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

We decided that the Plan has to waive the copayments for hyperbaric oxygen therapy provided from December
10, 2019 to January 20, 2020.
You asked the Plan to waive the copayments for hyperbaric oxygen therapy. You say that you disagree with the
charges. The Plan denied your request. The Plan says that the claims were processed correctly and you are
being charged the correct 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 does not say in clear and accurate terms
how much you should expect to pay for hyperbaric oxygen therapy.
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a $25
copayment for hyperbaric oxygen therapy. The Plan contract does not clearly say how much enrollees must pay
for therapeutic services. This means that the Plan did not follow Medicare rules for disclosure of cost sharing
information. Therefore, we decided that the Plan has to waive the copayments for hyperbaric oxygen therapy
provided from December 10, 2019 to January 20, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays provided on January 8, 2020.
You asked the Plan to pay for the bitewings. You say that the dental office contacted the Plan and was told that
your benefits were by calendar year, not 12 months consecutive. You also say that you were only about a
month short of the 12 consecutive months between this year's bitewings and last years. The Plan denied your
request. The Plan says bitewing x-rays are payable once in any period of 12 consecutive months. The Plan also
says that you were not eligible for additional bitewing x-rays on this date of 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, bitewing x-rays and are limited to one
set, up to four films, every 12 months. The record shows that you received bitewing x-rays on February 13,
2019 and your bitewing x-rays benefit was then exhausted. Therefore, we decided that the Plan does not have
to pay for the bitewing x-rays provided on January 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the full mouth x-ray provided on January 16, 2020.
You asked the Plan to pay for the dental service. You say that the dental office did not tell you what type of xrays
they were taking. You also say that you were not aware that full mouth x-rays were not covered. The Plan
denied your request. The Plan says the full mouth x-ray is not a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the full mouth x-ray is not among
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the full mouth xray
provided on January 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a respiratory assist device provided on February 13, 2020.
You asked the Plan to pay for the respiratory assist device. 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
respiratory assist device. We found no exception that would require the Plan to pay for this item. Therefore, we
decided that the Plan does not have to pay for a respiratory assist device provided on February 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from
August 20, 2018 to August 22, 2018.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the
charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being
charged the correct 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 $360
copayment each day for days 1-5 for inpatient hospital care.
You had an inpatient hospital stay from August 20, 2018 to August 22, 2018. Therefore, you are responsible to
pay a $360 copayment for days 1-2 (August 20, 2018 to August 21, 2018). $360 (copayment) x 2 (inpatient
days) = $720.
You have been asked to pay the total copayment amount of $720 for an inpatient hospital stay. An inpatient
hospital stay falls within the inpatient hospital care 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 an inpatient hospital stay provided from August 20, 2018 to August 22, 2018.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pay for the Irinotecan injection provided on July 8, 2019.
You asked the Plan to pay for the Irinotecan injection. You say that the Irinotecan injection provided on July 8,
2019 was medically necessary. The Plan denied your request. The Plan says that the Irinotecan injection
provided on July 8, 2019 was not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the Irinotecan injection. Our reviewer says
that the Irinotecan injection provided on July 8, 2019 was medically necessary. Our physician reviewer found
the enrollee is with metastatic cholangiocarcinoma on single agent Gemzaar. He had a treatment break from
1/19 to 4/2019. A CT of the chest, abdomen and pelvis confirmed the mass in the pancreatic head is larger, new
metastatic sites and disease progression. The provider wanted to initiate combo chemo treatment with
Irinotecan, fluorouracil and leucovorin.
The use of Irinotecan is not FDA-approved for the enrollee's diagnosis. The use is supported by Guion-
Dusserre JF, Lorgis V, Vincent J, et al. FOLFIRI plus bevacizumab as a second-line therapy for metastatic
intrahepatic cholangiocarcinoma. World J Gastroenterol 2015; 21:2096 and NCCN Guidelines Version 2.2020
Gallbladder Cancer also support the use.
The documentation supports that the drug was safe and effective and otherwise reasonable and necessary 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 the Irinotecan injection have been met. Therefore, we decided that the Plan has
to pay for the Irinotecan injection provided on July 8, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the knee injection provided on December
19, 2019.
You asked the Plan to waive the copayment for the knee injection. You say that you do no agree that the knee
injection treatment is a surgery. The Plan denied your request. The Plan says you have been charged 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 $250
copayment for surgery services provided at an in-network outpatient hospital. For this date of service, you have
been asked to pay the allowed amount of the claim because this amount is less than the $250 copayment for the
knee injection.
You have been asked to pay a $230.09 copayment for the knee injection. The knee injection falls within the
"Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical
centers" benefit category. The record shows the knee injection is considered a surgical procedure.
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 knee injection provided on December 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on December 18, 2019.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says nonemergent,
non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. 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 laboratory services provided on December 18, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the drainage of the skin abscess (10060) provided on August 23, 2019.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says that according to the Medicare policy, the
maximum allowable fee for this service is $0 and thus the claim has been processed correctly.
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. Therefore, we decided that the Plan has to pay for the drainage of the skin
abscess (10060) provided on August 23, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount for the periodic oral evaluation (D0120) and
prophylaxis (D1110) provided on January 10, 2020 by an out of network provider.
You asked the Plan to pay the full amount for the dental services. You say that you did not know that the
provider in this case did not accept your plan. The Plan denied your request. The Plan says the provider in this
case is not a network provider. The Plan says there is a 50% coinsurance for preventive dental services that you
receive out of network. The Plan also says it is your responsibility to verify the provider's network status before
receiving the 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 and the oral exam and prophylaxis are
covered services, there is a 50% coinsurance when you receive these services out of network. This is a
contractual obligation you agreed to when you enrolled in the Plan's dental coverage. Therefore, we decided
that the Plan does not have to pay any additional amount for the periodic oral evaluation (D0120) and
prophylaxis (D1110) provided on January 10, 2020 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgently needed services provided on January 9, 2020.
You asked the Plan to waive the copayment for urgently needed services. You say that you feel that you should only owe a $10 copayment for urgent care visits and the provider should not matter. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $10 copayment for each office visit with a primary care provider and a $45 copayment for each office visit to other providers for urgently needed services. The medical records show that you received urgently needed services on January 9, 2020 at an urgent care facility. Therefore, you are responsible to pay the $45 copayment. You have been asked to pay a $45 copayment for urgently needed services. Urgently needed services fall within the urgently needed services 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 urgently needed services provided on January 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on February
14, 2020.
You asked the Plan to waive the copayment for the laboratory work. You say that you do not have money for
services that should be covered with your office visit. The Plan denied your request. The Plan says you have
been charged 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 $10
copayment for Medicare-covered lab services. For this date of service, you have been asked to pay the allowed
amount of the claim because this amount is less than the $10 copayment for the laboratory work.
You have been asked to pay a $6.10 copayment for the laboratory work. The laboratory work 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 laboratory work provided on February 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that an acute inpatient rehabilitation facility admission is
medically necessary. The Plan denied your request. The Plan says that you do not meet criteria for coverage of
an acute inpatient rehabilitation facility admission.
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 that you are medically stable with no evidence of a need for supervision by a physical
medicine and rehabilitation physician or a need for acute rehabilitation nursing care. While you may benefit
from further physical and occupational therapy, you do not require an intensive therapy program. An inpatient
rehabilitation facility admission is not medically necessary based on your current functional status and medical
stability.
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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on November
12, 2019.
You asked the Plan to waive the copayment for the ambulance ride. You say that you were told you would not
be responsible for the ambulance transportation. The Plan denied your request. The Plan says you have been
charged 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 $225
copayment for Medicare-covered ambulance services per day.
You have been asked to pay a $225 copayment for the ambulance ride. The ambulance ride falls within the
"Ambulance services" 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
ambulance ride provided on November 12, 2019.
Your complaint about the hospital's mistake is not a valid appeal for medical coverage. This part of your
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision
about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test provided on March 4, 2020.
You asked the Plan to pay for the drug test. The Plan denied your request. The Plan says non-emergent, nonurgent
services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
drug test. 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 a drug test provided on March 4, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the cervical spine (72141).
You asked the Plan to pre-approve an MRI of the cervical spine. You say that the service is necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
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 an MRI of the cervical spine. Our reviewer says that the service is medically necessary. Our physician reviewer found the enrollee is noted to have neck/upper back pain with bilateral shoulder/upper extremity pain and intermittent hand numbness/tingling. Physical examination notes no clinical evidence of carpal tunnel syndrome. Plain x-rays have shown some mild arthritis. The enrollee has used both over-the-counter (OTC) medications and prescription medication. The enrollee has participated in physical therapy (PT) and worn wrist braces. Given the neurologic symptoms and failure of conservative therapy, the requested MRI is shown to be medically necessary and reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI of the cervical spine have been met. Therefore, we decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the cervical spine (72141).
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.