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

 
We decided that the Plan does not have to pay for genetic testing for heart transplant provided on October 20, 
2022. 
 
You asked the Plan to pay for genetic testing for heart transplant. You say that this was medically necessary 
and should be 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 genetic testing for heart 
transplant provided on October 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on October 13, 2022. 
 
You asked the Plan to pay for the office visit. You say that the provider did not have the correct insurance 
information. 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 the office visit provided 
on October 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular cancer genomics (CGx) testing June 17, 2022. 
 
You asked the Plan to pay for the CGx testing. You say that this testing will help in choosing the right cancer 
treatment for the enrollee. The Plan denied your request. The Plan says the testing should be billed with a 
single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. The test panel is a single test with multiple components and is characterized by a single unit of service (UOS = 1). A panel cannot be unbundled and billed as individual 
components regardless of the fact that the test reports multiple individual pathogens and/or targets. Based on 
this information, we decided that Medicare rules for coverage of the CGx testing have not been met. Therefore, 
we decided that the Plan does not have to pay for the molecular cancer genomics (CGx) testing June 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit provided on September 06, 
2022. 
 
You asked the Plan to pay for the domiciliary or rest home visit. You say that the enrollee was in a nursing 
home and authorization should not be required. 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 the domiciliary or rest 
home visit provided on September 06, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for an in-network, inpatient urology consultation provided from September 
5, 2022, to September 10, 2022 
 
You asked the Plan to pay for an in-network, inpatient urology consultation. You say that you had this 
consultation during an in-network inpatient stay. You did not have a choice of who you saw while you were 
there. The Plan denied your request. The Plan says that this provider is out-of-network 
 
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 failed to forward information regarding their decision that this provider 
was out-of-network. Therefore, we decided that the Plan has to pay for an in-network, inpatient urology 
consultation provided from September 5, 2022, to September 10, 2022  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0998) provided on October 20, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this service is non-covered. 
 
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 October 20, 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 ambulance services (A0998) provided on October 
20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an magnetic resonance imaging (MRI) 
provided on November 08, 2022. 
 
You asked the Plan to waive the copayment for an magnetic resonance imaging (MRI). You say that you 
disagree with the copayment. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 
copayment for outpatient diagnostic tests/MRIs. 
 
You have been asked to pay a $350 copayment for an magnetic resonance imaging (MRI). This item/service 
falls within the outpatient diagnostic tests/MRIs 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 magnetic resonance imaging (MRI) provided on November 08, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a single axis (L5828), stance flexion feature (L5845), 
fluid stance extension (L5848), and microprocessor control feature, swing and stance phase (L5856). 
 
You asked the Plan to pre-approve a single axis, stance flexion feature, fluid stance extension, and 
microprocessor control feature. You say that you would like this denial to be overturned for the prescribed 
microprocessor-controlled knee system. The Plan denied your request. The Plan says this request does not meet 
Medicare criteria as reasonable and necessary. 
 
The Plan follows Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of foot. 
 
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 a single axis, stance flexion feature, 
fluid stance extension, and microprocessor control feature. Our reviewer says that the requested items are not 
medically reasonable and necessary for the enrollee. Our physician reviewer found the records document that 
the enrollee is a K3 level ambulator. Our reviewer also found that the provided records from the enrollee's 
treating physician do not fully clarify why a K3 mechanical knee would not meet their mobility needs and why 
only the microprocessor-controlled knee system is appropriate for them. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a single axis, stance flexion feature, fluid stance extension, and microprocessor 
control feature have not been met. Therefore, we decided that the Plan does not have to pre-approve a single 
axis (L5828), stance flexion feature (L5845), fluid stance extension (L5848), and microprocessor control 
feature, swing and stance phase (L5856).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sales tax (D9985). 
 
You asked the Plan to pre-approve sales tax. You say that these services are medically necessary. The Plan 
denied your request. The Plan says these services have been processed correctly. 
 
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 pre-approve sales 
tax (D9985).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve unspecified dental implant procedure, by report 
(D6199). 
 
You asked the Plan to pre-approve dental services. You say that you need the requested services for your 
quality of dental health. 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 Plan's coverage rules apply in this case. Unspecified dental implant 
procedure, by report (D6199) is not covered under the Plan's dental benefits. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested unspecified dental 
implant procedure, by report (D6199) is not among those covered under this benefit. Therefore, we decided that 
the Plan does not have to pre-approve unspecified dental implant procedure, by report (D6199).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on November 17, 
2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you disagree with the copayment. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 
copayment for outpatient diagnostic tests/ultrasound. 
 
You have been asked to pay a $100 copayment for an ultrasound. This item/service falls within the outpatient 
diagnostic tests/ultrasound 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 
ultrasound provided on November 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SSBCI benefits. 
 
You asked the Plan to pre-approve the SSBCI benefits. You say that you believe you are eligible for the SSBCI 
benefits. The Plan denied your request. The Plan says your provider returned the attestation form stating that 
you do not meet all three of the criteria. Therefore, you do not qualify for services under SSBCI program. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the SSBCI benefits have not been met. Specifically, we have confirmed that you do not meet the 
intensive care management criteria listed in the EOC, which is 2 or more inpatient admission in the last 60 
days, or 3 or more emergency room visits in the last 60 days. Therefore, we decided that the Plan does not have 
to pre-approve the SSBCI benefits.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a denosumab injection provided on 
October 12, 2022. 
 
You asked the Plan to waive the coinsurance for a denosumab injection. You say that you were unaware of a 
copayment for the injection drug. 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 Medicare Part B non-chemotherapy prescription drugs.  
 
You have been asked to pay a total of $229.56 coinsurance for a denosumab injection ($1147.80 allowed 
amount x 20% coinsurance = $229.56 coinsurance). This item/service falls within the Medicare Part B non-
chemotherapy 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 a 
denosumab injection provided on October 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infusion therapy and office visits (96127, 96365, 99215, 
J3490) provided on September 5, 2022, through September 24, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for infusion therapy and office visits. You say that the requested treatments are 
medically necessary due to your medical condition. The Plan denied your request. The Plan says the requested 
provider is not Medicare certified and does not accept Medicare payments. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Records show that you were told prior to starting treatment that the services were not covered, and 
you would have to pay out of pocket. Therefore, we decided that the Plan does not have to pay for infusion 
therapy and office visits (96127, 96365, 99215, J3490) provided on September 5, 2022, through September 24, 
2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary partial denture (D5225), and mandibular 
partial denture (D5226). 
 
You asked the Plan to pre-approve the dental services. You say that n?A The Plan denied your request. The 
Plan says dental services from an out-of-network provider are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve maxillary 
partial denture (D5225), and mandibular partial denture (D5226).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110), and complete 
denture - mandibular (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that the dentures are deemed unrepairable. 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 services was exhausted on date of service October 21, 2021. Therefore, 
we decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110), and complete 
denture - mandibular (D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM). 
 
You asked the Plan to pay for the CGM. You say that the items should be covered as the enrollee disagrees 
with the denial. The Plan denied your request. The Plan says the services 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 have not been met. Therefore, we 
decided that the Plan does not have to pay for a continuous glucose monitor (CGM).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network diagnostic colonoscopy and 
laboratory services provided on October 12, 2022. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy and laboratory services. You say that 
you were told you were fine, and this should not be diagnostic. 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 $290 
copayment for outpatient surgery provided in an outpatient hospital facility.  
 
Your contract with the Plan also clearly says that you must pay a $10 copayment for outpatient diagnostic 
laboratory tests.  
You have been asked to pay a $290 copayment for a diagnostic colonoscopy. This item/service falls within the 
outpatient surgery provided in an outpatient hospital facility benefit category. You have also been asked to pay 
$3.93 copayment for laboratory services because the allowed amount for this service is less than the $10 
copayment. This item/service falls within the outpatient diagnostic laboratory 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 copayment for an in-network diagnostic colonoscopy and laboratory 
services provided on October 12, 2022.
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 insert. You say that you would like reconsideration because the 
requested foot insert is medically necessary. 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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown (D2751). 
 
You asked the Plan to pre-approve a crown. You say that you need this crown. The Plan denied your request. 
The Plan says that medical criteria for D2751 have not been met. 
 
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 has failed to provide a 2023 Evidence of Coverage. Therefore, we 
decided that the Plan has to pre-approve a crown (D2751).  
 
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.