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

We decided that the Plan does not have to waive the copayment for emergency care provided on May 24, 2021. 
 
You asked the Plan to waive the copayment for emergency care. You say that you were later admitted to the 
hospital, but you should have been admitted to the emergency room on May 24, 2021. The Plan denied your 
request. The Plan says the claims were processed correctly, and you are being charged the correct 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 $90 
copayment for emergency care.  

You have been asked to pay a $90 copayment for emergency care. Emergency care 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 provided on 
May 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the periodic oral evaluation (D0120), bitewing x-rays 
(D0274), panoramic x-ray (D0330), and prophylaxis (D1110), provided on March 12, 2021, by an OON 
provider. 
 
You asked the Plan to pay more for the periodic oral evaluation, bitewing x-rays, panoramic x-ray, and 
prophylaxis. You say that per your plan guide you are supposed to get two OON cleanings and one bitewing x-
ray per year at a $0 copay. The Plan denied your request. The Plan says the cost share was applied correctly per 
your plan benefits. The Plan also says that cost sharing is a contractual obligation of the Plan and cannot be 
waived. 

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 are responsible for the difference 
between the billed amount and allowed amount for covered dental services received OON. Therefore, we 
decided that the Plan does not have to pay more for the periodic oral evaluation (D0120), bitewing x-rays 
(D0274), panoramic x-ray (D0330), and prophylaxis (D1110), provided on March 12, 2021, by an OON 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee could be treated with a BiPAP. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a ventilator. Our reviewer says that the 
requested ventilator is not medically necessary. Our physician reviewer found the ventilator at issue is being 
prescribed as a bi-level positive airway pressure (BiPAP) device which is not covered by Medicare. Certain 
BiPAP devices can provide the average volume-assured pressure support (AVAPS) mode of support. The 
patient is likely to benefit from nocturnal BiPAP support. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hyperthermia cancer treatment. 
 
You asked the Plan to pre-approve hyperthermia cancer treatment. You say that the records provided support 
the need for the requested treatment. The Plan denied your request. The Plan says the records do not show that 
the requested treatment will be used along with radiation therapy to treat a type of skin cancer or a tumor just 
beneath the skin. 
 
The Plan follows Medicare rules. Medicare rules say that hyperthermia cancer treatment is covered for certain 
indications.  
 
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 hyperthermia cancer treatment. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found the record 
indicates that the enrollee has breast cancer metastatic to bone and liver.  The noted diagnosis is not a covered 
indication.  The elements of the coverage criteria are not satisfied.  The requested service cannot be 
recommended.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hyperthermia cancer treatment have not been met. Therefore, we decided that 
the Plan does not have to pre-approve hyperthermia cancer treatment.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided on February 10, 2021 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the skilled nursing services. You say that the service was provided with no 
adequate time frame to obtain authorization for the service. You also say that the services rendered were 
medically necessary. The Plan denied your request. The Plan says the services were rendered by a non-
contracted provider. The Plan also says that prior authorization was not 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. 
Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided on February 
10, 2021 by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transesophageal echocardiography (TEE). 
 
You asked the Plan to pre-approve TEE. You say that TEE is medically necessary. The Plan denied your 
request. The Plan says the records show that the enrollee may have a problem with her heart. The Plan did not 
receive physical exam results that show a reason this study is needed. The records did not include a detailed 
history that shows this study is needed. 
 
The Plan follows Medicare rules. Medicare rules say that TEE is medically necessary under the following 
situations: TTE is not technically adequate, TTE demonstrates pathology but does not provide adequate data 
for clinical decision making, TEE is expected to provide information not available with TTE or is expected to 
provide a better view of a structure seen on TTE, and/or TEE is expected to contribute significant additional 
information useful in the patient's management 
 
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 TEE. Our reviewer says that TEE is not 
medically necessary. Our physician reviewer found the enrollee's available record does not support the 
Echocardiography criteria under LCD L37379 are met for any of the following indications: evaluate 
myocardial ischemia; quantify myocardial perfusion during stress; Identify the "area at risk" during acute 
myocardial infarction (AMI); determine the success of reperfusion interventions; assess myocardial viability. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TEE have not been met. Therefore, we decided that the Plan does not have to 
pre-approve TEE.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and 
services provided from May 15, 2021, to June 11, 2021. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that if the enrollee's medication had 
not been discontinued by the physician, this hospital stay would not have been necessary, and the enrollee 
would not have incurred these charges. The Plan denied your request. The Plan says this claim was processed 
correctly, and the enrollee's cost-share was assessed in accordance with the contract. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $300 copayment for each of the first five days of inpatient hospital care. There is a $0 copayment 
for additional days.

The enrollee has been asked to pay a $1,500 copayment for the inpatient hospital care. This means that the 
enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a 
contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the inpatient hospital admission and services provided from May 15, 
2021, to June 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Belbuca. 
 
You asked the Plan to pre-approve Belbuca. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee has a medical only policy which does not include Part D prescription 
coverage, therefore the criteria for self-administered drug coverage has not been met. 
 
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 Belbuca.  
 
Benefits for Belbuca 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: Partially Favorable

We decided that the Plan has to pre-approve MBBs at two levels. We decided that the Plan does not have to 
pre-approve a third level MBB.  
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan says that  
The services are not medically necessary. 

We decided that the Plan has to pre-approve MBBs at two levels. 
 
The Plan must follow Medicare rules. Medicare rules say that MBBs are covered at maximum of two levels 
when specific criteria are met. 
 
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 these services. Our reviewer says that 
diagnostic MBBs at two levels are medically necessary. Our physician reviewer found the enrollee has chronic 
neck pain. He had a trial of physical therapy. Magnetic resonance imaging (MRI) showed facet arthropathy, 
two small disc protrusions, and a past laminectomy at the C4 to C5 level. Performance of diagnostic MBBs at a 
site of former surgery is not supported. The request for three levels exceeds utilization limits and there is no 
indication presented to exceed the recommended two levels. Therefore, two levels are considered medically 
reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MBBs at two levels have been met. Therefore, we decided that the Plan has to 
pre-approve MBBs at two levels.  
 
We also decided that the Plan does not have to pre-approve a third level MBB. 
 
We looked at this physician's review, the file, and Medicare rules. The physician's review states that the third 
level MBB is not medically necessary. Based on this information, we decided that Medicare rules for coverage 
of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a third 
level MBB. 
 
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 must 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for X-rays provided on April 21, 2021. 
 
You asked the Plan to waive the copayments for X-rays. You say that you were told that you would not owe 
anything for X-rays. The Plan denied your request. The Plan says the claims were processed correctly and you 
are being charged the correct 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 $50 
copayment for each X-ray service. 
 
The record shows that you received X-rays on April 21, 2021. Therefore, you are responsible to pay the total 
allowed amount of $209.92, which is less than the total copayment amount.   
 
You have been asked to pay the total copayment amount of $209.92 for X-rays. X-rays 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 copayments for X-rays provided on April 21, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional physical therapy visits. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 these services. Our reviewer says that
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the requested additional therapy is not generally accepted as specific 
and effective therapy for your condition beyond what was approved by the plan. You have had prior therapy 
and the records do not show that the unique skills of a professional therapist are required to safely and 
effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or  
by or under the supervision of a therapist. The services are not part of a maintenance program and not required 
to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further 
deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 10 additional physical therapy visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share amount for the emergency room visit provided 
on May 29, 2021, and the inpatient hospital care provided from June 15, 2021, to June 23, 2021. 
 
You asked the Plan to waive the cost share amount for the emergency and inpatient services. You say that your 
regular doctor was not available. You say that you were advised to go to the hospital. You say that you were 
prepared for surgery and then was told you were not eligible for the surgery. You also say that you will not pay 
as nothing was done for you. The Plan denied your request. The Plan says the cost sharing amounts were 
applied correctly to the services that you received. 

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 $90 
copayment for emergency care and a copayment of $325 per day for days 1 to 5 for inpatient hospital care.  
 
You have been asked to pay $90 copayment for the emergency and a copayment of $325 per day for days 1 to 
5 for inpatient hospital care. The emergency room visit falls within the emergency care benefit category. The 
inpatient services fall within the inpatient hospital care benefit category. $325 x 5 days = $1,625. 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 share amount for the emergency room visit provided on May 29, 2021, and the 
inpatient hospital care provided from June 15, 2021, to June 23, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 these services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital 
on October 27, 2021 with acute kidney injury, Coronavirus, and a urinary tract infection. She received oral 
medications and had stable vital signs. She received physical and occupational therapy and is dependent to 
maximal assist with functional mobility. She needs varied assist with activities of daily living. She has no 
skilled nursing or skilled therapy needs and does not require skilled nursing or skilled therapy on a daily basis. 
As a practical matter, the enrollee does not require the necessary services on an inpatient basis at the SNF level 
of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 these services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital 
for fall risk and unsteady gait. She received oral medications and had stable vital signs. She received physical 
and occupational therapy in the hospital and needs moderate assist with bed mobility and contact guard to 
minimal assist with gait to short distances. She required varied assist with activities of daily living. She has no 
skilled nursing needs. She has skilled therapy needs but does not require skilled therapy on a daily basis. As a 
practical matter, she does not require the necessary services on an inpatient basis at the SNF level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be rendered by the out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says there are in-network providers available to render the 
requested service. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The service at issue in this appeal will not be provided in an emergency or urgent care situation. The Plan is not 
providing this service and is not making arrangements to provide this service. Therefore, we decided that the 
Plan does not have to pre-approve an office visit to be rendered by the out-of-network (OON) provider.