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

 
We decided that the Plan does not have to waive the copayment for a CT scan of chest (71260) performed on 
April 16, 2020 or to pay for self-administered drugs received from April 16 to April 18, 2020. 
 
You asked the Plan to waive the copayment for a CT scan of chest and to pay for self-administered drugs. You 
say that you should not be liable for these payments. The Plan denied your request. The Plan says the correct 
copayment for a CT scan of chest was applied and that self-administered drugs are covered under the Part D 
prescription drug benefit. 
 
Regarding the request to waive the copayment for a CT scan of chest: 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 $225 copayment for each Medicare-
covered advanced imaging service (not including x-rays).  
 
You have been asked to pay a $225 copayment for a CT scan of chest. A CT scan of chest falls 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 copayment for a CT scan of chest (71260) performed on April 16, 2020.  
 
Regarding the request to pay for self-administered drugs: 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 received from April 16 to April 18, 2020.  
 
Benefits for self-administered drugs 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cystourethroscopy services (CPT 52240) provided to the 
enrollee on February 4, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 52240 (1 unit) remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 52240 is "cystourethroscopy, with fulguration and/or 
resection of; large bladder tumor." 
 
We asked our coding 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 the services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our coding reviewer found the medical 
records provided do not include documented measurement to validate the Cystourethroscopy, with fulguration 
(including cryosurgery or laser surgery) and/or resection of; LARGE bladder tumor(s) was actually performed 
on a large bladder tumor. Stating "large" is not enough information to corroborate this service was performed, 
therefore, this service cannot be verified 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for cystourethroscopy services (CPT 52240) provided to the enrollee on February 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and coinsurance for IV infusion therapy and 
Medicare Part B drugs provided from January 16, 2020 to March 27, 2020. 
 
You asked the Plan to waive the deductible and coinsurance for IV infusion therapy and Medicare Part B drugs. 
You say that you feel that you should not be charged both a deductible and coinsurance for the services. 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. Your 
contract with the Plan says that there is a $1,000 deductible. Your contract with the Plan also clearly says that 
after the $1,000 deductible has been met, enrollee's must pay 20% coinsurance for IV therapy and Medicare 
Part B prescription drugs.  
 
You received IV infusion therapy and Medicare Part B drugs from January 16, 2020 to March 27, 2020. The 
record shows that you had not met the deductible amount prior to receiving the services. Therefore, you are 
responsible to pay your share of the cost-sharing charges.
 
The total amount you owe is: $1,875.03. 
 
The item or service you asked the Plan to waive the deductible and coinsurance for falls within the benefit 
category Medicare Part B prescription drugs and outpatient hospital services. The Plan has followed Medicare 
rules by clearly disclosing in the contract that there is a $1,000 deductible. The Plan has also followed 
Medicare rules by clearly disclosing in the contract that after the $1,000 deductible has been met, enrollee's 
must pay 20% coinsurance for IV therapy and Medicare Part B prescription drugs. This cost sharing is a 
contractual obligation that had not been met at the time IV infusion therapy and Medicare Part B drugs were 
received on January 6, 2020 to March 27, 2020. Therefore, we decided that the Plan does not have to waive the 
deductible and coinsurance for IV infusion therapy and Medicare Part B drugs provided from January 16, 2020 
to March 27, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an observation stay provided on April 19, 
2020. 
 
You asked the Plan to waive the copayment for an observation stay. You say that you resent that you were in 
observation because your finger still hurts and the doctor never looked at it. 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 $250 
copayment for observation services.  
 
You have been asked to pay a $250 copayment for an observation stay. An observation stay falls within the 
outpatient hospital observation 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 
an observation stay provided on April 19, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for insertion of tunneled centrally inserted central venous access 
device with subcutaneous port provided on December 5, 2019. 
 
You asked the Plan to pay for the insertion of tunneled centrally inserted central venous access device with 
subcutaneous port. The Plan denied your request. The Plan says the Plan requires utilization of network 
providers when possible and available and requires authorization for certain services. No medical necessity for 
an out-of-network provider, such as an urgent or emergency situation, has been documented. 
 
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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for insertion of tunneled centrally inserted central venous access 
device with subcutaneous port provided on December 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for telemedicine specialist visit provided by a 
participating provider on May 27, 2020. 
 
You asked the Plan to waive the copayment for telemedicine specialist visit. You say that you are hearing 
impaired and you had trouble having your therapy over the phone. The Plan denied your request. The Plan says 
the correct copayment has been applied. 
 
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 physician/practitioner services/in-network/specialist.  
 
You have been asked to pay a $40 copayment for telemedicine specialist visit. Since specialist services were 
provided, the correct copayment has been applied. Telemedicine specialist visit falls within the 
physician/practitioner services/in-network/specialist 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 telemedicine specialist visit provided by a participating provider on May 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (LSO), transcutaneous electrical 
nerve stimulation (TENS) unit, and supplies provided on December 30, 2019. 
 
You asked the Plan to pay for orthosis, TENS unit, and supplies. You say that you have submitted a letter of 
medical necessity and proof of delivery. The Plan denied your request. The Plan says the denial of payment for 
these items is correct, because the records do not support that a face-to-face examination occurred between the 
ordering physician and enrollee and there is no proof of delivery to the enrollee. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the Plan sufficient 
information to determine whether payment is due. 
 
We looked at the file and Medicare rules. Although a shipment tracking number was submitted, proof of 
delivery of these items was not submitted to the Plan. The Plan requested this information, but it was not 
submitted. Without this information, you have not furnished sufficient information to justify payment of this 
claim as billed. Based on this information, we decided that Medicare rules for coverage of orthosis, TENS unit, 
and supplies have not been met. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral 
orthosis (LSO), transcutaneous electrical nerve stimulation (TENS) unit, and supplies provided on December 
30, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the CGM is medically necessary. The Plan denied 
your request. The Plan says that coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that CGM's are covered when 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 CGM. Our reviewer says that the 
CGM is medically necessary in this case. Our physician reviewer found the enrollee has diabetes. The enrollee 
checks their blood glucose multiple times daily and injects insulin 4 times daily. Dosage is adjusted depending 
on the readings. A CGM is 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 the CGM have been met. Therefore, we decided that the Plan has to pre-
approve a continuous glucose monitor (CGM).  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a diagnostic ultrasound provided on March 4, 2020. 
 
You asked the Plan to pay for the diagnostic ultrasound. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a diagnostic ultrasound provided on March 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a tennis club membership. 
 
You asked the Plan to pay for a tennis club membership. You say that you have been reimbursed for your 
tennis club membership in the past. The Plan denied your request. The Plan says this is not covered under your 
Wellness Allowance benefit. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits 
only for membership in a qualified health club or fitness facility. The Plan contract explicitly excludes sports 
activities such as golf and tennis. 
 
The Plan's rules for coverage of gym benefits have not been met because a tennis club is not a qualified health 
club or fitness facility and tennis is explicitly excluded from coverage. Therefore, we decided that the Plan does 
not have to pay for a tennis club membership.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visits and services received 
from March 11 to April 7, 2020. 
 
You asked the Plan to waive the copayment for specialist office visits and services. You say that you should 
not be charged for visits and services that were consequences of a physician procedure (a prostate exam). The 
Plan denied your request. The Plan says the correct copayments were applied. 
 
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 medically necessary medical care or surgery services furnished in a physician's office.  
 
You have been asked to pay a $30 copayment for specialist office visits and services. Specialist office visits 
and services falls within the "Physician/Practitioner services, including doctor's office visits" 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 specialist office visits and services received from March 11 
to April 7, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy provided on January 27, 
2020. 
 
You asked the Plan to waive the coinsurance for chemotherapy. You say that you cannot afford the 
chemotherapy charges. 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You received chemotherapy on January 27, 2020. The total allowed amount is $10,617.34 and 20% of that is 
$2,123.47.  
 
You have been asked to pay the total coinsurance amount of $2,123.47 for chemotherapy. Chemotherapy 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 chemotherapy provided on January 27, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a skilled nursing stay provided by a 
participating provider on February 25, 2020 to March 21, 2020. 
 
You asked the Plan to waive the copayment for a skilled nursing stay. You say that you were told that this 
would be covered 100%. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
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 $0 
copayment per day for days 1-20. There is a $178 copayment per day for days 21-100 for skilled nursing 
facility care/in-network.  
 
You have been asked to pay a $0 copayment per day for days 1-20. There is a $178 copayment per day for days 
21-26 for a skilled nursing stay. The total amount you are being asked to pay is $890 ($178 x 5 days (days 21-
26) = $890). A skilled nursing stay falls within the skilled nursing facility care/in-network 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 skilled nursing stay provided by a participating provider 
on February 25, 2020 to March 21, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided October 3, 2019 to October 7, 
2019. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you disagree with the denial. The Plan 
denied your request. The Plan says that the services were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the enrollee presented to the hospital on October 3, 2019 to the emergency department (ED) 
with weakness, nausea, vomiting, and diarrhea for three days. She was noted to be c. diff positive and was 
placed on oral Vancomycin. The records support that, at the time of the inpatient admission, the admitting 
physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided October 3, 2019 to October 7, 2019.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on February 4, 
2020. 
 
You asked the Plan to pay for the hospital outpatient clinic visit. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require prior authorization.  
 
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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on February 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio. 
 
You asked the Plan to pre-approve Entyvio (J3380). You say that you want the enrollee to be treated with this 
drug. The Plan denied your request. The Plan says the enrollee has not first tried and had a contraindication or 
intolerance to Remicade, Inflectra, or Stelara. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Entyvio (J3380). Our reviewer says that 
the drug is not reasonable and medically necessary. Our physician reviewer found Entyvio does not meet 
criteria in lieu of Plan-proposed step therapy with the alternative biologics as mentioned that are Plan-
preferred. The plan's required drugs would not likely be less effective and/or likely have adverse effects for the 
enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Entyvio (J3380) have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Entyvio.