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

 
We decided that the Plan does not have to pre-approve Perjeta and Trazimera. 
 
You asked the Plan to pre-approve Perjeta and Trazimera. 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 Perjeta and Trazimera. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the requested use of Perjeta 
and Trazimera is not FDA-approved for your diagnosis. The use is not supported by one of the major drug 
compendia or by clinical research that appears in a CMS-approved medical journal. There is no phase III data published.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Perjeta and Trazimera have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Perjeta and Trazimera.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an x-ray and magnetic resonance imaging 
(MRI) provided on April 4, 2023. 
 
You asked the Plan to waive the copayments for an x-ray and MRI. You say that you should not be liable for 
another cost share because the provider was not able to use the images taken. 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 $30 
copayment for each Medicare-covered x-ray and a $125 copayment for each Medicare-covered advanced 
radiology service.  
 You have been asked to pay a $155 copayment for an x-ray and MRI. This total includes a $30 copayment for 
an x-ray and a $125 copayment for an MRI. This item/service falls within the outpatient diagnostic tests 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 an x-ray and magnetic resonance imaging 
(MRI) provided on April 4, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home modifications, stair lift provided on February 1, 2023.  
 
You asked the Plan to pay for a stair lift. You say that you would like reconsideration because the requested 
stair lift is medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pay for home modifications, stair lift provided on 
February 1, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT scan, head, or brain; without contrast material 
(70450) provided on February 26, 2023. 
 You asked the Plan to pay for the CT scan. You say that CPT code 70450 was a separate procedure performed 
and should be paid. The Plan denied your request. The Plan says payment for code 70450 is bundled into 
payment for code 70496. 
 
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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the CT scan, head, or brain; without contrast material (70450) 
provided on February 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation to be provided by an OON provider.  
 
You asked the Plan to pre-approve a consultation. You say that you are requesting reconsideration of the 
denied services. The Plan denied your request. The Plan says these services were not approved. 
 
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 
a consultation to be provided by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for chemotherapy drugs provided from 
January 24, 2023, to May 23, 2023. 
 
You asked the Plan to reduce the copayment for chemotherapy drugs. You say that you were not informed of 
your option to get the self-administered injections through Part D at a lower 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 Part B oral anti-cancer drugs.  
 
 You have been asked to pay $6,525 for chemotherapy drugs. This total includes a $1,305 copayment per visit, 
which is 20% of the allowed amount for oral chemotherapy drugs ($6,525 allowed x 20% = $1,305 x 5 visits = 
$6,525). 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 reduce the copayment for chemotherapy drugs provided from January 24, 2023, to May 23, 
2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and 
pelvis. 
 
You asked the Plan to pre-approve the CT scan. You say that the services are medically necessary. The Plan 
denied your request. The Plan says there are no results of an x-ray that support further imaging. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CT scan. Our reviewer says that the 
CT scan is not medically necessary. Our physician reviewer found the available clinical documentation does 
not support that a CT scan of the abdomen and pelvis is medically reasonable and necessary 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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the abdomen and pelvis.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical procedure provided on April 10, 2023. 
 You asked the Plan to pay for the surgical procedure. You say that the enrollee was not on hospice when the 
services were rendered. The Plan denied your request. The Plan says Original Medicare is responsible for 
payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on April 8, 2023. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the surgical procedure 
provided on April 10, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital facility visits provided 
from April 11, 2023, to April 29, 2023. 
 
You asked the Plan to waive the copayment for outpatient hospital facility visits. You say that you were told 
the provider checked with the Plan and confirmed there was no charge. 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 $295 
copayment for each outpatient hospital facility visit.  
 
You have been asked to pay $4,425 for outpatient hospital facility visits. This total is less than the standard 
copayment for the hospital facility visits because your maximum out-of-pocket was met. This item/service falls 
within the physician/practitioner 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. Therefore, we decided that the Plan does not have to waive the copayment 
for outpatient hospital facility visits provided from April 11, 2023, to April 29, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for chemotherapy treatment provided on May 
15, 2023. 
 
You asked the Plan to reduce the coinsurance for chemotherapy treatment. You say that your monthly income 
has been reduced while you are on leave and the cost share for the treatment is too much. 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 chemotherapy and non-chemotherapy prescription drugs.  
 
You have been asked to pay $4,146.24, which is less than the standard coinsurance for chemotherapy 
treatment. 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 reduce the coinsurance for chemotherapy treatment provided on May 15, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient therapy services provided from January 13, 
2022, to March 1, 2022. 
 
You asked the Plan to pay for SNF stay. You say that you were not aware of the enrollee's Plan at the time of 
admission and authorization. The Plan denied your request. The Plan says the claim was submitted after the 
timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for SNF stay was not filed until May 26, 2023. This means that more than one 
calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan 
does not have to pay for the outpatient therapy services provided from January 13, 2022, to March 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray and palliative (emergency) treatment 
(D0220, D9110) provided on April 26, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental 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. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
intraoral x-ray and palliative (emergency) treatment (D0220, D9110) provided on April 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for maxillary and mandibular partial dentures (D5211, D5212) 
provided on May 4, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 June 1, 2021. Therefore, 
we decided that the Plan does not have to pay for maxillary and mandibular partial dentures (D5211, D5212) 
provided on May 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cleaning, topical application of fluoride, and occlusal guard 
(D9944, D1110, D1206) provided on April 13, 2023, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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. This benefit does not include occlusal 
guards. 
 
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. Coverage for 
the occlusal guard denied correctly as they do not fall within your dental benefits, regardless of the providers 
network status. 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 a cleaning, topical application of fluoride, and occlusal guard 
(D9944, D1110, D1206) provided on April 13, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation, intraoral x-ray, cone beam 
computed tomography (CT) scan, endodontic therapy, retreatment of previous root canal therapies (D0140, 
D0364, D0220, D3346, D3310) provided on June 9, 2022, to June 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental 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. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a limited 
oral evaluation, intraoral x-ray, cone beam computed tomography (CT) scan, endodontic therapy, retreatment 
of previous root canal therapies (D0140, D0364, D0220, D3346, D3310) provided on June 9, 2022, to June 23, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6531. 
 
You asked the Plan to pre-approve the compression stockings. You say that you are appealing the denied 
compression stockings. The Plan denied your request. The Plan says the enrollee is not suffering from active 
ulcers, or any burn and/or recent surgical wound that need compression stockings. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6531 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that the enrollee has open venous stasis ulcers or a qualifying wound. This means 
that the enrollee does not have a medical condition for which compression stockings can be covered or paid for 
by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings 
identified with code A6531.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics.  
 
You asked the Plan to pre-approve foot orthotics. You say that because of your health condition you should 
warrant the foot inserts to help relieve your pain. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
  Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an OON provider.  
 
You asked the Plan to pre-approve physical therapy. You say that the enrollee cannot go to another provider 
because of the language barrier. The Plan denied your request. The Plan says the service can be provided by an 
in-network provider. 
  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 
physical therapy to be provided by an OON provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient services received on October 20, 2022, to 
November 1, 2022.  
 
You asked the Plan to pay for the inpatient services. You say that the services should be covered. The Plan 
denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 The enrollee ended Medicare Hospice benefits on October 7, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the inpatient services 
received on October 20, 2022, to November 1, 2022. You should submit a separate claim for the date of service 
November 1, 2022, so the plan can process the non-hospice date.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the vision services provided on May 25, 
2023. 
 
You asked the Plan to waive the copayment for the vision services. You say that you never received services. 
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 $32 
copayment for in-network vision care. 
 
You have been asked to pay a $32 copayment for the vision services. This item/service falls within the in-
network 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. The medical records show services were rendered. Therefore, we decided that the Plan does not 
have to waive the copayment for the vision services provided on May 25, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve the therapy services. You say that you live an hour from the network 
provider and the driving increases your pain. You have also used your requested provider for years. The Plan 
denied your request. The Plan says network providers are available to render necessary care. 
 
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 
physical therapy services to be provided by an out-of-network (OON) provider.