Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hemlibra. 
 
You asked the Plan to pre-approve Hemlibra. You say that the requested Hemlibra is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail a factor VIII replacement product. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Hemlibra. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found based on the medical records 
provided there is no indication that the enrollee has tried and failed the required drug(s). Based on the medical 
records provided and the Medicare-approved major drug compendia there is no indication that the plan's 
required drug(s) would likely be less effective and/or likely have adverse effects for the 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 Hemlibra have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hemlibra.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance provided on July 03, 2022. 
 
You asked the Plan to pay for ambulance. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for ambulance provided on 
July 03, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for dental services provided on May 5, 2021 
to November 8, 2021 
 
You asked the Plan to waive the cost-sharing for the dental services. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the records indicate the 
enrollees other health plan has the primary responsibility for this claim. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
 The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has [indicate the 
plan's method of coordination]. As the secondary insurer, the Plan cannot be held responsible for the dental 
services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan 
does not have to waive the cost-sharing for dental services provided on May 5, 2021 to November 8, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exam (92014) provided on October 
18, 2022. 
 
You asked the Plan to waive the copayment for the eye exam. You say that you received a regular eye exam. 
The Plan denied your request. The Plan says this cost sharing was charged 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 $40 
copay for exams to diagnose and treat diseases and injuries of the eye under the Vision care benefit category. 
 
You have been asked to pay a $40 copay for the eye exam. This service falls within the Vision care benefit 
category. Specifically, the record shows that the provider filed the claim as a medical exam and evaluation, not 
as a routine eye exam. 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 eye exam (92014) provided 
on October 18, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on September 20, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for psychotherapy. You say that these services are medically necessary. The Plan 
denied your request. The Plan says the enrollee's primary care physician 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 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 psychotherapy provided on September 20, 2022, 
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic radiographic imaging (D0330) provided on May 
6, 2022. 
 
You asked the Plan to pay for the dental services. You say that this is being denied in error. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service September 1, 2021. 
Therefore, we decided that the Plan does not have to pay for panoramic radiographic imaging (D0330) 
provided on May 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0210), localized delivery of 
antimicrobial agents (D4381), gingival irrigation (D4921), drugs dispensed in office (D9630), a core build-up 
(D2950), and periodontal scaling and root planing (D4341), provided on November 1, 2022. 
 
You asked the Plan to pay for dental services. You say that you needed these services done. The Plan denied 
your request. The Plan says the rendered dental services have been correctly denied. 
 
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, D0210, D4381, D4921, D9630, and 
D2950 are not among those covered under this benefit. D4341 was met and exhausted on April 26, 2022. 
Therefore, we decided that the Plan does not have to pay for intraoral imaging (D0210), localized delivery of antimicrobial agents (D4381), gingival irrigation (D4921), drugs dispensed in office (D9630), a core build-up 
(D2950), and periodontal scaling and root planing (D4341), provided on November 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance copayment for diagnostic radiology services 
and a specialist office visit provided on June 14, 2022, to June 20, 2022. 
 
You asked the Plan to waive the coinsurance copayment for diagnostic radiology services and a specialist 
office visit. You say that you disagree with the cost share. The Plan denied your request. The Plan says this cost 
sharing was charged 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 20% 
coinsurance for outpatient diagnostic tests and a $45 copayment for physician/practitioner services/specialist.  
 You have been asked to pay a 20% coinsurance for diagnostic radiology services and a $45 copayment for a 
specialist office visit. The total allowed amount $766.38. You are being asked to pay $75 ($766.38 X 10% = 
$76.63). You are being asked to pay less than the required amount. The total amount you are being asked to 
pay $120 ($75 + $45 = $120). 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 coinsurance copayment for diagnostic 
radiology services and a specialist office visit provided on June 14, 2022, to June 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for semi-precision attachments  placement (D6192) Tooth #04, 
06, and 12 provided on September 16, 2022. 
 
You asked the Plan to pay for dental services. You say that you would like the Plan to cover the billed services. 
The Plan denied your request. The Plan says this service is not covered under your Plan. 
 
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. Semi-precision attachments  
placement (D6192) is not covered under the Plans dental benefits. 
 
   
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 semi-
precision attachments  placement (D6192) Tooth #04, 06, and 12 provided on September 16, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has hold you harmless for a follow up visit. 
 
You asked the Plan hold you harmless for a follow up visit. You say that you never saw this provider. You 
would like this dismissed as the visit never happened. The Plan denied your request. The Plan says that the 
charge is correct. 
 
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. The Plan has not provided medical records or other documentation to support 
that the billed services took place. Therefore, we decided that the Plan has hold you harmless for a follow up 
visit.  
 
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 a core build-up (D2950) provided on October 17, 2022. 
 
You asked the Plan to pay for a core build-up. You say that you needed this service. The Plan denied your 
request. The Plan says the rendered denied service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 a core 
build-up (D2950) provided on October 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 crowns (D2799), 2 core buildup (D2950), a crown 
repair (D2980), a lower partial denture (D5226), 3 surgical placement of implants (D6010), 3 custom fabricated 
abutments (D6057), 3 crowns supported by an abutment (D6058), 2 bone grafts at time of implant placement 
(D6104), and 6 resin applications to desensitize root (D9911). 
 
 You asked the Plan to pre-approve these dental services. You say that you are requesting help for the dental 
services because you have been in pain and not able to eat. The Plan denied your request. The Plan says the 
services you are requesting are 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 pre-approve 2 
crowns (D2799), 2 core buildup (D2950), a crown repair (D2980), a lower partial denture (D5226), 3 surgical 
placement of implants (D6010), 3 custom fabricated abutments (D6057), 3 crowns supported by an abutment 
(D6058), 2 bone grafts at time of implant placement (D6104), and 6 resin applications to desensitize root 
(D9911).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 16, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that these services are medically necessary. The Plan 
denied your request. The Plan says prior authorization was not obtained by the enrollee's primary care 
physician. 
 
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 an office visit provided on August 16, 2022, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite-four or more surfaces, posterior 
(D2394), and pin retention-per tooth (D2951) provided on October 14, 2022. 
 
You asked the Plan to pay for the resin-based composite and pin retention. You say that you need help with this 
bill as you now live on social security. The Plan denied your request. The Plan says these services are not 
covered by the Plan's dental 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 pay for a resin-
based composite-four or more surfaces, posterior (D2394), and pin retention-per tooth (D2951) provided on 
October 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of lumbar spine 
without contrast (72148). 
 
You asked the Plan to pre-approve MRI of lumbar spine without contrast. You say that the MRI is medically 
necessary. The Plan denied your request. The Plan says the enrollee has not seen the provider since October 27, 
2021. 
 
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 MRI of lumbar spine without contrast. 
Our reviewer says that the MRI is not medically necessary. Our physician reviewer found that there is no 
interval physical examination or documentation of interval therapies tried.  The rational for repeating the MRI 
without new physical findings or new symptoms is unclear. The request is deemed not medically reasonable 
and 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 MRI of lumbar spine without contrast have not been met. Therefore, we decided 
that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of lumbar spine without contrast 
(72148).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from January 17, 2023, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from January 17, 2023, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
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 inpatient psychiatric care from January 
17, 2023, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental 
health treatment beyond the date in question of January 17, 2023, forward. Our physician reviewer found the 
enrollee did not require inpatient mental health treatment beyond January 17, 2023, as she was not a danger to 
herself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active 
treatment was taking place beyond the date in question. It did not appear that the services for the dates in 
question were reasonably expected or medically necessary to improve the enrollees condition or for the 
purpose of 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 inpatient psychiatric care from January 17, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from January 17, 
2023, forward.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, and 88360 billed for date of 
service January 25, 2022. 
 
You asked the Plan to pay for procedure code(s) 88341, 88342, and 88360. You say that these services were 
medically necessary. The Plan denied your request. The Plan says this code is included in the facility payment 
and is not separately payable.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342, and 
88360. This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88341, 
88342, and 88360. Based on this information, we decided that Medicare rules for coverage of procedure code 
88341, 88342, and 88360 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code(s) 88341, 88342, and 88360 billed for date of service January 25, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a negative pressure wound therapy electrical pump 
(E2402) and wound care set (A6550). 
 
You asked the Plan to pre-approve a negative pressure wound therapy electrical pump and wound care set. You 
say that the services are necessary. The Plan denied your request. The Plan says based on the documentation 
provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a Negative Pressure Wound Therapy pump (E2402) 
and supplies (A6550, A7000) are covered when specific criteria are 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 a negative pressure wound therapy 
electrical pump and wound care set. Our reviewer says that the services are not medically necessary. Our 
physician reviewer found the records reveal the enrollee having been using a negative pressure wound therapy 
pump for the past 4 months without notable improvement in the wound to suggest any benefit from its use. The 
negative pressure wound therapy electrical pump and wound care set were requested for extended use. 
However, as it has not been shown to lead to improved clinical outcomes with recent 4-month use which is 
sufficient time to determine if it will help or not, this enrollee does not meet criteria for this device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a negative pressure wound therapy electrical pump and wound care set have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a negative pressure wound therapy 
electrical pump (E2402) and wound care set (A6550).