Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to waive the copayment for the drug administration. We decided that the Plan 
does not have to waive the copayment for the triamcinolone acetonide injection.   
You asked the Plan to waive the copayments for the triamcinolone acetonide injection and drug administration 
provided on May 26, 2022. You say that you were told you would only have one copayment for services 
rendered that day. The Plan says that this cost sharing was charged correctly. 
 
We decided that the Plan has to waive the copayment for the drug administration.  
 
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 enrollees must pay $0 for the administration of chemotherapy drugs as well as 
for infusion therapy. The Plan says you must pay a $15 copayment for drug administration. Based on the Plan 
contract, however, you cannot be asked to pay more than $0 for the administration of chemotherapy drugs as 
well as for infusion therapy. Therefore, we decided that the Plan has to waive the copayment for the drug 
administration.  
 
We also decided that the Plan does not have to waive the copayment for the triamcinolone acetonide 
injection. 
 
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 $15 
copayment for each chemotherapy or infusion therapy Part B drug. Therefore, we decided that the Plan does 
not have to waive the copayment for the triamcinolone acetonide injection. 
 
You have been asked to pay a $15 copayment for a triamcinolone acetonide injection. This item/service falls 
within the Medicare Part B 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. 
 
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 the ambulance response and treatment with no transport 
(A0998) provided on February 14, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
ambulance took your vitals, and everything was normal, so you made the decision to not to be taken to the 
hospital. You also say that you saved the Plan and Medicare money by not going to the hospital. The Plan 
denied your request. The Plan says the ambulance was called, and you refused to be transported to an 
emergency facility. 
 
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 February 14, 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 (A0998) provided on February 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab services provided on September 23, 
2022. 
 
You asked the Plan to waive the copayment for lab services. You say that this should be part of your annual 
visit, it should not have a seperate copay. 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 $10 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $10 copayment for lab services. 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 lab services provided on September 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two labial veneers (D2962 x2) provided on September 7, 
2022. 
 
You asked the Plan to pay for the labial veneers. You say that you were never told this service was not a 
covered benefit. The Plan denied your request. The Plan says this service is not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the two 
labial veneers (D2962 x2) provided on September 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 23, 2023. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advanced. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for laboratory services provided on June 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CGM supplies (K0553). 
 
You asked the Plan to pre-approve CGM supplies. You say that you need a prescription so you can order it 
outside of the Plan. The Plan denied your request. The Plan says that the coverage criteria has 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 you do not use insulin with at least 
three daily injections and do not 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 CGM supplies have 
not been met. Therefore, we decided that the Plan does not have to pre-approve CGM supplies (K0553).  
 
Your complaint about sending your prescription to your designated outside pharmacy is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation (A0170). 
 
You asked the Plan to pre-approve additional mileage for routine transportation. You say that you need to get 
to your medical appointment. The Plan denied your request. The Plan says your benefit only allows 36 one-way 
trips with each one-way trip not exceeding 50 miles of driving distance. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when the driving distance for a one-way trip is within 50 miles.  
 
   
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, the provider is 
located 78 miles away from your residence. The Plan only covers distances up to 50 miles. Therefore, we 
decided that the Plan does not have to pre-approve additional mileage for routine transportation (A0170).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the frames (V2020) and bifocal lenses 
(V2200) purchased on August 19, 2022, from an out-of-network (OON) provider. 
 
You asked the Plan to reduce the coinsurance for the frames and lenses. You say that you were never told 
progressive lenses were not covered. You also say you were told you could go anywhere outside the approved 
vision network to buy glasses, and you would be reimbursed $150. The Plan denied your request. The Plan says 
this cost sharing was charged correctly. The Plan also says no misinformation was provided to you. 
 
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 an 80% 
coinsurance for OON routine vision care under the Vision care benefit category.  
 
 
 
 You have been asked to pay an 80% coinsurance for the frames and lenses. These items fall within the Vision 
care benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. You also received the eyewear from an OON provider. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to reduce the coinsurance for the frames (V2020) and bifocal lenses (V2200) purchased on August 19, 2022, 
from an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on August 12, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for chiropractic services. You say that the records attached support the services 
provided. The Plan denied your request. The Plan says there is no authorization on file for the services 
provided. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for chiropractic services provided on August 12, 
2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pay for the CGM. You say that your physician ordered the CGM. The Plan denied your 
request. The Plan says the Medicare criteria for a CGM was not 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 you do not use insulin with at least 
three daily injections. 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 therapeutic continuous glucose 
monitor (CGM).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ear microscopy exam provided on 
September 1, 2022. 
 
You asked the Plan to waive the copayment for the ear microscopy exam. You say that your $35 office visit 
copayment should have covered 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 $30 
copayment for non-radiological diagnostic services.  
 
You have been asked to pay $28.58, which is less than the $30 copayment for the ear microscopy exam. This 
item/service falls within the non-radiological diagnostic 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 an ear microscopy exam provided on September 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete upper and lower dentures (D5110, D5120) 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service October 5, 2021. 
Therefore, we decided that the Plan does not have to pre-approve complete upper and lower dentures (D5110, 
D5120)
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Opdivo. 
 
You asked the Plan to pre-approve Opdivo. You say that the enrollee is not a candidate for chemotherapy or 
chemoimmunotherapy. The Plan denied your request. The Plan says the enrollee has not met requirements for 
Opdivo. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Opdivo. Our reviewer says that the 
enrollee does not meet criteria for use of Opdivo. Our physician reviewer found Opdivo is not Food & Drug 
Administration (FDA) approved for the enrollee's diagnosis. The enrollee has an EGFR mutation and targeted 
therapy is available with osimertinib and other EGFR targeted therapies. The requested use of Opdivo is not 
supported by one of the major drug compendia or by clinical research appearing in a Medicare-approved 
medical journal. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to 
pre-approve use of Opdivo.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic testing done in hospital only provided on July 13, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for diagnostic testing done in hospital only. You say that the records attached 
support the services provided. The Plan denied your request. The Plan says there was no authorization obtained 
prior to services rendered. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for diagnostic testing done in hospital only provided 
on July 13, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that due to the enrollee's significant comorbidities, 
extended hospital stay, ICU stay, medical complexity, and ability to tolerate an intensive rehabilitation 
program, they would benefit from close daily medical supervision at an IRF. The Plan denied your request. The 
Plan says based on Medicare guidelines, the IRF services you are requesting do not meet the requirements for 
approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on September 20, 2022. 
 
You asked the Plan to pay for the evaluation and management service. You say that this service should be 
covered. The Plan denied your request. The Plan says the provider in this case is not your assigned PCP. 
 
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 in this case is not your assigned Primary Care Provider (PCP). The Plan did not pre-approve the 
service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, 
we decided that the Plan does not have to pay for the office visit provided on September 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (36415) provided on August 12, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you disagree with the denial and are requesting 
reconsideration due to medical necessity. The Plan denied your request. The Plan says this claim has been 
denied for no prior authorization on file. 
 
 
 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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for laboratory services (36415) provided on August 
12, 2022, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that there is a significant risk of lung 
cancer in your family. You also say that you were exposed to a significant amount of second-hand smoke 
throughout your childhood, and as an adult, even though you did not smoke, and you believe it is equivalent of 
at least 20 pack years. The Plan denied your request. The Plan says you requested a lung cancer screening due 
to having a family history of lung cancer and exposure to second-hand smoke. The Plan also says the records 
show that you have never smoked cigarettes. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 We reviewed the file and the Medicare rules. We find that you do not have a tobacco smoking history of at 
least 30 pack-years, and you are not a current smoker or former smoker who quit within the last 15 years. 
Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) 
scan for lung cancer screening.