Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for each spinal injection provided on August 
24, 2022, to October 27, 2022. 
 
You asked the Plan to reduce the copayment for each spinal injection. You say that this is an ambulatory 
surgical center not an outpatient hospital. 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 $250 
copayment for in-network outpatient surgery at an outpatient hospital. 
 
You have been asked to pay a $250 copayment for each spinal injection. This item/service falls within the in-
network outpatient surgery at an outpatient hospital 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 records show that the injections were provided at an 
outpatient hospital. Therefore, we decided that the Plan does not have to reduce the copayment for each spinal 
injection provided on August 24, 2022, to October 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5130) purchased on  
June 24, 2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable as 
they were purchased from an out-of-network provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased through the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract states that coverage is provided for 
hearing aids only when purchased through the Plans select hearing aid provider. However, the hearing aids in 
this case were purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to 
issue reimbursement for the hearing aids (V5130) purchased on June 24, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 87631 and 87798 provided on October 21, 2021. 
 
You asked the Plan to pay for procedure codes 87631 and 87798. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not 
covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-
of-network with the Plan. The documentation submitted does not include prior notice from the Plan that these 
tests would not be covered. Without this information, we cannot determine whether the lab order made 
constituted plan-directed care. Therefore, we decided that the Plan has to pay for procedure codes 87631 and 
87798 provided on October 21, 2021.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on December 07, 2022. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for lab testing provided on 
December 07, 2022.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee did not have a 3-day qualifying inpatient stay.

The Plan must follow Medicare rules. Medicare rules say that beneficiaries must have been an inpatient of a hospital for a medically necessary stay of at least 3 consecutive calendar days for SNF services to be approved.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Specifically, the documentation does not show that the enrollee had a 3-day inpatient hospital stay prior to this request. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan supartz visco-3 injection. 
 
You asked the Plan to pre-approve Hyalgan supartz visco-3 injection. You say that the services are necessary. 
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 Hyalgan supartz visco-3 injection. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the medical records received from the enrollee's provider, dated April 14, 
2023, state that the enrollee has not failed at least three (3) months of physical therapy. The review has 
determined that the items/services at issue in this case are not medically reasonable or 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 Hyalgan supartz visco-3 injection have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Hyalgan supartz visco-3 injection.
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 the Freestyle Libre 3 sensor. The Plan denied your request. The Plan says 
that you are requesting a CGM product that does not meet Medicare's definition of durable medical equipment 
(DME) and, therefore, is not in a defined Medicare benefit category. 
 
The Plan must follow Medicare rules. Medicare rules say that a non-adjunctive continuous glucose monitor 
(CGM) must be billed with code E2103. The rules also say that only devices reviewed by the PDAC and 
assigned code E2103 may be billed using this code.   
We looked at the file and Medicare rules. The request at issue is for the Freestyle Libre 3 non-adjunctive CGM. 
The records show 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. The Freestyle Libre 3 is not specified as a product that 
may be billed using code E2103. Therefore, the Freestyle Libre 3 is not eligible for reimbursement. However, 
this device has not been reviewed by the PDAC and has not been assigned code E2103. As such, this non-
adjunctive CGM device is not eligible for coverage at this time. Therefore, we decided that the Plan does not 
have to pre-approve a Freestyle Libre 3 sensor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that you have been without diabetic supplies for two and 
half months. The Plan denied your request. The Plan says the medical criteria for a CGM have not been met. 
 
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 insulin with at 
least three daily injections, or require frequent self-adjustment of insulin dosage based on the blood glucose 
testing results. Based on this information, we decided that Medicare rules for coverage of a CGM have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous 
glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ankle-foot orthosis (L1932) to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve an ankle-foot orthosis to be provided by an OON provider. You say that the 
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able 
to provide these services. Therefore, coverage criteria have not been met. 
 
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 
an ankle-foot orthosis (L1932) to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 1, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on November 1, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided on 
December 06, 2022. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that you were seen in urgent 
care. 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 $65 
copayment for emergency care. 
 
You have been asked to pay a $65 copayment for the emergency room visit. This item/service falls within the 
emergency 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 you were seen in the emergency department. Therefore, we decided that the 
Plan does not have to waive the copayment for the emergency room visit provided on December 06, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abutment support crown (D6058) for tooth #19 provided 
on July 22, 2022. 
 
You asked the Plan to pay for the dental service. You say that you needed an implant, and you would like the 
Plan to pay for the crown. The Plan denied your request. The Plan says the denial of payment for this service is 
correct, because the abutment support crown is not covered by the Plan. 
 
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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
abutment support crown (D6058) for tooth #19 provided on July 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pulp vitality tests (D0460) Tooth #3 provided on January 18, 
2023. 
 
You asked the Plan to pay for dental services. You say that you do not agree with the denial of payment for the 
services you received. The Plan denied your request. The Plan says this service is not covered under your Plan. 
 
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. Pulp vitality tests (D0460) is 
not covered under the Plans dental benefits. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D0460 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for pulp vitality tests 
(D0460) Tooth #3 provided on January 18, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance image (MRI) 
provided on September 08, 2022. 
 
You asked the Plan to waive the copayment for a magnetic resonance image (MRI). You say that you do not 
understand why you are responsible for a cost share but the Plan is not. 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 $375 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $375 copayment for a magnetic resonance image (MRI). This item/service falls 
within the outpatient diagnostic test 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 total you owe is $255.50, which is less than the standard $375 copayment 
for an MRI. Therefore, we decided that the Plan does not have to waive the copayment for a magnetic 
resonance image (MRI) provided on September 08, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) 
provided on October 18, 2022. 
 
You asked the Plan to waive the copayment for a magnetic resonance imaging (MRI). You say that you were 
referred to the facility by your provider because they were unable to accommodate an MRI and you should not 
be held liable for 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 $100 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $100 copayment for a magnetic resonance imaging (MRI). This item/service falls within the outpatient diagnostic test 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 magnetic resonance imaging (MRI) provided on October 18, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for observation care provided on September 28, 2022. 
 
You asked the Plan to pay for observation care. You say that you are requesting reconsideration. 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 observation care 
provided on September 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for basic metabolic panel provided on September 29, 2022. 
 
You asked the Plan to pay for basic metabolic panel. 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 basic metabolic panel 
provided on September 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the physical therapy visit provided on 
December 16, 2022. 
 
You asked the Plan to waive the copayment for the physical therapy visit. You say that these services 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 $25 
copayment for outpatient rehabilitation services. 
 
You have been asked to pay a $25 copayment for the physical therapy visit. This item/service falls within the 
outpatient rehabilitation services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The medical records show you were seen by a provider on December 16, 2022. 
Therefore, we decided that the Plan does not have to waive the copayment for the physical therapy visit 
provided on December 16, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on November 19, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that a 
bystander called 911 against your wishes. You also say that when the paramedics arrive you were feeling 
better. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on November 19, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on November 19, 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 the CGM. You say that your diabetes is escalating, and you need the 
requested CGM. The Plan denied your request. The Plan says the requested product is excluded from Medicare 
coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that a non-adjunctive CGM must be billed with code 
E2103. The rules also say that only devices reviewed by the PDAC and assigned code E2103 may be billed 
using this code.  We looked at the file and Medicare rules. The request at issue is for the Freestyle Libre 3 non-adjunctive CGM. 
However, this device has not been reviewed by the PDAC and has not been assigned code E2103. As such, this 
non-adjunctive CGM device is not eligible for coverage at this time. Therefore, we decided that the Plan does 
not have to pre-approve a Freestyle Libre 3 sensor.