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

 
We decided that the Plan does not have to waive the copayment for outpatient surgery on February 16, 2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that this should be covered because 
you had surgery and had a bill but was unaware that there was a copayment for outpatient surgery The Plan 
denied your request. The Plan says the cost-sharing you are being charged is correct. 
 
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 per day for other outpatient procedures and services, including, but not limited to, diagnostic and 
therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital or ambulatory surgical 
center.  
 
 
 You have been asked to pay a $100 copayment for outpatient surgery. Outpatient surgery 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 outpatient surgery on February 
16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day continuous glucose monitor 
(CGM) sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre 14-day CGM sensor. You say that you have type 2 
diabetes, and this is medically necessary. The Plan denied your request. The Plan says you do not meet prior 
authorization criteria. 
 
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 and 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 Freestyle Libre 14-day CGM sensor have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 14-day continuous glucose 
monitor (CGM) sensor.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy on January 06, 2022, to 
January 07, 2022. 
 
You asked the Plan to waive the copayment for physical therapy. You say that they should not charge you for 
therapy they did in the hospital. The Plan denied your request. The Plan says the cost-sharing you are being 
charged is correct. 
 
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 $35 
copayment for each physical therapy and speech-language therapy visit. Outpatient Rehabilitation Services. 
Covered services include: physical therapy, occupational therapy, and speech language therapy. There were 2 
visits, resulting in a total copayment amount of $70.   
 
 
 You have been asked to pay a $35 copayment for each physical therapy. Physical therapy 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. Therefore, we decided that the Plan does not have to waive the copayment for 
physical therapy on January 06, 2022, to January 07, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an injection of sclerosant of multiple incompetent veins 
(36471). 
 
You asked the Plan to pre-approve an injection of sclerosant. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for coverage of 
the requested services 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 an injection of sclerosant. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee has no complaints other than reporting bilateral telangiectasias. The 
enrollee has no edema. There is no documentation that the telangiectasias are associated with ulceration or 
appear to be at risk for hemorrhage. There is no documentation that the enrollee had a variceal hemorrhage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an injection of sclerosant have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an injection of sclerosant of multiple incompetent veins (36471).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care services provided on 
January 26, 2021. 
 
You asked the Plan to pay for the subsequent nursing facility care services. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee was enrolled in 
hospice for this date of service  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on February 19, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent 
nursing facility care services provided on January 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI). 
 
You asked the Plan to pre-approve an MRI. You say that your physician feels it is necessary because of the 
cause of your back pain before they can prescribe a method of treatment and the best way to determine the pain 
is through an MRI. The Plan denied your request. The Plan says the authorization for this service is denied 
because the National Coverage Determination has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 an MRI. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found Patient has no neuro deficit or red flag to 
mandate MRI of the lumbar spine. No plain x-rays have been done. She has evidence of urinary tract infection 
with leukocytosis. No focal neurological deficit. The medical necessity for the requested MRI of the lumbar 
spine has not been established in the records provided. 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a magnetic resonance imaging (MRI).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for influenza virus vaccine provided on September 22, 2021. 
 
You asked the Plan to pay for influenza virus vaccine. The Plan denied your request. The Plan says the 
enrollee's network PCP or Plan must give approval in advance before the enrollee can use providers that are not 
in the Plan's network. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for influenza virus vaccine provided on September 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for hammertoe repair provided on December 
16, 2021. 
 
You asked the Plan to waive the copayment for hammertoe repair. You say that you were told you do not owe 
this as the Plan has paid it. The Plan denied your request. The Plan says you have been charged the correct 
copayment 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 $200 
copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center, 
including but not limited to hospital or other facility charges and physician or surgical charges.  
 
 
 
 You have been asked to pay a $200 copayment for the hammertoe repair. The hammertoe repair falls within the 
Outpatient Surgery and Other Medical 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 hammertoe repair provided 
on December 16, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve PT with an out-of-network provider. You say that the requested services are 
medically necessary. The Plan denied your request. The Plan says services with out-of-network providers are 
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 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 
physical therapy (PT) to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency transportation (A0427) provided on August 
20, 2021. 
 
You asked the Plan to pay for the emergency transportation. You say that you were not transported anywhere. 
You also say that the ambulance only assisted you at your home where they treated your wound. The Plan 
denied your request. The Plan says the Medicare ambulance benefit is a transportation benefit, and with no 
transport there is no payable service. The Plan also says that the trip report confirms you refused transportation. 
 
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 August 20, 2021. 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 emergency transportation (A0427) provided on 
August 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Suprep Bowel Sol Prep Kit. 
 
You asked the Plan to pre-approve a Suprep Bowel Sol Prep Kit. You say that the enrollee needs this 
medication for a colon cancer screening. The Plan denied your request. The Plan says this medication falls 
under Part D coverage and the enrollee does not have Part D pharmacy (drug) benefit administered by the Plan. 
Drugs covered under Part D are not eligible for coverage under Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve a Suprep Bowel Sol Prep 
Kit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve the requested services. You say that the scooter is medically necessary due 
to his medical condition. The Plan denied your request. The Plan says the device is not covered. 
 
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.  
 
We looked at the file and the rules. The records provided show that you need a scooter for doctors 
appointments, the store, and the bus. The scooter 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 power scooter.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services on November 6, 
2021. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you do not feel that you 
should have to pay the copay because it was an emergency, and he needed the services. The Plan denied your 
request. The Plan says the members benefit states that there is a $90 copay charge for each emergency room 
and is only waived if they were admitted. The member was not admitted 
to the hospital and discharged same day. 
 
 
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 $90 
copayment for emergency room services.  
 
You have been asked to pay a $90 copayment for emergency room services. Emergency care falls within the 
emergency room 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 emergency 
room services on November 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day continuous glucose monitor 
(CGM) device. 
 
You asked the Plan to pre-approve a Freestyle Libre CGM device. You say that the CGM is medically 
necessary. The Plan denied your request. The Plan says you do not meet prior authorization criteria. 
 
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 use insulin with at least three daily injections and 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 Freestyle 
Libre CGM device have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre 14-day continuous glucose monitor (CGM) device.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 home test kit and sales tax purchased on 
January 6, 2022. 
 
You asked the Plan to pay for the COVID-19 home test kit and sales tax. You say that the denial reason is 
incorrect. You also say that the purchase of a specified number of COVID-19 home test kits has been approved 
and is covered by Medicare. The Plan denied your request. The Plan says you purchased the COVID-19 home 
test kit on January 6, 2022, which is prior to the January 15, 2022 effective date to obtain the tests as 100% 
fully covered. 
 
The Plan must follow Medicare rules. Medicare rules say that starting January 15, 2022, most people with a 
health plan can go online, or to a pharmacy or store to purchase an at-home over-the-counter COVID-19 
diagnostic test authorized by the U.S. Food and Drug Administration (FDA) at no cost. Medicare rules also 
says that Medicare does not make separate payment for sales tax. 
 
 
  We looked at the file and Medicare rules. This COVID-19 home test kit was purchased prior to the effective 
date of January 15, 2022. Based on this information, we decided that Medicare rules for coverage of the 
COVID-19 home test kit and sales tax have not been met. Therefore, we decided that the Plan does not have to 
pay for the COVID-19 home test kit and sales tax purchased on January 6, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services received on February 14, 2022. 
 
You asked the Plan to pay for the psychotherapy services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services received are not a covered benefit. 
 
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. Therefore, we decided that the Plan does not have to pay for the psychotherapy services received on 
February 14, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a tissue ablation and atria reconstruction without cardiopulmonary 
bypass (MAZE) procedure. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has failed cardioversions 
and medical therapy. The Plan denied your request. The Plan says that it is considered experimental and 
unproven. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 the requested services. Our physician 
reviewer found that at issue is the appropriateness and medical necessity of performing a convergent hybrid 
ablation procedure in a patient with longstanding persistent atrial fibrillation. The request is for authorization of 
the performance--not of the stand-alone, surgical MAZE procedure--but of the minimally-invasive procedure 
incorporating epicardial ablation--performed by a cardiac surgeon--in conjunction with an endocardial catheter 
ablation procedure--performed by a cardiac electrophysiologist, often the same day in a combined procedure, 
or sometimes a few days or weeks later. The CONVERGE trial (Delugio 2020) demonstrated the superiority of 
this hybrid approach combining epicardial and endocardial ablation compared with an endocardial catheter 
ablation procedure alone. While the simpler endocardial catheter ablation procedure would be more appropriate 
for paroxysmal atrial fibrillation, proceeding directly to a convergent hybrid procedure would be acceptable 
because of the poor results of endocardial catheter ablation alone, with the frequent need to later carry out a 
convergent hybrid procedure. As a result, authorization for the performance of a convergent hybrid ablation 
procedure would be considered appropriate and reasonable in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have been met. Therefore, we decided that the Plan has to 
pre-approve a tissue ablation and atria reconstruction without cardiopulmonary bypass (MAZE) procedure.  
 
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.