Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided by an out-of-network 
provider. 
 
You asked the Plan to pay more for the dental services. You say that this was an emergency situation. The Plan 
denied your request. The Plan says you are responsible for any charged amount above the Plans cost-sharing 
amount when your services are received from an out-of-network provider.  
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for dental services provided by an out-of-
network provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from May 10, 2023, to 
May 23, 2023. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you felt that you were able to be 
discharged a week earlier but was not able to speak with anyone. The Plan denied your request. The Plan says 
this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $0 
copayment for days 1 to 20 and a $175 copayment per day for days 21 to 100 for SNF care.  
 
 
  You have been asked to pay $1,050 for a SNF stay ($175 per day x 6 days = $1,050). This item/service falls 
within the SNF 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 a SNF stay provided 
from May 10, 2023, to May 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 05, 2023. 
 
You asked the Plan to pay for lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for lab services provided on 
June 05, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 28, 2023, to June 30, 2023. 
 
You asked the Plan to pay for lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for lab services provided on 
June 28, 2023, to June 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on May 24, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the enrollee could not choose an 
in-network provider. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for subsequent nursing 
facility care provided on May 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0100). 
 
You asked the Plan to pre-approve the additional trips. You say that you had surgery and need the trips to go to 
your follow-up and other appointments. The Plan denied your request. The Plan says the records show that you 
have reached your maximum allowance of 24 trips. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve the 
additional trips for your medical appointments. 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 trips (A0100).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on July 12, 2023. 
 
You asked the Plan to pay for physical therapy. You say that you disagree with the denial for the physical 
therapy visit. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for physical therapy 
provided on July 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care, and related services 
provided on May 24, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care, and related services. You say that the enrollee 
could not choose an in-network provider. The Plan denied your request. The Plan says that unauthorized, out-
of-network care is not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for subsequent nursing 
facility care, and related services provided on May 24, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on July 17, 2023. 
 
You asked the Plan to pay for physical therapy. You say that you disagree with the denial for the physical 
therapy services. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for physical therapy 
provided on July 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth consultation provided on May 24, 2023. 
 
You asked the Plan to pay for a telehealth consultation. You say that the enrollee was in a nursing home at the 
time services were rendered. The Plan denied your request. The Plan says that unauthorized, out-of-network 
care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a telehealth consultation 
provided on May 24, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a SNF stay provided on January 1, 2023. 
 
You asked the Plan to waive the deductible for a SNF stay. You say that you do not believe you should be 
responsible for the deductible applied. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible which applies to SNF care and enrollees must pay $0 
copayment for days 1 to 20 and a $196 copayment per day for days 21 to 100 for SNF care, after the deductible 
has been met.  
 
 The item or service you asked the Plan to waive the deductible for falls within the SNF care benefit category. 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which 
applies to SNF care. This cost sharing is a contractual obligation that had not been met at the time a SNF stay 
was received on January 1, 2023. Therefore, we decided that the Plan does not have to waive the deductible for 
a SNF stay provided on January 1, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on June 26, 2023, to July 19, 
2023. 
 
You asked the Plan to pay for physical therapy. You say that you disagree with the denial for the physical 
therapy services. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for physical therapy 
provided on June 26, 2023, to July 19, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Atezolizumab. 
 
You asked the Plan to pre-approve Atezolizumab. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Atezolizumab. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found given the multiple sites of progression, 
the continued use of atezolizumab would not be reasonable or medically necessary. The use is not supported by 
one of the major drug compendia or by clinical research that appears in a CMS-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 Atezolizumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Atezolizumab.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on July 10, 2023. 
 
You asked the Plan to pay for physical therapy. You say that you disagree with the denial for the physical 
therapy services. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for physical therapy 
provided on July 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive metabolic panel provided on June 09, 2023. 
 
You asked the Plan to pay for a comprehensive metabolic panel. You say that the enrollee does not have an 
option of what lab service to use. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a comprehensive 
metabolic panel provided on June 09, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided on July 18, 2023. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you were never aware there was 
a copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for Outpatient rehabilitation services. 
 
You have been asked to pay a $40 copayment for physical therapy. This item/service falls within the Outpatient 
rehabilitation 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. You have been asked to pay a $40 copayment for a physical therapy visit. Therefore, we 
decided that the Plan does not have to waive the copayment for physical therapy provided on July 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physicians services provided on July 04, 2023. 
 
You asked the Plan to pay for physicians services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for physicians services 
provided on July 04, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a chemotherapy injection and outpatient 
hospital facility visit provided on May 30, 2023. 
 
You asked the Plan to waive the cost share for a chemotherapy injection and outpatient hospital facility visit. 
You say that you disagree with the cost share applied. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay 20% coinsurance for Medicare Part B prescription drugs and a $290 copayment for services provided 
at an outpatient hospital facility.  
 
The enrollee has been asked to pay $386.43 for a chemotherapy injection and outpatient hospital facility visit. 
This total includes $78.43 coinsurance, which is 20% of the allowed amount for a Medicare Part B 
chemotherapy drug injection ($392.17 allowed x 20% = $78.43) and a $290 copayment for outpatient hospital 
facility services. The chemotherapy injection falls within the Medicare Part B prescription drugs benefit 
category. The outpatient hospital facility visit falls within the outpatient surgery and other medical services 
provided at hospital outpatient facilities benefit category. 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 cost 
share for a chemotherapy injection and outpatient hospital facility visit provided on May 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction provided on July 5, 2023. 
  
You asked the Plan to pay for the refraction. You say that you went in for a medical eye exam and the provider 
did not tell you that they would be doing a refraction. The Plan denied your request. The Plan says the 
refraction is not a covered benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when provided during a routine eye examination. 
 
We looked at the file and the Plan's rules. The refraction was provided during a medical eye examination and 
therefore, it is not a covered benefit. Based on this information, we decided that the Plan's rules for coverage of 
the refraction have not been met. Therefore, we decided that the Plan does not have to pay for the refraction 
provided on July 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for localized delivery of antimicrobial agents via a 
controlled release vehicle into diseased crevicular tissue, per tooth (D4381) provided on May 4, 2023, and May 
9, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the localized delivery of antimicrobial 
agents was administered on the same day as the periodontal scaling and root planning. You also say that this 
should be covered. The Plan denied your request. The Plan says your benefit for the localized delivery of 
antimicrobial agents $2,000 dollar limit was met. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. Specifically, 
the benefit for supplemental dental coverage is limited to $2,000 annually. The records show that the Plan paid 
$235 under claim number ending in 86628 for dental services provided on January 17, 2023. The record show 
the Plan paid $436 under claim ending in 41085 for dental services provided on May 4, 2023. The records 
show that the Plan paid $686 under claim number ending in 93113 for dental services provided on May 9, 
2023. The records show that the Plan paid $148 under claim ending in 75403 for dental services provided on 
May 27, 2023. The record shows that the Plain paid $436 under claim number ending in 89088, for dental 
services provided on August 22, 2023. The records show the Plan paid $59 under claim ending in 71929 for 
dental services provided on August 22, 2023. This means that the Plan paid $2,000 in total for dental services 
provided in 2023. This exhausted the annual dental benefit allowance for the 2023 calendar year. Therefore, we 
decided that the Plan does not have to pay more for localized delivery of antimicrobial agents via a controlled 
release vehicle into diseased crevicular tissue, per tooth (D4381) provided on May 4, 2023, and May 9, 2023.