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

 
We decided that the Plan does not have to waive the copayment for the abdominal ultrasound performed by an 
in-network provider on October 27, 2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you think that this service should 
be covered. 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 $130 
copayment for in-network Medicare-covered diagnostic radiology services, which includes ultrasounds, 
performed in a physicians office or at a free-standing facility (such as a radiology center or medical clinic). 
 
 
 
 You have been asked to pay a $87.72 copayment for the ultrasound because the allowed amount for this service 
is less than the $130 copayment. This item/service 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 the 
abdominal ultrasound performed by an in-network provider on October 27, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on October 
06, 2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the 
copaymet. 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 $300 
copayment for ambulance services. 
 
You have been asked to pay a $300 copayment for ambulance services. This item/service falls within the 
ambulance 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 ambulance services 
provided on October 06, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) and supplies (K0553, 
K0554). 
 
You asked the Plan to pay for the CGM and supplies. You say that the items should be covered as the enrollee 
disagrees with the denial. The Plan denied your request. The Plan says the items denied correctly as the 
enrollee does not meet the clinical requirements to be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the CGM and supplies have not been met. 
Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor (CGM) and supplies 
(K0553, K0554).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a urogynecology second opinion to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the second opinion. You say that you would like a second opinion for 
treatment. 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 
a urogynecology second opinion to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that the item should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair 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 pre-approve a shower chair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the aflibercept injection provided on 
December 6, 2022. 
 
You asked the Plan to waive the cost sharing for the injection. You say that you were not aware that there was a 
cost share for this service. 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 20% 
coinsurance for Part B drugs, including chemotherapy drugs. 
 
You have been asked to pay a cost share of $365.16 for the injection ($1825.78 allowed amount x .20 = 
$365.16). 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 cost sharing for the aflibercept injection provided on December 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on August 04, 
2022. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the records attached support the 
services provided. 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 domiciliary or rest 
home visit provided on August 04, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography scan and related services provided on 
May 16, 2022. 
 You asked the Plan to pay for computed tomography and related services.. You say that the enrollee was not 
enrolled in hospice until June 10, 2022. 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 May 12, 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 computed tomography scan 
and related services provided on May 16, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a SNF stay provided from May 24, 2022, 
to May 31, 2022. 
 
You asked the Plan to reduce the copayment for a SNF stay. You say that you were informed by a Plan 
representative that you should only be required to pay for 3 days at a rate of $188 per day. 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 each day for days 1 to 20, a $188 copayment each day for days 21 to 44, and $0 copayment for 
additional covered days up to 100 for Medicare-covered SNF care.  
 
 
  You have been asked to pay a total copayment of $1,504 for a SNF stay ($188 per day x 8 days = $1,504). This 
item/service falls within the Medicare-covered 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 reduce the copayment for a SNF stay provided from May 24, 2022, to May 31, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient mental health visit provided on August 18, 
2022. 
 
You asked the Plan to pay for an outpatient mental health visit. You say that the records attached support the 
services provided. 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 outpatient mental 
health visit provided on August 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for general health panel laboratory services provided on October 
26, 2022. 
 
You asked the Plan to pay for general health panel laboratory services. You say that the records attached 
support the services provided. 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 general health panel 
laboratory services provided on October 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on December 23, 
2021. 
 
You asked the Plan to pay for periodontal maintenance. You say that you disagree with the denial for 
periodontal maintenance. 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 dates of service March 9, 2021, June 10, 
2021, and September 13, 2021. Therefore, we decided that the Plan does not have to pay for periodontal 
maintenance (D4910) provided on December 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 01, 2022. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and should be covered. 
The other two visits were covered. 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 September 01, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from August 12, 2022, 
to August 26, 2022. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you would like a reconsideration of 
the cost share because you were unaware you would be responsible for a copayment after day 20. 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 $188 copayment per day for days 21 to 100 for skilled nursing facility care.  
 
You have been asked to pay a total copayment of $2,632 for a SNF stay ($188 per day x 14 days = $2,632). 
This item/service falls within the skilled nursing facility 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 August 12, 2022, to August 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on September 30, 
2022. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the records attached support the 
services provided. 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 domiciliary or rest 
home visit provided on September 30, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services provided on July 21, 2022. 
 
You asked the Plan to pay for hospital services. You say that this should be covered. The Plan denied your 
request. The Plan says the 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 July 11, 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 hospital services provided 
on July 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an advance care planning service provided on November 07, 
2022. 
 
You asked the Plan to pay for an advance care planning service. You say that the records attached support the 
services provided. 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 advance care 
planning service provided on November 07, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an IRF stay provided from October 25, 
2022, to November 3, 2022. 
 
You asked the Plan to waive the copayment for an IRF stay. You say that the inpatient facility stated you would 
not have 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 $300 
copayment for days 1 to 6 and the Plan pays 100% of covered expenses after day 6 for an inpatient 
rehabilitation stay.  
 
 
  You have been asked to pay a total copayment of $1,696 for an IRF stay. This total is less than the standard 
copayment because your out-of-pocket maximum was met with the cost share applied to this claim. This 
item/service falls within an 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 
copayment for an IRF stay provided from October 25, 2022, to November 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3 sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre 3 sensor. You say that the requested Libre 3 is medically 
necessary. The Plan denied your request. The Plan says that a Freestyle Libre 3 is not a Medicare-covered 
product. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
The record shows that you are requesting coverage of a non-adjunctive CGM. As of January 1, 2023, the 
appropriate coding for a non-adjunctive CGM is E2103. Therefore, we decided that the Plan does not have to 
pre-approve a Freestyle Libre 3 sensor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cleaning (D1110) provided on October 24, 2022. 
 
You asked the Plan to pay for the dental service. You say that you have been with the provider for more than 
10 years and the dental procedures were 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid for benefit for cleanings on the dates of service February 9, 2022, and June 2, 2022; 
therefore, your benefit for the requested item or service was exhausted on the date of service of June 2, 2022. 
Therefore, we decided that the Plan does not have to pay for a cleaning (D1110) provided on October 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 01, 2022. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
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 April 01, 2022.