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

 
We decided that the Plan does not have to waive the deductible for a screening mammogram provided on 
October 13, 2021. 
 
You asked the Plan to waive the deductible for a screening mammogram. You say that you had a screening 
mammogram which should be covered in full. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible which applies to out of network mammograms.  
 
The records show your mammogram was done by an out of network facility, therefore your deductible applies. 
The item or service you asked the Plan to waive the deductible for falls within the Breast Cancer Screening 
(Mammograms) benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract 
that there is a $750 deductible which applies to out of network mammograms. This cost sharing is a contractual 
obligation that had not been met at the time a screening mammogram was received on October 13, 2021. Therefore, we decided that the Plan does not have to waive the deductible for a screening mammogram 
provided on October 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the autograft for spine surgery (20936) provided on May 3, 
2021. 
 
You asked the Plan to pay for the autograft for spine surgery (20936). You say that the documentation related 
to the procedures should be reviewed and the claim processed for payment. The Plan denied your request. The 
Plan says bundled services are not eligible for separate reimbursement. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 20936 is autograft for spine surgery only (includes 
harvesting the graft); local (eg, ribs, spinous process, or laminar fragments) obtained from same incision (List 
separately in addition to code for primary procedure).  
We find that CPT code 20936 is not supported in the medical record. Specifically, CPT code 20936 has a status 
indicator of B. This means that CPT code 20936 is considered bundled and not separately payable. Based on 
this information, we decided that Medicare rules for coverage of the autograft for spine surgery (20936) have 
not been met. Therefore, we decided that the Plan does not have to pay for the autograft for spine surgery 
(20936) provided on May 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services to be rendered by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the dental services. You say that you have had a bad experience with the in-
network dental provider, and you would like to go to an OON provider. The Plan denied your request. The Plan 
says going to an OON provider is not medically necessary because the requested service can be rendered by an 
in-network provider. 
 
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 
covered when they are received OON.  
 
 
 
  
Therefore, we decided that the Plan does not have to pre-approve dental services to be rendered by an out-of-
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Kerecis Omega-3 skin substitute 
(Q4158). 
 
You asked the Plan to pre-approve Kerecis Omega-3 skin substitute. You say that the requested treatment is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not 
been met because the provided documentation does not support medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that documentation is required specifically addressing 
circumstances as to why the wound has failed to respond to standard wound care treatment of greater than 4 
weeks and must reference specific interventions that have failed.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Kerecis Omega-3 skin substitute have not been met. Specifically, the provided medical records do 
not address failure to respond to standard wound care treatment. Therefore, we decided that the Plan does not 
have to pre-approve treatment with Kerecis Omega-3 skin substitute (Q4158).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 (3 units) billed for date of service June 
21, 2021. 
 You asked the Plan to pay for procedure code 88341. You say that this test provides valuable information to the 
physician, so it should be covered. The Plan denied your request. The Plan says this code is bundled and no 
separate payment is made for it when billed with 88360. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that procedure 
code 88341 is a column II code to column I code 88360. This claim has not been billed with an appropriate 
modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 88341 (3 units) billed for date of 
service June 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a humidifier provided on October 21, 
2021. 
 
You asked the Plan to waive the coinsurance for a humidifier. You say that the humidifier is part of the sleep 
apnea machine, and you should not be charged for it. The Plan denied your request. The Plan says you have 
been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for durable medical equipment.  
 
The records show the humidifier is separate from the continuous positive airway pressure (CPAP) machine. 
You have been asked to pay $54.80, which is 20% of the allowed amount for a humidifier ($274 allowed amount x 20% coinsurance = $54.80). A humidifier falls within the Durable Medical Equipment (DME) and 
Related 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 coinsurance for a humidifier 
provided on October 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Pride Victory 4-Wheeled Power Scooter. 
 
You asked the Plan to pre-approve a Pride Victory 4-Wheeled Power Scooter. You say that the item is 
medically necessary. The Plan denied your request. The Plan says records indicate this item was requested for 
use primarily outside of home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a Pride Victory 4-Wheeled Power Scooter.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy visits provided from June 
7, 2021, to July 7, 2021. 
 
You asked the Plan to waive the copayments for physical therapy visits. You say that at each session you asked 
about the copayment and were told the office was waiting to hear from the insurance company. You also say 
you were unaware of the copayment for the services and cannot afford them. The Plan denied your request. The 
Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for in-network physical therapy services.  
 
 You have been asked to pay a total of $280, which is a $40 copayment for each physical therapy visit ($40 
copayment x 7 visits).  
 
Date of Service Copayment 
June 7, 2021 $40 
June 9, 2021 $40 
June 14, 2021 $40 
June 16, 2021 $40 
June 23, 2021 $40 
June 30, 2021 $40 
July 7, 2021 $40 
Total $280 
 
Physical therapy visits fall 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. Therefore, we decided that the Plan 
does not have to waive the copayments for physical therapy visits provided from June 7, 2021, to July 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant placements (D6010) for teeth # 29 and 30. 
 
You asked the Plan to pre-approve the dental services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says implant placement is not listed as a covered service. 
 
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 implants are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve implant 
placements (D6010) for teeth # 29 and 30.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Remicade (J1745). 
 
You asked the Plan to pre-approve remicade. You say that the drug is medically necessary. The Plan denied 
your request. The Plan says that the drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Remicade. Our reviewer says that this 
drug is medically necessary. Our physician reviewer found the record indicates that the enrollee has a diagnosis 
of ankylosing spondylitis.  The Food and Drug Administration has stated that the requested drug is indicated 
for the enrollee's condition and has indicated a usual dose but has not placed a prohibition on other dosing 
regimens. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Remicade have been met. Therefore, we decided that the Plan has to pre-
approve Remicade (J1745).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) (K0554) and 
supplies (K0553). 
 
You asked the Plan to pre-approve a CGM and supplies. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the item is not medically necessary. 
 
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 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 and supplies have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a continuous glucose monitor (CGM) (K0554) and supplies (K0553).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided on 
October 8, 2021. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that your physician 
recommended a colonoscopy after receiving positive test results. You also say you never would have had the 
colonoscopy if your physician would not have recommended it. The Plan denied your request. The Plan says 
you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for outpatient surgery.  
 
 The records show you were referred to a specialist who recommend a diagnostic colonoscopy. You have been 
asked to pay a $250 copayment for a diagnostic colonoscopy. A diagnostic colonoscopy falls within the 
Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers 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 diagnostic colonoscopy 
provided on October 8, 2021.
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 you are immobile, and your legs are tightening up. 
You are experiencing neuropathy and need physical therapy and extra care The Plan denied your request. The 
Plan says the criteria for admission to an SNF are not met. Your recent therapy assessment indicates that you 
are very weak and does not demonstrate a recent significant decline in function. You are also not noted to have 
complex wound care needs or daily skilled nursing needs The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found that you do not have documented skilled 
nursing needs. No wound care records are identified. Your feeding PEG is not new. You do not have 
documented skilled therapy needs. You appear to be functioning at or near your baseline. Daily skilled services 
are not required to establish a maintenance program or to prevent deterioration of your condition. Your care 
needs, custodial and intermittent, can, as a practical matter, be provided at a lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110). 
 
You asked the Plan to pre-approve the complete maxillary denture. You say that the enrollee misplaced her 
denture, and her health has started to decline. You also say that the enrollee cannot financially afford to pay out 
of pocket for a new denture. The Plan denied your request. The Plan says this service exceeds the maximum 
count allowed per period. 
 
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, complete maxillary denture (D5110) is 
limited to one procedure every five plan years. The record shows that the enrollee received a complete 
maxillary denture (D5110) on November 10, 2021 and the enrollee's complete maxillary denture (D5110) 
benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete 
maxillary denture (D5110).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on October 
17, 2021. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you cannot afford the 
copayment due to little income. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 
copayment per trip for ambulance services.  
 
 
  
You have been asked to pay a $350 copayment for ambulance services. Ambulance services fall 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 17, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital observation provided 
from January 28, 2021, to January 29, 2021. 
 
You asked the Plan to waive the copayment for an esophagogastroduodenoscopy. You say that this procedure 
should have been done as inpatient since you stayed overnight. The Plan denied your request. The Plan says 
they have made a partial uphold decision and you are responsible for a $65 copayment for outpatient hospital 
observation.  
 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 outpatient hospital observation. The Plan contract also says that to be an inpatient, your 
provided must write an order to admit you formally as an inpatient of the hospital. Even if you stay in the 
hospital overnight, you might still be considered an outpatient. 
 
The records show you were under outpatient observation from January 28, 2021, to January 29, 2021.  Even 
though you spent the night, you were not formally admitted as an inpatient. You have been asked to pay a $65 
copayment for outpatient hospital observation. Outpatient hospital observation falls within the Outpatient 
Hospital Observation benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for outpatient 
hospital observation provided from January 28, 2021, to January 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a specialist office visit provided on 
October 7, 2021. 
 
You asked the Plan to reduce the copayment for a specialist office visit. You say that the urgently needed 
service copayment is only $5. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for specialist office visits. 
 
The records show you were not seen at an urgent care center. You have been asked to pay a $30 copayment for 
a specialist office visit. A specialist office visit falls within the Physician/Practitioner Services, Including Doctors Office Visits benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment for a specialist 
office visit provided on October 7, 2021.