Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy visits provided on January 05, 2022, to 
January 31, 2022. 
 
You asked the Plan to pay for physical therapy visits. You say that this was medically necessary and should be 
covered. 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 physical therapy visits 
provided on January 05, 2022, to January 31, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care service provided on 
August 26, 2022, to August 27, 2022. 
 
You asked the Plan to waive the copayment for emergency care service. You say that you are disputing the 
share cost. 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 $90 
copayment for Emergency care. 
 
You have been asked to pay a $90 copayment for emergency care service. This item/service falls within the 
Emergency 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 emergency care 
service provided on August 26, 2022, to August 27, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on August 
17, 2022. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you disagree with the 
copayment. 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 $325 
copayment for outpatient surgery/outpatient hospital facility.  
 
You have been asked to pay a $325 copayment for an outpatient surgery. This item/service falls within the 
outpatient surgery/outpatient hospital facility 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 outpatient surgery provided on August 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on August 8, 
2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you are disputing the share 
cost. 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 $375 
copayment for outpatient hospital services.  
 
You have been asked to pay $375 copayment for outpatient surgery. This item/service falls within the 
outpatient hospital 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 outpatient 
surgery provided on August 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on August 15, 
2022. 
 
You asked the Plan to waive the copayment for the office visit. You say that you pay a high premium and 
should not have to pay to see your doctor. 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 $10 
copayment for physician/practitioner services, including doctors office visits (PCP). 
 
You have been asked to pay a $10 copayment for the office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits (PCP) 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 office visit provided on August 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a facility visit provided on September 08, 2022. 
 
You asked the Plan to pay for a facility visit. You say that we depend on the facility staff to verify eligibility 
and to obtain authorization. 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 a facility visit provided 
on September 08, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from May 
28, 2021, to June 2, 2021. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the DRG was updated.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code N17.9. 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 inpatient hospital services at the DRG originally billed. Our 
reviewer says that the services at issue in this case were not supported by the medical records. Our physician 
reviewer found that the review indicates that the enrollee's renal function improved with fluid therapy and 
correction of hyperglycemia. The review has determined that the documentation did not support N17.9 - acute 
kidney failure, unspecified.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from May 28, 2021, to June 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral exam (D0150) and the complete 
series of intraoral x-rays (D0210) provided on August 30, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services were necessary. 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 June 29, 2022. Therefore, 
we decided that the Plan does not have to pay for the comprehensive oral exam (D0150) and the complete 
series of intraoral x-rays (D0210) provided on August 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient stay provided on June 13, 2022. 
 
You asked the Plan to pay for an inpatient stay. You say that this was medically necessary and should be 
covered. 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 an inpatient stay 
provided on June 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intravenous sedation (D9239 and D9243) and 
alveoloplasty (D7320) provided by a participating provider. 
 
You asked the Plan to pre-approve intravenous sedation and alveoloplasty. You say that you would like the 
Plan to cover this. The Plan denied your request. The Plan says the requested services 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 
intravenous sedation (D9239 and D9243) and alveoloplasty (D7320) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation. 
 
You asked the Plan to pre-approve additional non-emergency transportation. You say that you need additional 
trips to go to appointments. The Plan denied your request. The Plan says as of November 23, 2022, you have 
used or scheduled 30 one-way trips. The Plan also says additional routine transportation trips beyond the 30 
trips allowed by the Plan is not a covered benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 30 one-way trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation for the 2022 benefit 
year. Therefore, we decided that the Plan does not have to pre-approve additional non-emergency 
transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical placement of implant body (D6010). 
 
You asked the Plan to pre-approve a surgical placement of implant body (D6010). You say that when you chew 
the food you are having a hard time. The Plan denied your request. The Plan says this service is not covered 
under your benefit 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. 
 
 
  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 a 
surgical placement of implant body (D6010).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the pulp cap-indirect (excluding final 
restoration) (D3120 x 3), porcelain crowns (D2740 x 2), core buildups, including any pins when required 
(D2950 x 2), and the gingivectomy or gingivoplasty to allow access for a restorative procedure, per tooth 
(D4212 x 2) provided on January 3, 2022. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are 
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 services provided are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to issue reimbursement for 
the pulp cap-indirect (excluding final restoration) (D3120 x 3), porcelain crowns (D2740 x 2), core buildups, 
including any pins when required (D2950 x 2), and the gingivectomy or gingivoplasty to allow access for a 
restorative procedure, per tooth (D4212 x 2) provided on January 3, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Obinutuzumab and Bendamustine. 
 
You asked the Plan to pre-approve Obinutuzumab and Bendamustine. You say that the services are 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. 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 Obinutuzumab and Bendamustine. Our 
reviewer says that the services are medically necessary. Our physician reviewer found the combination of 
obinutuzuma and bendamustine use is supported by one of the major drug compendia or by clinical research 
that appears in a CMS-approved medical journal. Rituximab is not requested due to an adverse reaction. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Obinutuzumab and Bendamustine have been met. Therefore, we decided that 
the Plan has to pre-approve Obinutuzumab and Bendamustine.  
 
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 limited oral exam (D0140), intraoral - periapical first 
radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230), and extraction, 
erupted tooth or exposed root (elevation and/or forceps removal) (D7140) provided on August 16, 2022, and 
August 18, 2022. 
 
You asked the Plan to pay for the limited oral exam, first periapical x-ray, additional periapical x-ray and tooth 
extraction. You say that these services were necessary to evaluate your dental problems. The Plan denied your 
request. The Plan says these services are not covered under your 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 the 
limited oral exam (D0140), intraoral - periapical first radiographic image (D0220), intraoral - periapical each 
additional radiographic image (D0230), and extraction, erupted tooth or exposed root (elevation and/or forceps 
removal) (D7140) provided on August 16, 2022, and August 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS HF system. 
 
You asked the Plan to pre-approve the CardioMEMS HF system. You say that the requested CardioMEMS HF 
system is medically necessary. The Plan denied your request. The Plan says the requested CardioMEMS HF 
system is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CardioMEMS HF system. Our 
reviewer says that the requested CardioMEMS HF system is not medically necessary. Our physician reviewer 
found the CardioMEMS device was approved by the Food and Drug Administration (FDA) in 2014 and 
consists of a sensor device placed in the pulmonary artery to allow measurement of pulmonary artery pressure 
in the management of patients with congestive heart failure (CHF). The clinical study on which FDA approval 
was based showed improved clinical outcomes and decreased hospitalizations in patients in whom the 
CardioMEMS system was implanted, reflecting a patient population with preserved ejection fraction and was 
somewhat limited in scope. Subsequent follow-up studies remain encouraging and suggest an improvement in 
heart failure symptoms with the use of the device. In addition, published expert opinion in the cardiology literature is supportive of the clinical usefulness of CardioMEMS.  Nonetheless, there remains a dearth of 
randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of 
CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not be 
considered medically appropriate and necessary in this enrollees clinical management. 
 
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 CardioMEMS HF system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the CardioMEMS HF system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye and medical exam provided on July 19, 2022. 
 
You asked the Plan to pay for the eye and medical exam. You say that you are a diabetic and require an annual 
diabetic eye exam. You say this should be a covered service. The Plan denied your request. The Plan says the 
provider was out-of-network.  
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when received by a network provider. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the eye and medical exam have not been met. 
Therefore, we decided that the Plan does not have to pay for the eye and medical exam provided on July 19, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete mandibular denture (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that your full lower denture fell off and broke. 
You also say that you need to have the lower denture desperately as you have no teeth on the bottom jaw. 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 8, 2020. 
Therefore, we decided that the Plan does not have to pre-approve a complete mandibular denture (D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit services (99202) provided on August 29, 
2022. 
 
You asked the Plan to pay for procedure code 99202. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a new patient is a patient that has not been seen 
by a physician in the same group of the same specialty within the prior three years. 
 
In this case, the enrollee was seen by a provider within the same group practice and specialty as identified by the Tax Identification number, Taxonomy number, and the National Provider Identifier number for services 
billed on April 20, 2021. This is not a new patient per Medicare rules. Therefore, we decided that the Plan does 
not have to pay for the office visit services (99202) provided on August 29, 2022.