Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for an in-network inpatient stay provided from 
February 10, 2023, to February 11, 2023. 
 
You asked the Plan to waive the cost for an in-network inpatient stay. You say that your provider misdiagnosed 
you, which has led to so many unnecessary bills and payments. You do not feel you should have to pay 
anymore. 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 $350 
copayment, and a $1000 deductible for inpatient hospital care.  
 
You have been asked to pay a $1350 total cost for an in-network inpatient stay. This item/service falls within 
the inpatient hospital care benefit category.  This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the cost for an in-network inpatient stay provided from February 10, 2023, to 
February 11, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mental health visit provided on May 1, 2023, by an OON 
provider.  
 
You asked the Plan to pay for a mental health visit. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a mental health visit provided on May 1, 2023, by 
an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network (OON) 
provider on May 24, 2023. 
 
You asked the Plan to pay for the dental services. You say that you weren't aware the provider was OON. The 
Plan denied your request. The Plan says the dental services were received from an out-of-network provider and 
are not covered by your supplemental benefits.  
 
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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services provided by an out-of-network (OON) provider on May 24, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B prescription drugs 
provided on February 05, 2023. 
 
You asked the Plan to waive the coinsurance for Medicare Part B prescription drugs. You say that you disagree 
with the cost share. 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for Medicare Part B prescription drugs. This item/service falls 
within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance 
for Medicare Part B prescription drugs provided on February 05, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 30 additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional routine transportation trips. You say that the services are 
medically necessary for you to get to your appointments. The Plan denied your request. The Plan says the 
requested services will exceed your benefit limit. 
 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 72 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 30 additional routine transportation trips.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs. 
 
You asked the Plan to pay for the medication. The Plan denied your request. The Plan says the medication is 
not covered as a medical benefit under the Plan. 
 
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 pay for self-administered drugs.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on February 
01, 2023, to February 08, 2023. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you disagree with the 
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 $330 
copayment for outpatient surgery. 
 
You have been asked to pay a $330 copayment for an outpatient surgery. This item/service falls within the 
outpatient surgery 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. However, since the allowed amount is less than the standard copayment, you only owe $203.90. 
Therefore, we decided that the Plan does not have to waive the copayment for an outpatient surgery provided 
on February 01, 2023, to February 08, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames, the progressive lens, the polarization, the 
polycarbonate lens, and the prism lens provided on February 21, 2023. 
 
You asked the Plan to pay for the vision services. You say that you were not told that you needed to use a 
specific provider. You say there was not enough information on post-cataract glasses coverage. The Plan 
denied your request. The Plan says the benefit has been exhausted. 
 
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 up to a $200 benefit allowance per year. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid $200 towards services on February 21, 
2023, which exhausted the benefit. Based on this information, we decided that the Plan's rules for coverage of 
the vision services have not been met. Therefore, we decided that the Plan does not have to pay for the frames, 
the progressive lens, the polarization, the polycarbonate lens, and the prism lens provided on February 21, 
2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve imaging/treatment using a certain type of radiation 
called Proton Beam Treatment (PBT) (codes 77387, 77470, 77520, 77522, 77523, 77525, and G6002). 
 
You asked the Plan to pre-approve imaging/treatment using PBT. You say that in this elderly patient with 
extremely poor lung function, proton therapy will reduce the volume of lung receiving dose and preserve their 
fragile lungs relative to other techniques. The Plan denied your request. The Plan says the requested service is 
not covered by Medicare or the health plan. 
 
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 imaging/treatment using PBT. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found proton therapy is an accepted, safe and effective treatment modality for 
lung cancer. It is not clear however, that proton therapy affords any benefit over intensity-modulated radiation 
therapy (IMRT). A comparison plan is not provided, and it is not evident that proton therapy would reduce 
exposure to the lungs or central thoracic structures (esophagus, cord, central airway) in a clinically meaningful 
way. Our reviewer found that standard dosimetric constraints should readily be met with an IMRT plan. Our 
physician reviewer also found that there is no plausible reason that proton therapy would be more beneficial 
than standard therapy for this particular patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of imaging/treatment using PBT have not been met. Therefore, we decided that the 
Plan does not have to pre-approve imaging/treatment using a certain type of radiation called Proton Beam 
Treatment (PBT) (codes 77387, 77470, 77520, 77522, 77523, 77525, and G6002).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of an interspinous stabilization device 
(22869, 22870). 
 
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 the requested service is not medically necessary.  
 
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 this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that interspinous process distraction devices are experimental. More research is needed. 
 
  
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the insertion of an interspinous stabilization device (22869, 22870).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lesion excision procedure and the wound repair provided 
on June 6, 2023, by an OON provider.  
 
You asked the Plan to pay for a lesion excision procedure and the wound repair. You say that you are 
requesting reconsideration of the denied claim. The Plan denied your request. The Plan says the service was not 
authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a lesion excision procedure and the wound repair 
provided on June 6, 2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 20, 2023, to July 05, 2023. 
 
You asked the Plan to pay for an office visit. You say that this service is supported in the records. 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 an office visit provided 
on June 20, 2023, to July 05, 2023.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve a lecanemab-irmb (Leqembi) injection (J0174). 
 
You asked the Plan to pre-approve Leqembi. You say that you deem the administration of Leqembi medically 
necessary to slow the progression of the patient's Alzheimer's Disease. The Plan denied your request. The Plan 
says that Leqembi is not covered outside of a Medicare-approved clinical trial. 
 
The Plan follows Medicare rules. Medicare rules say that monoclonal antibodies directed against amyloid for 
the treatment of AD is covered when medically reasonable and necessary for patients who have a clinical 
diagnosis of MCI due to AD or mild AD dementia, both with confirmed presence of amyloid beta pathology 
consistent with AD. 
 
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 Leqembi. Our reviewer says that this 
request is medically reasonable and necessary. Our physician reviewer found the record indicates that the 
patient has a diagnosis of mild cognitive impairment secondary to Alzheimer's disease with one copy of the 
ApoE4 gene with documented amyloid beta pathology. The Food and Drug Administration has stated that the 
requested drug is indicated for the enrollee's condition.  Our reviewer found that the case file includes 
confirmation of the required registry submission. The elements of the coverage criteria are satisfied. Our 
physician reviewer also found that the requested service is 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 Leqembi have been met. Therefore, we decided that the Plan has to pre-approve 
a lecanemab-irmb (Leqembi) injection (J0174).  
 
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 recement or re-bond crown (D2920) provided on July 18, 
2023. 
 
You asked the Plan to pay for the dental services. You say that this was medically necessary. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already 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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service October 14, 2021. 
Therefore, we decided that the Plan does not have to pay for recement or re-bond crown (D2920) provided on 
July 18, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient psychiatric hospital care provided from 
May 19, 2023, through May 20, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient psychiatric hospital care 
provided was 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 pay for these services. Our reviewer says that the 
acute inpatient psychiatric hospital care provided was not medically necessary. Our physician reviewer found 
that the enrollee was involuntarily admitted for acute inpatient psychiatric hospitalization on May 19, 2023 
with Bipolar Disorder, Current Episode Manic, Severe without Psychotic Features, Other Stimulant 
Dependence, and Uncomplicated and Posttraumatic Stress Disorder. Based upon the review of the records 
provided, it was not expected that this enrollee would improve in a reasonable period of time as she did not 
have dangerousness to self or others and was not showing any auditory/visual hallucinations or any aggressive 
behaviors. It did 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 she did not have dangerousness to self or others. The 
health plans denial of inpatient psychiatric services appears appropriate. This enrollee did not appear to require 
inpatient mental health treatment as she was not a danger to herself or others and was cooperative with care 
without any aggressive behaviors. It did not appear that active treatment was taking place. It did not appear that 
the services were reasonably expected to improve the enrollees condition or were for the purpose of a 
diagnosis. It did appear that the records were supervised and evaluated by a physician. Based upon the review 
of the records provided, the enrollee does not meet criteria for coverage of the acute inpatient mental health 
treatment provided as she was not shown to be a danger to herself or others and did not have auditory or visual 
hallucinations. She was noted to be cooperative and compliant with treatment while not showing any 
aggressive behaviors as she awaited placement. 
 
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 pay for the acute inpatient psychiatric hospital care provided from May 19, 2023, through May 20, 
2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the inpatient hospital stay on June 24, 2023, 
to June 27, 2023. 
 
You asked the Plan to waive the cost share for the inpatient hospital stay. You say that you are requesting 
reconsideration stating you are appealing due to needing the medical services because of the condition and 
circumstances. 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 $231 
copayment per admission for inpatient hospital care. Plan requires prior authorization for inpatient services.  
 
 
 You have been asked to pay a $16,587.94 cost share for the inpatient hospital care. You have been asked to pay 
a total of $16,587.94. The Plan received an authorization, but the authorization was denied for inpatient 
services. This item/service falls within the inpatient hospital care benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the cost share for the inpatient hospital stay on June 24, 2023, to June 27, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the patient needs the long-term acute 
care immediately. You also say that there is no one at the patient's home that could assist them, and due to the 
patient's medical condition, they are unable to assist themself.  The Plan denied your request. The Plan says the 
patient is receiving appropriate in-patient acute care and does not require transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 
 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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the patient is receiving appropriate care in the current acute care setting as provided 
by Health Plan. Our reviewer also found that the documentation does not support that LTACH services are 
medically appropriate at this time. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.