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

 
We decided that the Plan does not have to waive the cost sharing for intravenous (IV) infusions, chemotherapy 
administrations, and Part B drug injections provided by a network provider on December 20, 2021. 
 
You asked the Plan to waive the cost sharing for the IV infusions, chemotherapy administrations, and Part B 
drug injections. You say that the maximum out-of-pocket amount was met for the year, and you should not be 
responsible for the cost share from December 21, 2021. The Plan denied your request. The Plan says you have 
been asked to pay the correct cost-sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for services obtained for services obtained from a specialist, or under certain circumstances, 
treatment by a nurse practitioner or physician's assistant of other non-physician health care professionals in a 
specialist's office and 20% coinsurance for each Medicare-covered chemotherapy drug and the administration 
of that drug. 
 
You have been asked to pay $822.44 for the IV infusions, chemotherapy administrations, and Part B drug 
injections. The IV infusions fall within the Physician/Practitioner Services, Including Doctors Office Visits 
benefit category. The chemotherapy administrations and Part B drug injections fall within the Medicare Part B 
Prescription Drugs benefit category. See chart below. 
 
Date of Service Service Allowed Amount Copayment/ 
Coinsurance 
Member Liability 
December 20, 2021 Intravenous 
infusion 
$61.78 $40 $40 
December 20, 2021 Intravenous 
infusion 
$20.52 $40 $20.52 
December 20, 2021 Chemotherapy 
administration 
$59.44 20% $11.89 
December 20, 2021 Chemotherapy 
administration 
$141.40 20% $28.28 
December 20, 2021 Chemotherapy 
administration 
$30.24 20% $6.05 
December 20, 2021 Chemotherapy 
administration 
$68.63 20% $13.73 
December 20, 2021 Injection, aprepitant $219.70 20% $43.94 
December 20, 2021 Injection, 
dexamethasone 
sodium phosphate 
$1.20 20% $0.24 
December 20, 2021 Injection, 
oxaliplatin 
$22.00 20% $4.40 
December 20, 2021 Injection, 
oxaliplatin 
$6.82 20% $1.36 
December 20, 2021 Injection, 
oxaliplatin 
$4.18 20% $0.84 
December 20, 2021 Injection, 
nivolumab 
$13,852.80 20% $671.71  This is 
less than the 
standard amount 
because you met your maximum out-
of-pocket amount. 
Total    $822.44  This is 
less than the actual 
amount. 
 
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 cost sharing for intravenous (IV) infusions, chemotherapy administrations, 
and Part B drug injections provided by a network provider on December 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment eyelid repair (67904) lens spher bifoc plano 
4.00d (V2200) vision supply, accessory and/or service component of another (V2797) anti-reflective coating 
(V2750) provided September 3, 2021 to September 23, 2021. 
 
You asked the Plan to waive the copayment the vision services. You say that you disagree with the denial of 
payment and would like the Plan to reconsider payment. The Plan denied your request. The Plan says the claim 
was reprocessed with the correct cost share was applied per the Evidence of Coverage. 
 
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 $35 
copayment and the Plan covers up to $150 for eyeglasses or contact lenses every year for Vision care.  
 You have been asked to pay $328 ($35 copayment + $294.05 eyeglasses). The Plan had paid the benefit 
maximum of $150 for the eyeglasses. You are responsible for any amount over the $150 benefit. The vision 
services fall within the Vision 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 
eyelid repair (67904) lens spher bifoc plano 4.00d (V2200) vision supply, accessory and/or service component 
of another (V2797) anti-reflective coating (V2750) provided September 3, 2021 to September 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implant 
(D6010) provided on January 31, 2022. 
 
You asked the Plan to pay for the endosteal implant. You say that you were unaware that implants were not 
covered under your plan. The Plan denied your request. The Plan says this service is not 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 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
surgical placement of implant body: endosteal implant (D6010) provided on January 31, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bilateral screening mammography rendered on November 
30, 2021. 
 
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 is a duplicate. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the 
Plan on a separate claim for the same date of service. 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 bilateral screening mammography rendered on November 30, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from September 8, 2021, 
to October 2, 2021. 
 
You asked the Plan to pay for the home health services. You say that the proper documents were submitted 
withing the timeframe for the claim to be paid. The Plan denied your request. The Plan says the RAP claim was 
not submitted within 5 days of the start of service. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Specifically, the record indicates the RAP was not 
submitted within 5 days of the from the start of care date, September 8, 2021. Therefore, we decided that the 
Plan does not have to pay for the home health services provided from September 8, 2021, to October 2, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for acute inpatient hospital services provided to the enrollee from 
December 20, 2021, to December 30, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this should be paid for. The Plan 
denied your request. The Plan says that the previously planned procedures were underwent without 
complication. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the enrollee was a resident of a nursing facility, with a history of chronic obstructive pulmonary 
disease, transient ischemic attack, post-traumatic stress disorder, and tobacco abuse, who was scheduled for an 
outpatient esophagogastroduodenoscopy (EGD) and colonoscopy on 12/20/2021. He was not nothing by mouth 
(NPO), and the procedures were cancelled. He voiced concern over being transferred back to the nursing 
facility over fear of retaliation and there was a concern of elder abuse. He was admitted, underwent the EDG on 
12/22/2021, which demonstrated esophagitis. The colonoscopy was rendered 12/23/21, and he was treated with 
Venofer. A new placement was provided and he was discharged on 12/30/2022. The review has determined 
that the record did show that at the time of inpatient admission the admitting physician reasonably expected 
that the patient's necessary hospital care (including earlier ED and/or observation care) would span two 
midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met.  Therefore, we decided that the Plan has to pay for acute inpatient hospital services provided to the enrollee 
from December 20, 2021, to December 30, 2021.  
 
 
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 2D photographic images (D0350 x 4), oral hygiene 
instruction (D1330), and panoramic x-ray (D0330) provided on January 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that had you known the x-rays were not covered you 
would not have had them done. You also say that you feel you are not responsible for this bill. The Plan denied 
your request. The Plan says the dental services were denied correctly. 
 
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 2D photographic images and oral 
hygiene instruction are not among those covered under this benefit. Additionally, the record shows that 1 
complete series or panoramic x-ray are covered every 5 calendar years. The record shows that the Plan paid for 
a complete series x-ray that you received on the date of service in this case. Therefore, we decided that the Plan 
does not have to pay for the 2D photographic images (D0350 x 4), oral hygiene instruction (D1330), and 
panoramic x-ray (D0330) provided on January 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve osseous surgery (D4261), and bone replacement graft 
(D4263 and D4264) to be provided by a participating provider. 
 
You asked the Plan to pre-approve osseous surgery and bone replacement graft. You say that you would like 
the Plan to pay for this. The Plan denied your request. The Plan says the requested dental services are not 
covered benefits. 
 
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 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
osseous surgery (D4261), and bone replacement graft (D4263 and D4264) to be provided by a participating 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #8 and a mandibular partial 
denture (D5214). 
 
You asked the Plan to pre-approve a crown and mandibular partial denture. The Plan denied your request. The 
Plan says these services are each allowed one time every 60 months. The Plan also says that you received both 
of 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, crowns and are limited to once per 60 
months, and the replacement of lost or broken dentures less than five (5) years of age are excluded from 
coverage. The record shows that you received a crown (D2740) for tooth #8 on September 20, 2018 and a 
mandibular partial denture (D5214) on June 15, 2017, and your crown (D2740) benefit for tooth #8 and 
mandibular partial denture (D5214) benefit have been exhausted. Therefore, we decided that the Plan does not 
have to pre-approve a crown (D2740) for tooth #8 and a mandibular partial denture (D5214).
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the MLH1 gene analysis. We decided that the Plan does not have to pay 
for BCR/ABL1 gene analysis.  
 
You asked the Plan to pay for the MLH1 gene analysis. You say that this testing is medically reasonable and 
necessary. The Plan says that the criteria for coverage have not been met as the diagnosis does not support 
services rendered. 
 
We decided that the Plan has to pay for the MLH1 gene analysis.  
 
The Plan follows Medicare rules. Medicare rules say that genetic testing services are subject to the criteria 
listed in the Medicare rules section.  
 
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 MLH1 gene analysis. Our reviewer 
says that these services were medically necessary based on Medicare criteria. Our physician reviewer found 
that MLH1 gene analysis is part of panel for microsatellite instability and can be used as part of the approval 
for Keytruda. 
 
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 MLH1 gene analysis have been met. Therefore, we decided that the Plan has 
to pay for the MLH1 gene analysis.  
 
We also decided that the Plan does not have to pay for BCR/ABL1 gene analysis. 
 
The Plan follows Medicare rules. Medicare rules say that genetic testing services are subject to the criteria 
listed in the Medicare rules section. 
 
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 BCR/ABL1 gene analysis. Our 
reviewer says that this service was not medically necessary. Our physician reviewer found that the BCR-ABL 
gene analysis is for chronic myelogenous leukemia and was not medically 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 BCR/ABL1 gene analysis have not been met. Therefore, we decided that the 
Plan does not have to pay for BCR/ABL1 gene analysis. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (82728, 83540, 83550, 84100) provided October 
20, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says these services are not eligible for separate payment. 
 
The Plan must follow Medicare rules. Medicare rules say that laboratory services furnished to individuals for 
the treatment of end-stage renal disease (ESRD) are included in the ESRD PPS as Part B services and are not 
paid separately as of January 1, 2011. 
 
We looked at the file and Medicare rules. The lab services are included in the ESRD payment and not 
separately payable. Based on this information, we decided that Medicare rules for coverage of the lab services 
have not been met. Therefore, we decided that the Plan does not have to pay for lab services (82728, 83540, 
83550, 84100) provided October 20, 2021.
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 this is medically necessary. The Plan denied your 
request. The Plan says the services can be safely received in other settings, for example, a skilled nursing 
facility or home with caregiver support and home health services. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 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 on a review of the available records, the enrollee is medically stable, with right ankle 
fusion and debility. The enrollee does not need physician close supervision three times per week (at a 
minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. 
There are no rehab nursing needs identified or documented in the record. At the current functional level, the 
enrollee does not need 3 hours a day five days a week of IRF therapies with interdisciplinary management and 
the rehab needs can be met in an alternate and lower setting such as in an assisted living facility with therapies 
as needed. IRF admission is not medically necessary based on medical stability, lack of medical complexity, 
and lack of rehab nursing needs and current functional level. 
 
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 a Dexcom G6 sensor. 
 
You asked the Plan to pre-approve the Dexcom G6 sensor. You say that the patient has fluctuating blood 
glucose. The Plan denied your request. The Plan says since this drug requires prior authorization, the enrollee is 
required to meet certain criteria before we will cover this drug. The Plan also says that the information 
provided does not indicate that the enrollee is using 3 or more insulin shots per day or is on an insulin pump, or 
requires frequent changes to their insulin dosing. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic continuous glucose monitors (CGMs) 
are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least 
three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose 
testing results and have had an in-person visit with their treating physician to assess adherence to their CGM 
regimen and diabetes treatment plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of the Dexcom 
G6 sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 
sensor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740), and core build up (D2950) provided on 
September 21, 2021. 
 
You asked the Plan to pay for the dental services. You say that you have sent several bills to be reimbursed. 
You also say that you have not received reimbursement or explanation why these bills have not been taken care 
of. The Plan denied your request. The Plan says crowns and core build up 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the crowns and core build up are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown 
(D2740), and core build up (D2950) provided on September 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis tablets. 
 
You asked the Plan to pre-approve Eliquis tablets. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says Eliquis tablets are not covered under the enrollee's 
Medicare Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eliquis tablets.  
 Benefits for Eliquis tablets may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit and is not reasonable or necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.