Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda and Tecentriq for the enrollee. 
 
You asked the Plan to pre-approve Keytruda and Tecentriq. You say that this is medically necessary. The Plan 
denied your request. The Plan says that the clinical value and effectiveness of Keytruda combined with 
Tecentriq in the setting of Stage IV hepatocellular carcinoma with bone metastasis 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 Keytruda and Tecentriq. Our reviewer 
says that Keytruda and Tecentriq are not medically reasonable and necessary. Keytruda and Tecentriq are not 
FDA-approved for the enrollees diagnosis. The use of Keytruda and Tecentriq are not supported by one of the 
major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services 
approved medical journal. Our physician reviewer found that the enrollee's condition does not meet criteria for 
coverage of Keytruda and 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 Keytruda and Tecentriq have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Keytruda and Tecentriq for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the scaling and root planing (D4342 x 2), and extraction 
(D7140 x 3) provided on November 5, 2021. 
 
You asked the Plan to pay for the dental services. You say that the services you received are covered at 50%. 
You also say that the provider is in network. The Plan denied your request. The Plan says scaling and root 
planing and extraction are not listed as covered services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the scaling and root planing and extraction are not among those covered under this benefit. Additionally, the record shows that you are not 
enrolled in the optional supplemental dental rider that would cover these services. Therefore, we decided that 
the Plan does not have to pay for the scaling and root planing (D4342 x 2), and extraction (D7140 x 3) 
provided on November 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital services from March 30, 2022, 
through March 31, 2022. 
 
You asked the Plan to pre-approve inpatient hospital services from March 30, 2022, through March 31, 2022. 
You say that these services are medically necessary. The Plan denied your request. The Plan says that inpatient 
services were not necessary. 
 
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 pre-approve inpatient hospital services from March 
30, 2022, through March 31, 2022. Our reviewer says that inpatient hospital services from March 30, 2022, 
through March 31, 2022, are not medically reasonable and necessary. You underwent workup for stroke 
between 3/30/22 and 3/31/22 and your MRI was negative for acute changes. Vitals were stable on these dates 
and mental status was improving during workup and conservative treatment during these days. There was no 
indication prior to admission that you would require hospital services that would likely cross 2 midnights. Our 
physician reviewer found that your condition does not meet criteria for coverage of inpatient hospital services 
from March 30, 2022, through March 31, 2022. 
 
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 hospital services from March 30, 2022, through March 31, 2022, have 
not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital services from 
March 30, 2022, through March 31, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance service, basic life support, 
emergency transport (A0425, A0429) provided on November 30, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $440 
copayment for each Medicare-covered one-way trip by ground ambulance.  
 
You have been asked to pay $354.77 for the Medicare-covered one-way ground ambulance trip provided. This 
is the Plans allowed amount for this service which is less than the applicable copayment.  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 service, basic life support, emergency 
transport (A0425, A0429) provided on November 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller with harness, electronic
connection, and footplate width extensions.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that an expandable controller with harness and
electronic connection is used to control multiple power options. The rules say that footplates are described by
codes K000, K0041, or K0042.

We looked at the file and Medicare rules. The file shows that the requested expandable controller with harness
and electronic connection are not needed to control the approved power options. The requested footplates have
not been requested with the correct procedure code and cannot be approved. Therefore, we decided that the
Plan does not have to pre-approve an expandable controller with harness, electronic connection, and footplate
width extensions.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit (99326) provided on August 
5, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that since the member was in a nursing 
facility, the doctor was not responsible to get authorization. You also say that the nursing home is responsible 
to obtain prior authorization for their patients, which should cover medical treatments by the provider. The Plan 
denied your request. The Plan says this provider is out-of-network with the Plan, and authorization was not 
obtained prior to the services being rendered. 
 
 
 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 a domiciliary or rest home visit (99326) provided 
on August 5, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Laboratory Tests provided on May 7, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Laboratory Tests. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says prior authorization is required for an out-of-network 
office visit. 
 
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 Laboratory Tests provided on May 7, 2021 by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180 x 2) 
provided from January 12, 2021, to July 20, 2021. 
 
You asked the Plan to pay for the comprehensive periodontal evaluations. You say that you had tissue grafting 
before Medicare. You say that your dentist advised you would always need to have the periodontal cleaning. 
You say that this service was paid last year. You also say that you do not understand why this is being denied 
now. The Plan denied your request. The Plan says comprehensive periodontal evaluation is not listed as 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 comprehensive periodontal 
evaluation is not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for the comprehensive periodontal evaluation (D0180 x 2) provided from January 12, 2021, to July 20, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a specialist office visit and X-rays of the 
ankle provided on November 8, 2021. 
 
You asked the Plan to reduce the copayment for the specialist office visit and X-rays. You say that you feel 
only the specialist visit copayment should apply. 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 $35 
copayment per visit with a specialist. Your contract with the Plan also clearly says that you must pay a $20 copayment for X-rays and ultrasounds. 
 
You have been asked to pay a $35 copayment for the specialist office visit. The specialist office visit falls 
within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. You have also 
been asked to pay a $20 copayment for the X-rays. The X-rays fall within the Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies benefit category. The total for the visit is $55. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to reduce the copayment for a specialist office visit and X-rays of the ankle provided on November 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit (Q5106). 
 
You asked the Plan to pre-approve Retacrit. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not covered for the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that erythropoiesis stimulating agent (ESA) treatment 
is not reasonable and necessary for beneficiaries with anemia associated with the treatment of acute and 
chronic myelogenous leukemias. 
 
We looked at the file and Medicare rules. The record shows that the enrollee has been treated for acute 
myelogenous leukemia. Based on this information, we decided that Medicare rules for coverage of Retacrit 
have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit (Q5106).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Prescription drugs and outpatient services 
on May 19, 2021 to September 20, 2021. 
 
You asked the Plan to waive the copayment for Prescription drugs and outpatient services. You say that you 
were not told that I would have anything to pay. The Plan denied your request. The Plan says the cost share 
amount you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $125 
copayment, 20% coinsurance, a $750 deductible for Prescription drugs and outpatient services. The claims for 
dates of service May 19, 2021 and June 23, 2021 applied a 20% coinsurance for the Part B prescription drug 
and applied $110.99 to your years plan deductible since you hadnt met your 2021 years plan deductible prior 
to these servies.  However, you had met your yearly plan deductible by September 20, 2021 so the claim 
applied just the 20% coinsurance for Part B prescription drug. The allowed amount of the claim is $557.97. 
However, after the deductible was met the remaining amount of the claim is $266.98. You have been asked to pay a $125 copayment, 20% coinsurance, a $750 deductible for Prescription drugs and 
outpatient services. Prescription drugs and outpatient services falls within the Outpatient surgery, including 
services provided at hospital outpatient facilities and ambulatory surgical centers and Medicare Part B 
prescription drugs benefit categories. 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 Prescription drugs 
and outpatient services on May 19, 2021 to September 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the cost share liability for the walker (E1399) purchased on 
June 10, 2021. 
 
You asked the Plan to adjust the cost share. You say that you are requesting a reconsideration of the Plan's 
denial for additional payment. The Plan denied your request. The Plan says the cost share has been applied 
correctly to the item provided. 
 
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 a 20% coinsurance for durable medical equipment.  
 
The enrollee has been asked to pay a $12.52 coinsurance (Medicare allowed amount of $62.62 x 20% 
coinsurance) for the durable medical equipment provided.  The Plan issued reimbursement to the enrollee in the amount of $50.10 for the durable medical equipment 
purchased. This amount reimbursed to the enrollee and the coinsurance liability of $12.62 equals $62.62, which 
is the Medicare allowed amount for this item purchased. 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 adjust the cost 
share liability for the walker (E1399) purchased on June 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the maximum-out-of-pocket for advanced imaging services 
provided on November 5, 2021. 
 
You asked the Plan to waive the maximum-out-of-pocket for the advanced imaging services. You say that the 
services should be covered as you disagree with the charges. The Plan denied your request. The Plan says the 
maximum-out-pocket was not met at the time of services because one of your previous claims was reprocessed 
retroactively causing your maximum-out-of-pocket to not be met. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $3,900 maximum-out-of-pocket which applies to Outpatient 
diagnostic tests and therapeutic services and supplies.  
 
 
  The item or service you asked the Plan to waive the maximum-out-of-pocket for falls within the benefit 
category Outpatient diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare 
rules by clearly disclosing in the contract that there is a $3,900 maximum-out-of-pocket which applies to 
Outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation 
that had not been met at the time the advanced imaging services was received on November 5, 2021. Therefore, 
we decided that the Plan does not have to waive the maximum-out-of-pocket for advanced imaging services 
provided on November 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from 
September 3, 2021, to September 24, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you do not think it 
is fair to charge that amount. The Plan denied your request. The Plan says the enrollee has 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 $325 per 
day for days 1-6 and $0 per day for additional days for each benefit period.  
 The file shows that you were in the hospital from September 3, 2021, to September 24, 2021. Therefore, you 
have been asked to pay $325 per day for the first 6 days of inpatient hospital services. The total for your stay is 
$1,950 ($325 copayment x 6 days = $1,950). The inpatient hospital services fall 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 inpatient hospital services 
provided from September 3, 2021, to September 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo. 
 
You asked the Plan to pre-approve Opdivo. You say that this is medically necessary. The Plan denied your 
request. The Plan says this use is not supported. 
 
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 Opdivo. Our reviewer says that the 
requested use of Opdivo is not supported. Our physician reviewer found the requested use of Opdivo is not 
FDA-approved, supported by one of the major drug compendia, or supported by clinical research for the 
enrollee's diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Opdivo.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a therapeutic prophylactic or a diagnostic injection provided 
on October 15, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a therapeutic prophylactic or a diagnostic injection. You say that it was 
medically necessary to treat the enrollee and you would like the claim to be reprocessed for payment. The Plan 
denied your request. The Plan says the rendering provider is an out-of-network provider and there was no 
referral from an in-network provider or an approved authorization. Also, the service rendered was not urgent or 
emergent. 
 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 a therapeutic prophylactic or a diagnostic injection 
provided on October 15, 2021, by an out-of-network (OON) provider.