between the member and 
ordering physician. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for wrist hand 
orthosis (L3916) and shoulder elbow wrist hand orthosis (L3960) provided on April 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction and preventive procedure provided on June 25, 
2020. 
 
You asked the Plan to pay for the extraction and preventive procedure. You say that you did not take any child 
to this provider. The Plan denied your request. The Plan says the benefits for the extraction have been satisfied 
and the frequency limitation has been exceeded. The Plan also says that the unspecified preventive procedure 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, unspecified preventive procedure is not 
a covered benefit. The contract also clearly states that extractions are limited to two procedures per calendar 
year. The record shows that you received three extractions on June 25, 2020, two of which were covered by the 
Plan, and your extractions benefit has been exhausted. Therefore, we decided that the Plan does not have to pay 
for the extraction and preventive procedure provided on June 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2750) for tooth # 22. 
 
You asked the Plan to pre-approve the dental service. You say that the tooth under your crown got infected. 
You say that now you need a new crown on this tooth. You also say that this is medically necessary. The Plan 
denied your request. The Plan says 1 crown per tooth every 60 months is covered. The Plan also says that the 
frequency limit has been reached. 
 
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 frequency limit of once per tooth 
every 60 months has been reached. The record shows that you received a crown on tooth # 22 on September 
22, 2019. Therefore, we decided that the Plan does not have to pre-approve a crown (D2750) for tooth # 22.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infusion supplies rendered from February 18, 2020, to 
February 25, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid proof of delivery. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS 
suppliers are required to maintain proof of delivery. 
 
We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 pay for the infusion supplies rendered from February 18, 2020, to 
February 25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient admission provided from December 13, 2019, 
through December 14, 2019. 
 
You asked the Plan to pay for the inpatient admission. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented. 
 
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 
inpatient admission. 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 an inpatient admission provided from December 13, 2019, 
through December 14, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Neulasta Onpro (J2505). 
 
You asked the Plan to pre-approve Neulasta Onpro. 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 follows Medicare rules. Medicare rules say that administration of G-CSF for primary prophylaxis 
should not be used routinely in all chemotherapy patients receiving usual outpatient regimens. 
 
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 Neulasta Onpro. Our reviewer says that 
the medication is not medically necessary. Our physician reviewer found review of guidelines do not support 
the enrollee's chemotherapy regimen is associated with risk of febrile neutropenia greater than 20%.  
Additionally, records do not support the enrollee has increased risk based on the factors outlined in the 
 
 
referenced LCD. Medical necessity cannot be determined. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Neulasta Onpro have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Neulasta Onpro (J2505).