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

 
We decided that the Plan does not have to waive the copayment for a specialist office visit (99214), a brief 
emotional/behavioral assessment (96127) and for the administration of patient-focused health risk assessment 
instrument (96160) rendered on May 26, 2021. 
 
You asked the Plan to waive the copayment for a specialist office visit, a brief emotional/behavioral assessment 
and for the administration of patient-focused health risk assessment instrument. You say that you do not 
remember the services that were given on May 26, 2021. You also say you do not believe that the cost share is 
correct. The Plan denied your request. The Plan says you were 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 $10 
copayment for services obtained from a specialist and $20 copayments for Medicare-covered non-radiological 
diagnostic services.  
 
You have been asked to pay a $10 copayment for an office visit. You also have been asked to pay $8.44, which 
is less than the $20 copayment for a brief emotional/behavioral assessment. You have also been asked to pay 
$4.84, which is less than the $20 copayment for the administration of patient-focused health risk assessment 
instrument ($10 copayment + $8.44 copayment + $4.84 copayment = $23.28). A brief emotional/behavioral 
assessment and an administration of patient-focused health risk assessment instrument fall within the 
Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 a specialist office visit (99214), a brief emotional/behavioral assessment (96127) 
and for the administration of patient-focused health risk assessment instrument (96160) rendered on May 26, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Venclexta tablets. 
 
You asked the Plan to pre-approve self-administered drug. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, 
because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare 
Part D prescription drug benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Venclexta tablets.  
 Benefits for self-administered drug may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from November 8, 2021, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from November 8, 2021, 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 
November 8, 2021, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental 
health treatment beyond the date in question of November 8, 2021, forward. Our physician reviewer found you 
did not require inpatient mental health treatment beyond November 8, 2021, as you were not a danger to 
yourself 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 your 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 November 8, 2021, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from November 8, 
2021, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the root canal (D3320), cone beam computed tomography 
(CT) with capture and interpretation (D0364), periapical x-ray (D0220), and limited oral evaluation (D0140) 
provided on June 22, 2020. 
 
You asked the Plan to pay for the dental services. You say that you were advised that the dental office did not 
give the correct code for the procedure. The Plan denied your request. The Plan says there is an annual 
allowance of $750 for covered dental service. The Plan also says that the annual allowance has 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, the annual allowance has been exhausted. The record shows that the Plan paid $209 for dental services received on June 8, 2020, $216 for 
dental services received on July 2, 2020, $192 for dental services received on December 14, 2020, and $133 for 
dental services received on August 25, 2020. $209 + $216 + $192 + $133 = $750. The Evidence of Coverage 
clearly states that you are responsible for any amount above the dental coverage limit. Therefore, we decided 
that the Plan does not have to pay for the root canal (D3320), cone beam computed tomography (CT) with 
capture and interpretation (D0364), periapical x-ray (D0220), and limited oral evaluation (D0140) provided on 
June 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the topical application of fluoride varnish with dental code 
D1206 provided on May 27, 2021. 
 
You asked the Plan to pay for dental code D1206. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says dental code D1206 is not covered under the 
Plan's supplemental dental benefit. 
 
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, dental code D1206 is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the topical application 
of fluoride varnish with dental code D1206 provided on May 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of authorization for this drug is correct, because the enrollee does 
not meet criteria for Keytruda. 
 
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. Our reviewer says that the 
enrollee does not meet the Medicare criteria for the requested use of Keytruda. Our physician reviewer found 
the record indicates that the enrollee has a diagnosis of metastatic adenocarcinoma of the gallbladder.  The 
record does not indicate microsatellite instability-high (MSI-H) and/or deficient mismatch repair.  The record 
indicates that the enrollee was previously treated with nivolumab.  The Food and Drug Administration has not 
stated that the requested drug is indicated for the enrollee's condition. The requested use of Keytruda is not 
supported by one of the major drug compendia or by clinical research that appears in a Medicare-approved 
medical journal.  
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 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Keytruda.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D3320, D2950, and D2740) provided on 
November 5, 2020. 
 
You asked the Plan to pay for dental codes D3320, D2950, and D2740. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says dental codes D3320, D2950, 
and D2740 are not covered under the Plan's supplemental dental 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, dental codes D3320, D2950, and 
D2740 are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for the dental services (D3320, D2950, and D2740) provided on November 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99215) rendered by the out-of-network 
(OON) provider on May 4, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99215) rendered by the out-of-network (OON) provider on May 4, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services beginning 
November 12, 2021. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are 
medically necessary. The Plan denied your request. The Plan says that the records received show that your 
condition has improved, and you are no longer a threat to yourself or others. 
 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 hospital services. 
Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary. It is 
not expected you will improve in a reasonable period of time as you do not have suicidal or homicidal ideation 
noted and no auditory or visual hallucinations. You do not show any abnormal behaviors or any symptoms 
which would require acute treatment. It does not appear medically necessary and reasonable to have psychiatric 
care provided at the acute inpatient level of care rather than a lower level of care as you do not have 
dangerousness to self or others and were compliant with your treatment. Our physician reviewer found that 
your condition does not meet Medicare criteria for inpatient psychiatric hospital services. 
 
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 hospital services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient psychiatric hospital services beginning November 12, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation therapy. 
 
You asked the Plan to pre-approve endovenous ablation therapy. You say that based upon symptoms refractory 
to compression therapy and comprehensive venous ultrasound results, recommendation is to proceed with 
Varithena selerotherapy to the distal right greater saphenous vein, varicose veins, and right lesser saphenous 
vein as well as VenaSeal closure of the left greater saphenous vein, left lesser saphenous vein, and varicose 
veins. The Plan denied your request. The Plan says Medicare does not cover sclerotherapy for veins larger than 
four millimeters. The Plan states the blood vessels to be done in both legs are larger than four millimeters. The 
Plan states your doctor wants to do endovenous ablation with a chemical adhesive in one vein in your left leg 
and this is not covered by Medicare. 
 
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 endovenous ablation therapy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the documentation does not meet coverage criteria. Recommend the 
provider consider approved treatment options or submit for reevaluation with a rationale provided in the 
medical record for the specific treatments requested for an assessment of medical necessity. We looked at this 
physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of endovenous ablation therapy have not been met. Therefore, we decided that the Plan does not have 
to pre-approve endovenous ablation therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on February 2, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the service was medically 
necessary. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the subsequent nursing facility care provided on February 2, 
2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial observation care provided on June 30, 2021, by an 
OON provider. 
 
You asked the Plan to pay for the initial observation care. You say that preauthorization is not required for 
outpatient services. You also say that your provider rendered services to the enrollee in good faith that the in-
network facility would obtain the proper referrals and authorizations. The Plan denied your request. The Plan 
says these services were referred and rendered by non-network providers. The Plan also says that These 
services were not rendered in a network facility, nor were they approved in advance. 
 
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 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 the initial observation care provided on June 30, 
2021, by an OON provider.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve the insertion of a replacement loop recorder (33285). 
 
You asked the Plan to pre-approve the insertion of a replacement loop recorder. You say that the requested 
service is a medical necessity for the enrollee. The Plan denied your request. The Plan says that medical 
necessity rules for the requested service have not been met because records do not show how the loop 
recorder's results will be used in the management of enrollee's specific medical problem. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 the insertion of a replacement loop 
recorder. Our reviewer says that the requested items/services are considered medically reasonable and 
necessary in this case. Our physician reviewer found that the enrollee has poorly controlled, symptomatic atrial 
fibrillation (AF) and is under active management to attempt to get the AF under better control with both 
additional medications and adjustment of the current therapies. In addition, the enrollee has had episodes of 
bradycardia noted on the prior implantable loop recorder which could get more significant with the addition of 
more nodal blocking and rate slowing agents. Ongoing monitoring of the enrollee's response to therapy in this 
very symptomatic patient with recording of ventricular response heart rates is best and most easily monitored 
by replacing the current end of life implantable Linq recorder. This will allow the treating physician to assess 
control and response to therapy or consider AF ablation as an alternative if there is no good response to the 
medical treatment. 
 
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 insertion of a replacement loop recorder have been met. Therefore, we 
decided that the Plan has to pre-approve the insertion of a replacement loop recorder (33285).  
 
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 removable prosthodontic procedure (D5899) provided on 
May 27, 2021. 
 
You asked the Plan to pay for the removable prosthodontic procedure. You say that the Plan should pay the 
amount of $650.00 for the upper denture because your old denture is broken, and you had to have a new one 
made. The Plan denied your request. The Plan says this service is not a covered benefit. The Plan also says that 
when you contacted the Plan prior to this date of service you were advised that one upper and lower denture is 
covered. The Plan says that you were sent a provider list and a copy of benefits that show your plan is code 
specific. 
 
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 
removable prosthodontic procedure (D5899) provided on May 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a tooth extraction (D7210) and a periapical first radiographic 
image (D0220) provided on July 1, 2021, to July 7, 2021. 
 
You asked the Plan to pay for a tooth extraction and a periapical first radiographic image. You say that you 
were going in for surgery and needed to be cleared by a dentist.  You also say that an x-ray and cleaning were 
covered benefits. The Plan denied your request. The Plan says the services at issue are not covered under any 
normal circumstance. 
 
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 tooth 
extraction (D7210) and a periapical first radiographic image (D0220) provided on July 1, 2021, to July 7, 2021.