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

 
We decided that the Plan does not have to waive the copayment for specialist services provided by a 
participating provider on July 29, 2020. 
 
You asked the Plan to waive the copayment for specialist services. You say that you do not feel like you should 
have to pay for this because it wasn't your normal doctor. The Plan denied your request. The Plan says the 
correct copayment has been applied. 
 
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 $30 
copayment for physician/practitioner services/specialist.  
 
You have been asked to pay a $30 copayment for specialist services. The correct copayment has been applied 
to the services that were provided. Specialist services falls within the physician/practitioner services/specialist 
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 specialist services provided by a 
participating provider on July 29, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network outpatient mental health services provided to 
the enrollee on July 14, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network 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 outpatient 
mental health services provided to the enrollee on July 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on July 
28, 2020 by an OON provider. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you were not informed 
that this provider is OON. The Plan denied your request. The Plan says this service was rendered by an OON 
provider. The Plan also says that care you receive from an out-of-network provider will not be covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the problem 
focused limited oral evaluation provided on July 28, 2020 by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Xgeva injections (J0897). 
 
You asked the Plan to pre-approve Xgeva. You say that the drug is medically necessary to treat the enrollee's 
condition. The Plan denied your request. The Plan says the coverage of the drug is subject to step therapy. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.  
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve the Xgeva injections (J0897).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits provided from April 8, 2020 to May 27, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for OON office visits. You say that you were not informed this provided was out-of-
network. The Plan denied your request. The Plan says these visits were not authorized. 
 
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 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 the office visits provided from April 8, 2020 to 
May 27, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous revascularization, lower extremity and 
related services 
 
You asked the Plan to pre-approve percutaneous revascularization, lower extremity and related services. You 
say that the enrollee was previously approved for an angiogram and you are requesting the full procedure to be 
approved. The Plan denied your request. The Plan says the request for percutaneous revascularization, lower 
extremity (restoration of proper blood flow to your legs) is not considered 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 percutaneous revascularization, lower 
extremity and related services. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the documentation available for review 
does not provide a cohesive narrative with respect to symptoms the enrollee is having, physical examination 
and imaging findings, and assessment and plan based on this data. It has been 4 months since the enrollee's last 
evaluation that makes no mention of the ulcer noted months before. There is documentation that the enrollee 
has no complaints and no pain. There is also documentation in the same paragraph that the enrollee is having 
foot pain.  The physical examination describes palpable pedal pulses but there is an assessment of (ischemic) 
 
 
rest pain. In the records provided, there is no mention of the status of the right toe ulcer noted in June 2020. As 
the documentation of enrollee's history findings, physical exam findings, and treatment rationale are unclear or 
discordant, unable to overturn the health plan determination on the basis of medical necessity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous revascularization, lower extremity and related services have not 
been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous revascularization, 
lower extremity and related services
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the MRI provided on June 24, 2020. 
 
You asked the Plan to waive the copayment for the MRI. You say that it is unfair that insurance paid less than 
what you have to pay. You say that at least 80% should be paid. The Plan denied your request. The Plan says 
the copayment applied 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 $250 
copayment for diagnostic radiology from an in-network provider.  
 
You have been asked to pay a $250 copayment for the MRI. The MRI falls within the "Outpatient diagnostic 
tests and therapeutic services and supplies" 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 the MRI provided on June 24, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 
admission. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 admission to a SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee is with cerebral vascular 
accident (CVA) and respiratory failure, currently in IRF. From a nursing perspective, the enrollee received 
enteral nutrition and medications. The enrollee had stable vital signs. His lungs were clear. Regarding 
rehabilitation services, the enrollee received physical therapy, speech therapy and occupational therapy in the 
acute hospital. The enrollee was at a modified independent to contact guard assist level with functional 
mobility including gait to 80 feet with a rolling walker. The enrollee required varying assist with activities of 
daily living. He remained NPO. 
 
There are identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The 
enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet 
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of admission to a SNF have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the foot orthotics (L3010) provided on  
May 19, 2020. 
 
You asked the Plan to issue reimbursement for the foot orthotics. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that foot orthotics 
are not a covered benefit under your contractual policy or by Medicare for your condition. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to issue reimbursement for the foot orthotics 
(L3010) provided on May 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on July 30, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's primary care did not refer these services.
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 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 physician services provided on July 30, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hereditary cancer gene panel provided on February 12, 
2020. 
 
You asked the Plan to pay for the gene panel. You say that the service is covered by Medicare. The Plan denied 
your request. The Plan says testing for which the enrollee has no symptoms or documented conditions are not 
covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
 
 
The records provided do not show that the results of the testing will be used to determine a specific diagnosis 
or treatment strategy. The test at issue in this appeal was requested solely for screening purposes. Medicare 
does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
hereditary cancer gene panel provided on February 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the immediate mandibular denture and immediate 
maxillary denture provided on August 26, 2020. 
 
You asked the Plan to pay more for the immediate mandibular denture and immediate maxillary denture. You 
say that you were not aware that your dental plan had changed. You also say that you never received any 
documentation regarding the change. The Plan denied your request. The Plan says you have met your annual 
dental allowance of $1,000. 
 
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 Plan offers a $1,000 combined 
allowance for supplemental preventive and comprehensive services every year. The contract says that you are 
responsible for any amount over and above the allowance amount. The record shows that you met the annual 
maximum benefit while processing this claim from the August 26, 2020 date of service, and your annual 
maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay more for the 
immediate mandibular denture and immediate maxillary denture provided on August 26, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an Aprepitant injection (J0185) received 
on July 8, 2020, and a Neulasta injection (J2505) received on July 10, 2020. 
 
You asked the Plan to waive the coinsurance for an Aprepitant injection and a Neulasta injection. You say that 
the enrollee has to take these injections to maintain white blood cell count and fight cancer. The Plan denied 
your request. The Plan says the correct coinsurance was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay 20% coinsurance for Medicare Part B prescription drugs.  
 
The enrollee has been asked to pay $48.83, or 20% of the Medicare-allowed amount of $244.14, for an 
Aprepitant injection, and $556.73, or 20% of the Medicare-allowed amount of $2,783.64, for a Neulasta 
injection. An Aprepitant injection and a Neulasta injection fall within the "Medicare Part B prescription drugs" 
benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract 
with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. 
Therefore, we decided that the Plan does not have to waive the coinsurance for an Aprepitant injection (J0185) 
received on July 8, 2020, and a Neulasta injection (J2505) received on July 10, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve the continuation of inpatient mental health care from December 9, 
2020 and forward. 
 
You asked the Plan to pre-approve the continuation of inpatient mental health care from December 9, 2020 and 
forward. You say that the requested continuation of inpatient mental health care from December 9, 2020 and 
forward is medically necessary. The Plan denied your request. The Plan says that the requested continuation of 
inpatient mental health care from December 9, 2020 and forward is not medically necessary. 
 
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 the continuation of inpatient mental 
health care from December 9, 2020 and forward. Our reviewer says that the requested continuation of inpatient 
mental health care from December 9, 2020 and forward is medically necessary. Our physician reviewer found 
based upon review of the records provided, the continuation of inpatient mental health care for this enrollee 
does meet the criteria for continued acute inpatient mental health treatment for the dates in question of 
December 9, 2020 and forward. This enrollee was not shown to be a danger to herself or others. She was 
showing auditory but no visual hallucinations and is cooperative/compliant with treatment. 
 
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 continuation of inpatient mental health care from December 9, 2020 and 
forward have been met. Therefore, we decided that the Plan has to pre-approve the continuation of inpatient 
mental health care from December 9, 2020 and forward.  
 
 
 
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 pre-approve MRI of the breast for the enrollee.
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your
request. The Plan says this MRI cannot be approved as it is not considered reasonable and necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our reviewer says that the
requested MRI is not medically reasonable or necessary. Our physician reviewer found the lobulated density
was noted on a screening mammogram and further diagnostic workup including added views and ultrasound
has not been performed. As such, MRI is not yet indicated as a standard workup is necessary prior to further
advanced imaging such as MRI can be considered.
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 MRI have not been met. Therefore, we decided that the Plan does not have
to pre-approve MRI of the breast for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture and a mandibular partial 
denture. 
 
You asked the Plan to pre-approve the maxillary and mandibular partial dentures. You say that you are unable 
to eat with your current dentures. The Plan denied your request. The Plan says these services are allowed one 
time every 60 months. The Plan also says that you had these services less than 60 months ago. 
 
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, dentures are limited to one set every 5 
years. The record shows that you received a maxillary partial denture and a mandibular partial denture on 
November 7, 2017, and your dentures benefit has been exhausted. Therefore, we decided that the Plan does not 
have to pre-approve a maxillary partial denture and a mandibular partial denture.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the outpatient mental health services to be provided by 
an out of network (OON) provider. 
 
You asked the Plan to pre-approve the outpatient mental health services. You say that you have seen this 
provider before and would like to go back to her. The Plan denied your request. The Plan says the services are 
not emergent and there are in-network providers available that can provide these services. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the 
outpatient mental health services to be provided by an out of network (OON) provider.