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

We decided that the Plan does not have to waive the copayment for the x-ray you had on July 7, 2021.
You asked the Plan to waive the copayment for the x-ray. You say that this copayment should be $0 because you received this x-ray at a radiology place, not an office. The Plan denied your request. The Plan says you were charged this copayment 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 basic radiological services in an office. You have been asked to pay a $10 copayment for the x-ray. We confirmed that the provider from whom you received this service is considered a specialist office. The provider is considered a medical practice and their National Provider number indicates that they are part of a multi-specialty group. As a result, this provider is not considered a freestanding radiology facility. 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 x-ray you had on July 7, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nuclear medicine studies of heart muscle (78452).
You asked the Plan to pre-approve nuclear medicine studies. You say that this service is necessary for your health. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that nuclear stress test screening for coronary artery disease in asymptomatic patients will not be covered unless specific conditions are met We looked at the file and Medicare rules. In this case, the provider has noted that the enrollee is currently asymptomatic. In addition, the procedure is not being requested for medical necessity but as a screening for employment which is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of nuclear medicine studies have not been met. Therefore, we decided that the Plan does not have to pre-approve nuclear medicine studies of heart muscle (78452).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation, bitewing x-rays, 
panoramic x-ray, endodontic therapy, and extraction provided on May 17, 2021 by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for the comprehensive oral evaluation, bitewing x-rays, panoramic x-ray, endodontic 
therapy, and extraction. You say that you would like at least 80% of these services to be covered. The Plan 
denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that 
services need to be provided in-network to be eligible for payment. 
 
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 requested items or services are not 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral evaluation, bitewing x-rays, panoramic x-ray, endodontic therapy, and extraction provided 
on May 17, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One (J7325). 
 
You asked the Plan to pre-approve Synvisc-One. The Plan denied your request. The Plan says this request does 
not meet the Plan's Part B step therapy criteria for the requested viscosupplement device. 
 
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 Synvisc-One. Our reviewer says that 
Synvisc-One (J7325) is not medically reasonable and necessary for the enrollee. Our physician reviewer found 
the enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as 
outlined by the Plan, requires that these be trialed first. Our reviewer found that the documentation does not 
outline contraindications or reasons these medications were not considered or that the Plan's additional 
required drug would likely be less effective and/or likely have adverse effects for the enrollee. Our physician 
reviewer also found that without the support of the documentation, Synvisc-One is not approved, as step 
criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc-One (J7325).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for CT imaging services provided on May 23, 2021, by an outof-
network provider.
You asked the Plan to pay for CT imaging services. You say that the requested services were a medical
necessity for the enrollee. The Plan denied your request. The Plan says rules for out-of-network care have not
been met.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan must 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 CT imaging services provided on May 23, 2021,
by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
May 19, 2021, to May 24, 2021. 
 
You asked the Plan to waive the copayment for inpatient stay. You say that you cannot afford this copayment 
amount. The Plan denied your request. The Plan says the copayment 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 $175 
copayment per day for days 1 to 7 for inpatient care. This inpatient stay lasted 5 days, resulting in a copayment 
amount of $875.  
 
You have been asked to pay $175 copayment per day for days 1 to 7 for inpatient stay. Inpatient stay falls 
within the Inpatient Hospital Care benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
an inpatient hospital stay provided from May 19, 2021, to May 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the upper denture reline (D5750), lower denture reline (D5751), denture repair (D5511), upper denture adjustment (D5410), lower denture adjustment (D5411) provided from May 5, 2021, to May 14, 2021.
You asked the Plan to reimburse you for the dental services. You say that your dentures broke. You say that you paid the bill. You say that you need that money for other bills. You also say that The Plan denied your request. The Plan says the denture relines are not listed as covered services. The Plan says that denture repair is not listed as a covered service. The Plan also says that denture adjustments are not listed as covered services either.
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 denture related dental services are
not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse
you for the upper denture reline (D5750), lower denture reline (D5751), denture repair (D5511), upper denture
adjustment (D5410), lower denture adjustment (D5411) provided from May 5, 2021, to May 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the maxillary tissue conditioning (D5850) provided on June 14, 2021.
You asked the Plan to pay for the maxillary tissue conditioning. You say that you would like this service to be covered. The Plan denied your request. The Plan says this service is not included on your benefit plan and is not a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the 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 maxillary tissue conditioning (D5850) provided on June 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subcutaneous tissue debridement (11042, 11045) and the
home visits for the evaluation and management of an established patient (99349 x 2) rendered by the OON
provider on May 10, 2021, and May 15, 2021.
You asked the Plan to pay 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 the services were rendered by an out of
network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the
Plan does not have to pay for the subcutaneous tissue debridement (11042, 11045) and the home visits for the
evaluation and management of an established patient (99349 x 2) rendered by the OON provider on May 10,
2021, and May 15, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the non-emergency ambulance transportation provided June 25, 2021.
You asked the Plan to waive the copayment for the non-emergency ambulance transportation. You say that you were not aware you would be charged a copayment for these services. The Plan denied your request. The Plan says the copayment has processed correctly in this case.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for ambulance services. You have been asked to pay a $250 copayment for the non-emergency ambulance transportation. This service falls within the ambulance services benefit category. This means that you have been asked to pay the correct
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the non-emergency ambulance transportation provided June 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on June 24, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on June 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the positron emission tomography (PET) radiopharmaceutical provided on March 24, 2021.
You asked the Plan to pay for the PET. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered were not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that PET scans 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 pay for the PET. Our reviewer says that the documentation does not support that the services rendered were medically reasonable or necessary.
Our physician reviewer found a detailed clinical history is not provided. From the case summary and PET report, the enrollee has a history of recurrent prostate cancer for which the enrollee initially underwent proton therapy in 2009, the salvage brachytherapy in 2013 and apparently underwent radiotherapy for oligometastases in January 2020. A Prostate specific antigen (PSA) was 1.6 ng/ml on March 11, 2021. A March 24, 2021 Prostate-specific membrane antigen (PSMA) PET scan showed two new PSMA-avid left peri-aortic lymph nodes and a decrease in size of irradiated presacral and left internal iliac nodes. While PSMA-PET can be considered a standard of care approach for select enrolees with recurrent prostate cancer, the clinical records do not describe any recent imaging or why the PET was ordered. Therefore, the enrollee did not meet criteria for the services rendered. 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 PET have not been met. Therefore, we decided that the Plan does not have to pay for the positron emission tomography (PET) radiopharmaceutical provided on March 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the root canal (D3330) provided on June 14, 2021. 
 
You asked the Plan to pay for the dental service. You say that you were referred to this dentist. You say that 
you were in extreme pain while waiting to see the dentist. You also say that this service should be covered. The 
Plan denied your request. The Plan says the root canal 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 root canal is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the root canal (D3330) 
provided on June 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on April 
29, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the services provided by an out-of-network provider on April 29, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the cost shares for the durable medical equipment provided on 
May 17, 2021. 
 
You asked the Plan to waive the cost shares for the services provided. You say that an error caused an 
excessive copay. The Plan denied your request. The Plan says the claim processed 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 30% 
coinsurance for out-of-network for durable medical equipment.  
 
The file shows that you received a lightweight wheelchair from an out-of-network provider. You were charged 
$577.51, which allowed you to reach your deductible. You were then charged a 30% coinsurance of the 
remaining amount. The services fall within the durable medical equipment 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 cost shares for the durable medical equipment provided on May 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the automatic external defibrillator you received on April 15, 2021.
You asked the Plan to waive the coinsurance for the automatic external defibrillator. You say that you thought that insurance covered everything. You stated that you were never told that you would have to pay this much for this item. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for durable medical equipment. You have been asked to pay 20% coinsurance for the automatic external defibrillator. The automatic external defibrillator falls within the durable medical equipment 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 coinsurance for the automatic external defibrillator you received on April 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Truxima for the enrollee. 
 
You asked the Plan to pre-approve Truxima. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says that there is no indication their preferred drugs would likely be less 
effective, and/or cause adverse effects for the member. 
 
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 Truxima. Our reviewer says that 
Truxima is not medically reasonable and necessary for the enrollee. The record indicates that the enrollee has 
Non-Hodgkin's lymphoma. The requested medication is a new start. The provided records do not indicate that 
the enrollee has tried and failed the plan's preferred step one alternatives, Rituxan, Ruxience or Riabni. The 
record does not indicate that the enrollee has a contraindication to or would have an adverse effect from the 
plan's preferred step one alternatives. Our physician reviewer found that the enrollee's condition does not meet 
step therapy criteria for Truxima. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Truxima have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Truxima for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the chiropractic services you received on 
June 18, 2021. 
 
You asked the Plan to waive the copayment for the chiropractic services. You say that the Plan is not following 
Medicare rules by not paying 80%. The Plan denied your request. The Plan says you were charged this 
copayment 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 
copayment for chiropractic services.  
 
You have been asked to pay a $20 copayment for the chiropractic services. 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. Plans are not obligated to pay 80% of the cost for 
services- they are only obligated to cover services in accordance with your Evidence of Coverage. Therefore, 
we decided that the Plan does not have to waive the copayment for the chiropractic services you received on 
June 18, 2021.