Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric services rendered on January 24, 2019. 
 
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 the claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for these services was not filed until October 20, 2020. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the psychiatric services rendered on January 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endodontic therapy services received on June 9, 2020. 
 
You asked the Plan to pay for the endodontic therapy services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services received are 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. 
 
You received these dental services from an out of network provider. 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 
when received by an out of network provider. Therefore, we decided that the Plan does not have to pay for the 
endodontic therapy services received on June 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transforaminal lumbar interbody fusion (TLIF). 
 
You asked the Plan to pre-approve TLIF. 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 TLIF. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the medical records do not show that the enrollee has had adequate conservative measures. A 
trial and failure of physical therapy is needed. There are no red flags for surgery at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TLIF have not been met. Therefore, we decided that the Plan does not have to 
pre-approve transforaminal lumbar interbody fusion (TLIF).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for paravertebral facet joint injections (64493) 
provided on July 27, 2020. 
 
You asked the Plan to waive the copayment for paravertebral facet joint injections. You say that you should not 
be charged for this service because it took less than 10 minutes. The Plan denied your request. The Plan says 
this processed 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 $295 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital.  
 
You have been asked to pay a $295 copayment for paravertebral facet joint injections, which are considered a 
surgical service. 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 paravertebral facet joint 
injections (64493) provided on July 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodic oral evaluation (D0120), bitewings - four radiographic images (D0274) and prophylaxis - adult (D1110) provided on July 27, 2020, from out-of-network provider.
You asked the Plan to pay for the dental services. You say that you are requesting reimbursement of services rendered. The Plan denied your request. The Plan says the claim for the date of service July 27, 2020, processed correctly per procedure codes D0120, D1110, and D0274. The Plan states per plan benefits providers are paid based on Maximum Allowable Charge (MAC). The Plan states for services covered under the plan, you may still be billed by an out-of-network provider for any amount greater than the MAC payment made by the plan to the provider.
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. Review of the file show that you received a periodic oral evaluation (D0120), bitewings - four radiographic images (D0274) and prophylaxis - adult (D1110) on July 27, 2020, from an out-of-network provider. Providers are paid based on Maximum Allowable Charge (MAC). For services covered under the plan, you may still be billed by an out-of-network provider for any amount greater than the MAC payment made by the plan to the provider. The plan has an Annual Maximum of $1,000.00. An Annual maximum is the maximum dollar amount the dental plan benefit will pay toward the cost of "covered" dental care within the calendar year. After the annual maximum is exhausted, any remaining charges are your responsibility. Code D0120, Total Amount $45.00, Total Allowed $24.00, Plan Paid $24.00, Member Responsibility $21.00, Applied to Annual Maximum $24.00. Code D1110, Total Amount $121.00, Total Allowed $50.00, Plan Paid $50.00, Member Responsibility $71.00,
Applied to Annual Maximum $50.00. Code D0274, Total Amount $73.00, Total Allowed $33.00, Plan Paid $33.00, Member Responsibility $40.00, Applied to Annual Maximum $33.00. The total amount of patient responsibility is $132.00. Therefore, we decided that the Plan does not have to pay for periodic oral evaluation (D0120), bitewings - four radiographic images (D0274) and prophylaxis - adult (D1110) provided on July 27, 2020, from out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal surgery. 
 
You asked the Plan to pre-approve spinal surgery. You say that the requested spinal surgery is medically 
necessary. The Plan denied your request. The Plan says the requested spinal surgery 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 spinal surgery. Our reviewer says that 
the requested spinal surgery is not medically necessary. Our physician reviewer found the enrollee is with 
intractable low back pain that has failed all treatment measures. Criteria for spinal decompression and fusion 
have not been met. There is no spinal instability. There is no imaging showing severe spinal stenosis. Spine 
surgery is not needed at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spinal surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve spinal surgery.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approveintensity modulated radiation therapy (IMRT) with image guided radiation therapy (IGRT).You asked the Plan to pre-approveIMRT with IGRT. You say that the requested IMRT with IGRT is medically necessary.The Plan denied your request. The Plan says that the requested IMRT with IGRT is not medically necessary.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 IMRT with IGRT. Our reviewer says that the requested IMRT with IGRT is medically necessary. Our physician reviewer found IMRT is favorable as it would be furnished in accordance with accepted standards of care for patients with low volume metastatic disease. IGRT is generally needed when delivering IMRT to assure accurate set-up, so the request for IGRT is medically necessary as well.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IMRT with IGRT have been met.Therefore, we decided that the Plan has to pre-approveintensity modulated radiation therapy (IMRT) with image guided radiation therapy (IGRT).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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the x-ray exam of the chest (71046) 
provided on September 29, 2020. 
 
You asked the Plan to waive the copayment for the x-ray exam. You say that you should have a $0 copay 
because you were not given the x-ray at a hospital. The Plan denied your request. The Plan says the facility 
where you received your x-ray exam is classified as and bills as an outpatient facility, not a physician?s office. 
Outpatient x-ray exams are subject to a $110 copayment when they are provided anywhere other than a 
physician?s office.  
 
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 $110 
copayment for outpatient x-ray exams that are not provided at a physician?s office.  
 
You have been asked to pay a $73 copayment for an x-ray exam. An x-ray exam falls within the outpatient 
diagnostic tests benefit category. The location where you received your x-ray is classified as an outpatient 
facility rather than a physician?s office. The amount you have been asked to pay is equal to or less than the 
amount required by the Plan. 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 an x-ray exam of the chest 
(71046) provided on September 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a refraction (92015) provided by a non-preferred provider on 
July 20, 2020. 
 
You asked the Plan to pay for a refraction. You say that this is a covered service. The Plan denied your request. 
The Plan says this service is covered only when provided by a preferred provider. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when provided by a preferred provider. 
 
We looked at the file and the Plan's rules. The refraction at issue was not provided by a preferred provider. 
Based on this information, we decided that the Plan's rules for coverage of a refraction have not been met. 
Therefore, we decided that the Plan does not have to pay for a refraction (92015) provided by a non-preferred 
provider on July 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital outpatient clinic visit services provided on 
February 18, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the hospital outpatient clinic visit services. You say that you would like the plan 
to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered 
benefit. 
 
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 hospital outpatient clinic visit services 
provided on February 18, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 the enrollee does not require the intensity of services provided at an IRF.
Specifically, the enrollee is not shown to require, or to be able to perform, fifteen hours per week of
rehabilitative services with regular physician evaluation. The enrollee's care needs can be met 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tecentriq for the enrollee. 
 
You asked the Plan to pre-approve Tecentriq. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of for Tecentriq 
(Atezolizumab) in the setting of presumed recurrence of SCLC has not been demonstrated in the peer-reviewed 
literature. 
 
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 Tecentriq. Our reviewer says that 
Tecentriq is not medically reasonable and necessary for the enrollee. Tecentriq is not FDA-approved for the 
enrollees diagnosis. Tecentriq is not supported by one of the major drug compendia or by clinical research that 
appears in a CMS-approved medical journal. The use of Tecentriq is not listed as not indicated, not supported 
or not recommended in any of the compendia. Our physician reviewer found that the enrollee's condition does 
not meet Medicare criteria for Tecentriq. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Tecentriq have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Tecentriq for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan (J7321). 
 
You asked the Plan to pre-approve Hyalgan. You say that Hyalgan is medically necessary. The Plan denied 
your request. The Plan says a trial of Orthovisc and Synvisc is required before alternatives can be considered. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Hyalgan. Our reviewer says that 
Hyalgan is not medically necessary. Our physician reviewer found the record does not show a trial of the plan 
preferred drugs or any reason why they would be unsafe or ineffective for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hyalgan (J7321).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora domiciliary or rest home visit provided on September 22, 2020.You asked the Plan to pay forthe domiciliary or rest home visit. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these servicesare not urgent or emergent, nor were they 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 incases 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 servicesat 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 fora domiciliary or rest home visit provided on September 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that there is no mention that you require an intensive and coordinated 
interdisciplinary approach to rehabilitation. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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. You 
do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen 
hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a 
lower level of care. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 
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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that the member is not stable 
to go home and could be harmful to themselves or others. The Plan denied your request. The Plan says that the 
enrollee does not have acute symptoms that require 24 hour care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 psychiatric hospital services. 
Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary for the 
enrollee. It is not expected this enrollee will improve in a reasonable period of time as he is not showing any 
dangerousness to self or others, auditory or visual hallucinations and without aggressive behaviors while not 
showing any acute threats of safety. Our physician reviewer found that the enrollee's condition does not meet 
Medicare criteria for inpatient psychiatric hospital services. 
 
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 psychiatric hospital services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ambulance services to be provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve the ambulance services. You say that the enrollee is unable to get out of bed 
needs dialysis therapy. The Plan denied your request. The Plan says the enrollee is approved for an in-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. 
 
Review of the records received do not indicate that the enrollee is receiving out-of-network dialysis. There are 
in-network provider(s) within a reasonable distance from the enrollee's location that can provide this service or 
item. 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 the ambulance services to be provided by an out-of-network provider.