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

 
We decided that the Plan does not have to pre-approve Procrit. 
 
You asked the Plan to pre-approve the services. You say that this is needed for diagnoses of iron deficiency 
anemia and congenital syphilis. The Plan denied your request. The Plan says the step therapy requirements 
were not met.  
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 the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found there has not been 
a trial and failure of Retacrit. The documentation does not support that Retacrit would likely be less effective, 
and/or would likely have adverse effects for the enrollee in this case. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Procrit.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exam provided on July 5, 2021. 
 
You asked the Plan to waive the copayment for the eye exam. You say that there should be no copayment for vision services after cataract surgery. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, 
deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 copayment for an eye exam for the diagnosis or treatment of diseases, including cataracts.  
 
You have been asked to pay a $15 copayment for the eye exam. The eye exam falls within the Vision 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 the eye exam provided on July 5, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergent ambulance transportation services (A0428, 
A0425) provided on February 1, 2021. 
 You asked the Plan to pay for the ambulance services. You say that these transportation services were 
medically necessary. The Plan denied your request. The Plan says the documentation does not support that the 
enrollee was transported from the hospital (H) to their residence (R) twice on February 1, 2021. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules. The rules also say that providers must report services correctly and submit the 
necessary documentation to corroborate the services provided and confirm that Medicare coverage criteria are 
met. 
 
We looked at the file and Medicare rules. Documentation shows that two separate claims were submitted with 
codes A0428-HR and A0425-HR. The modifiers for both claims indicate that the enrollee was transported from 
the hospital facility to their residence. Documentation does not show that the enrollee was transported from the 
hospital to their residence twice on February 1, 2021. The Plan has paid one of these submitted claims, but the 
other remains denied due to lack of supporting documentation. Based on this information, we decided that 
Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for the non-emergent ambulance transportation services (A0428, A0425) provided on 
February 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mandibular partial denture (D5214) provided on December 
2, 2020. 
 
You asked the Plan to pay for a mandibular partial denture. You say that you are asking for an exception to the 
Plan's policy of paying for a mandibular partial denture. You also say the enrollee did not receive his dentures 
till 2021. The Plan denied your request. The Plan says the enrollee reached his annual dental maximum benefit 
amount for 2020. 
 
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.  
 
 
 We looked at the file and Medicare rules. The records show that prior to this date of service, the enrollee had 
reached $2,205 of the maximum allowed benefit for dental services. The enrollee received full payment by the 
Plan for the complete maxillary denture for $706, which brought the enrollee's total annual maximum benefit 
to $2,911. The Plan paid the remaining $89 of the annual maximum benefit towards the mandibular partial 
denture. The enrollee exhausted his $3,000 maximum allowed benefit on this date of service. The remaining 
balance is the enrollee's responsibility. Based on this information, we decided that the Plan's rules for coverage 
of a mandibular partial denture have not been met. Therefore, we decided that the Plan does not have to pay for 
a mandibular partial denture (D5214) provided on December 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapy services (procedure code 97530) provided to the enrollee on 
May 11, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan 
says Current Procedural Terminology (CPT) code 97530 remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must 
report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 97530 is "Therapeutic activities, direct (one-on-one) patient contact 
(use of dynamic activities to improve functional performance), each 15 minutes." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in this case were not 
supported by the medical records. Our reviewer found the documentation includes a home visit performed by an 
Occupational Therapist is the home setting. There is a more appropriate Healthcare Common Procedure Coding System 
(HCPCS) code to report for this service. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules 
for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for therapy 
services (procedure code 97530) provided to the enrollee on May 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ophthalmology visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the ophthalmology visit. You say that you would like reconsideration 
because this visit is medically necessary and you could be blinded from your condition. The Plan denied your 
request. The Plan says there are in-network providers available to render the necessary 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the ophthalmology visit to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you would like 
reconsideration because you do not drive and you have upcoming appointments. The Plan denied your request. 
The Plan says you have exhausted your routine transportation 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 Plan?s coverage rules apply in this 
case. The Plan covers a maximum of 40 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. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the emergency room services provided on June 3, 2021. 
 
You asked the Plan to pay for the emergency room services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
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. In this case, the Plan has provided no supporting evidence for their denial of 
payment. The Plan's reason for denial is they did not receive a corrected claim from the provider. However, the 
file does not provide any documentation showing the claim was billed incorrectly. There is not enough 
information in the case file provided by the Plan in order to substantiate the Plan's denial of payment. 
Therefore, we decided that the Plan has to pay for the emergency room services provided on June 3, 2021.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for inpatient hospital services you received 
from June 3, 2021, to June 9, 2021. 
 
You asked the Plan to reduce the copayment for the inpatient hospital services. You say that the hospital 
withheld medication from you, causing an atrial fibrillation condition.  You think that your bill should be cut in 
half. 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 $390 
copayment per day for days 1-5 for inpatient hospital services.  
 
You have been asked to pay a $390 copayment per day for days 1-5 for the inpatient hospital services. This 
copayment applies regardless of your satisfaction with the services received. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to reduce the copayment for inpatient hospital services you received from June 3, 2021, to June 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services (D9944) for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this 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 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 pre-approve 
dental services (D9944) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the endocrinology visits you had with an out-of-network provider 
on March 9, 2021, and June 8, 2021. 
 
You asked the Plan to waive the deductible for the out-of-network endocrinology visits. You say that you had your 90-day checkups 
virtually because of the Coronavirus.  You stated that this provider is in-network. The Plan denied your request. The Plan says this 
provider is not in-network with your specific Plan.  Because of this, the Plan states that your deductible was applied appropriately to 
these services. 
 
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 $500 deductible for out-of-network 
services.  
 
Records show that you had not met your deductible at the time of these services.  The Plan confirmed that this provider is not an in-network provider for your specific plan, so the deductible applies to these 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. Therefore, we decided that the Plan does not have to waive the deductible for the endocrinology visits you had 
with an out-of-network provider on March 9, 2021, and June 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more toward the crown and core buildup provided on May 4, 2021. 
 
You asked the Plan to pay more toward the crown and core buildup. You say that you were told the provider is in-network and you 
want help solving this bill. The Plan denied your request. The Plan says the remaining annual maximum amount was paid toward the 
crown which exhausted your benefits. 
 
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, you also have an annual maximum of $2,000 toward covered 
dental services. The Plan paid the remaining amount of your annual maximum toward the crown provided on May 4, 2021, which 
exhausted your benefits. You are responsible for the remaining amounts for the crown and core buildup. Therefore, we decided that 
the Plan does not have to pay more toward the crown and core buildup provided on May 4, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xgeva. 
 
You asked the Plan to pre-approve Xgeva. The Plan denied your request. The Plan says the enrollee has not 
tried and failed pamidronate or zoledronic acid. 
 
 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 Xgeva. Our physician reviewer found 
that the enrollee has a history of osteoporosis. The Plan requires a trial of pamidronate or zoledronic acid 
before they will approve the requested drug. In this case, the enrollee has not tried and failed the required 
drugs. There is no documentation provided indicating that the plan?s required drugs would likely be less 
effective 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 Xgeva have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Xgeva.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluations (D0140) and bitewing x-rays 
(D0270) provided on April 26, 2021, and June 17, 2021. 
 
You asked the Plan to pay for the oral exams and x-rays. You say that these services were medically necessary, 
and you cannot afford these bills. The Plan denied your request. The Plan says you had a previous limited oral 
exam and set of bitewing x-rays in March of 2021, which were covered at that time. Each of these services may 
only be covered once per plan year. Therefore, your benefit for these services is exhausted and payment will 
not be made for the dates at issue. 
 
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. The Plan can cover one limited exam to evaluate a problem (D0140) per plan year. The Plan can cover one set of bitewing x-rays 
(D0270, D0272, D0273, D0274 or D0277) per plan year. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, limited oral exams and bitewing x-rays 
are requested in a frequency that exceeds what is covered under this benefit. Documentation shows that you 
had a previous limited oral exam and set of bitewing x-rays provided on March 16, 2021, and these services 
were covered by the Plan at that time. Therefore, we decided that the Plan does not have to pay for the limited 
oral evaluations (D0140) and bitewing x-rays (D0270) provided on April 26, 2021, and June 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services (D9230). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this 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 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 pre-approve 
dental services (D9230).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower leg platform crutch (E0118). 
 
You asked the Plan to pre-approve a lower leg platform crutch (E0118). You say that you would like the plan 
to reconsider their denial. The Plan denied your request. The Plan says this equipment is not covered by 
Medicare or the Plan. 
 
The Plan covers all items that Medicare covers. Medicare rules state that a Platform Crutch is not covered by 
Medicare as it is not primarily medical in nature. While this item may be appropriate for your use, neither the 
Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-
approve a lower leg platform crutch (E0118).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Restasis emulsion. 
 
You asked the Plan to pre-approve self-administered drug. You say that the enrollee needs to try Restasis for 
treatment of her condition. 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 Restasis emulsion.  
 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the outpatient breast biopsy procedure you 
had on October 1, 2020, the cardiac blood pool imaging you received on October 26, 2020, the Pegfilgrastim 
injections you received on November 9, 2020, the Paclitaxel, Ondansetron, Dexamethasone, and 
Siphenhydramine injections you received on November 9, 2020, November 16, 2020, and November 23, 2020, 
and the catheter insertion procedure you had on December 4, 2020. 
 
You asked the Plan to waive the cost sharing for the biopsy and catheter procedures, the blood pool imaging 
test, and the drugs. You did not provide an argument with your appeal request. The Plan denied your request. 
The Plan says you were charged this cost sharing 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 $175 
copayment for ambulatory surgical services, a $200 copayment for diagnostic radiology services, and 20% 
coinsurance for Medicare Part B drugs.  
 
You have been asked to pay a $175 copayment for the breast biopsy and catheter procedures.  Both of these are 
considered ambulatory surgical procedures.  You were asked to pay a $200 copayment for the cardiac blood 
pool imaging, which is a type of diagnostic radiology service.  Finally, you were asked to pay 20% coinsurance 
for the various drugs you received.  Each of these drugs is a Medicare Part B drug. 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 sharing for the outpatient breast biopsy procedure you had on October 1, 2020, the cardiac 
blood pool imaging you received on October 26, 2020, the Pegfilgrastim injections you received on November 
9, 2020, the Paclitaxel, Ondansetron, Dexamethasone, and Siphenhydramine injections you received on 
November 9, 2020, November 16, 2020, and November 23, 2020, and the catheter insertion procedure you had 
on December 4, 2020.