Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Partially Favorable

 
We decided that the Plan has to reduce the cost sharing for the colonoscopy with polyp removal. We decided 
that the Plan does not have to waive the cost sharing for the colonoscopy with polyp removal.  
 You asked the Plan to waive the cost sharing for the colonoscopy with polyp removal performed by an in-
network provider on November 16, 2022. You say that you think that the cost sharing should be lower. The 
Plan says that this cost sharing was charged correctly. 
 
We decided that the Plan has to reduce the cost sharing for the colonoscopy with polyp removal.  
 
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 says that you must pay a 10% 
coinsurance for in-network outpatient surgery services. 
 
The Plan says you must pay a $62.44 coinsurance for outpatient surgery services. Based on the Plan contract, 
however, you cannot be asked to pay more than a 10% coinsurance for in-network outpatient surgery services. 
In this case, 10% of the $613.19 allowed amount is $61.32 ($1063.19 total allowed amount - $450 deductible = 
$613.19). Therefore, we decided that the Plan has to reduce the cost sharing for the colonoscopy.  
 
We also decided that the Plan does not have to waive the cost sharing for the colonoscopy with polyp 
removal. 
 
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% 
coinsurance for the colonoscopy, and the in-network $450 deductible applies to outpatient surgery services. 
 
The colonoscopy with polyp removal falls within the outpatient surgery including services provided at hospital 
outpatient facilities and ambulatory surgical centers benefit category. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $450 in-network deductible, which applies to outpatient surgery 
including services provided at hospital outpatient facilities and ambulatory surgical centers. This cost sharing is 
a contractual obligation that had not been met at the time the colonoscopy with polyp removal was performed 
on November 16, 2022. Therefore, we decided that the Plan does not have to waive the cost sharing for the 
colonoscopy with polyp removal. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy drugs and administration 
provided on September 1, 2022. 
 
You asked the Plan to waive the coinsurance for chemotherapy treatment. 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 prescription drugs.  
 
You have been asked to pay a $2.09 coinsurance for chemotherapy treatment ($10.44 allowed amount x 20% 
coinsurance = 2.09). This item/service falls within the Medicare Part B 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 chemotherapy drugs and administration provided on 
September 1, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an emergency room visit provided on 
October 17, 2022. 
 
You asked the Plan to reduce the copayment for an emergency room visit. You say that the billed amount is too 
excessive. 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 $75 
copayment for emergency care.  
 
You have been asked to pay a $75 copayment for an emergency room visit. This item/service falls within the 
emergency care benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to reduce the copayment for an emergency room visit 
provided on October 17, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the swallowing function radiologic examination (74230) and 
upper gastrointestinal tract radiologic examination (7240), provided on September 14, 2022. 
 
You asked the Plan to pay for the radiologic examinations. You say that the services were medically necessary. 
The Plan denied your request. The Plan says services were obtained in an excluded place of service. 
 The Plan must follow Medicare rules. Medicare rules say that this procedure will be reimbursed only when 
medically necessary and performed in one of the places listed in the Medicare Rules section. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the radiologic examinations have not been met. Therefore, we decided that the Plan does not have 
to pay for the swallowing function radiologic examination (74230) and upper gastrointestinal tract radiologic 
examination (7240), provided on September 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for incontinence supplies. 
 
You asked the Plan to pay for incontinence supplies. You say that you would like reconsideration because the 
requested incontinence supplies are medically necessary. The Plan denied your request. The Plan says the 
requested incontinence supplies are not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pay for incontinence supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses and related services provided on November 
14, 2022. 
 You asked the Plan to pay for the eyeglasses and related services. You say that you would like insurance to pay 
more or have a less expensive option. The Plan denied your request. The Plan says the benefit has been 
exhausted. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when up to a $200 allowance. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid $200 towards the vision services on 
November 14, 2022, which exhausted the benefit. Based on this information, we decided that the Plan's rules 
for coverage of the eyeglasses and related services have not been met. Therefore, we decided that the Plan does 
not have to pay for the eyeglasses and related services provided on November 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D5222, D0470 and D4921) on May 14, 
2021, to March 11, 2022. 
 
You asked the Plan to pay for the dental services (D5222, D0470 and D4921). You say that you would like to 
request reconsideration of the denied claim. The Plan denied your request. The Plan says the services are not 
covered 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. 
 
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 dental 
services (D5222, D0470 and D4921) on May 14, 2021, to March 11, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for a continuous glucose monitor (CGM) on May 16, 2022. 
 
You asked the Plan to pay for a continuous glucose monitor (CGM). You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says that the criteria for approval have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 pay for a continuous glucose monitor (CGM). Our 
reviewer says that the service is medically necessary. Our physician reviewer found there is adequate 
documentation that the patient is on mdi and that the patient will be using the blood glucose data to adjust the 
insulin doses on an ongoing basis. The criteria for CGM coverage are met. 
 
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 continuous glucose monitor (CGM) have been met. Therefore, we decided 
that the Plan has to pay for a continuous glucose monitor (CGM) on May 16, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transthoracic echocardiography (TTE) (93306). 
 
You asked the Plan to pre-approve TTE. You say that the service is medically necessary. The Plan denied your 
request. The Plan says the service is not medically necessary. 
 
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 TTE. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documentation of any supportive clinical evidence of any cardiac signs, symptoms 
or physical findings on examination. Clinical guidelines do not support carrying out a TTE in this setting. In 
summary, there is no supportive evidence for the medical necessity of a TTE in this 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 TTE have not been met. Therefore, we decided that the Plan does not have to 
pre-approve transthoracic echocardiography (TTE) (93306).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulation (97032) and the manual therapy 
(97140) provided on October 31, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the electrical stimulation (97032) and the manual therapy (97140) 
provided on October 31, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that inpatient admission is medically 
necessary. The Plan denied your request. The Plan says that inpatient level of care is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient admission are met in this case. Our 
physician reviewer found the record showed that at the time of inpatient admission the admitting physician 
reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pre-approve acute inpatient hospital care.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve home health services. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the services are not 
medically necessary. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found based on the 
medical records provided there is documentation that skilled nursing services are required. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99213 provided on October 14, 2022. 
 
You asked the Plan to pay for procedure code 99213. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services were not billed on the correct 
form.  
The Plan must follow Medicare rules. The rules say Section 1862 (a)(22) of the Act requires that all claims for 
Medicare payment must be submitted in an electronic form specified by the Secretary of Health and Human 
Services, unless an exception described at 1862 (h) applies. 
 
We looked at the file and Medicare rules. In this case, the file shows the services were provided in an RHC; 
however, the claim was incorrectly submitted on a Health Care Financing Administration (HCFA) form instead 
of a CMS-1450 (Uniform Bill-UB04) form. Therefore, we decided that the Plan does not have to pay for 
procedure code 99213 provided on October 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care visit provided on November 04, 2022. 
 
You asked the Plan to pay for wound care visit. You say that the records attached support the services 
provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for wound care visit 
provided on November 04, 2022.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve procedure codes E2377, E2313, and E2311. We decided that the 
Plan does not have to pre-approve procedure codes E0108, and E2300.  
 
You asked the Plan to pre-approve procedure codes E2377, E2313, E2311, E0108 and E2300. You say that the 
enrollee requires a caregiver to assist with transfers and activities of daily living. You say that the seat lift is 
medically necessary to perform certain tasks. You also say that an electronic controller interface is necessary. 
The Plan says that the set lift and mobile charger device do not have a medical purpose. The Plan also says that 
the upgraded electronics are not medically necessary. 
 
We decided that the Plan has to pre-approve procedure codes E2377, E2313, and E2311.  
 
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 procedure codes E2377, E2313, E2311. 
Our reviewer says that expandable controller upgrade (E2377), harness upgrade (E2313), and electrical 
connection (E2311) are medically necessary. Our physician reviewer found the provided documentation 
indicates that the complexity of the enrollee's seating and positioning needs necessitates a more complex group 
3 power wheelchair base. The expandable controller with harness and electronic connection are necessary to 
operate the group 3 power wheelchair base and the power tilt and recline and power elevating leg rests via a 
joystick. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes E2377, E2313, and E2311 have been met. Therefore, we 
decided that the Plan has to pre-approve procedure codes E2377, E2313, and E2311.  
 
We also decided that the Plan does not have to pre-approve procedure codes E0108, and E2300. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The items at issue in this appeal do not serve a purpose that is primarily medical in nature. These items are 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve procedure codes E0108, and E2300. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulation (97032) and the manual therapy 
(97140) provided on November 7, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not covered benefits. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the electrical stimulation (97032) and the manual therapy (97140) 
provided on November 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hemoglobin, glycosylated (A1c) (83036) provided May 
3, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that attached are the medical records. Please 
review CPT codes 83036 for the requested date for medical necessity. The Plan denied your request. The Plan 
says per LCD or NCD guidelines, procedure code 83036 has not met the associated diagnosis code.  

The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the laboratory services have been met. 
additional records were needed from the provider to determine medical necessity. The records show that the 
Plan made multiple attempts to obtain the needed medical records without success. Therefore, we decided that 
the Plan does not have to pay for the hemoglobin, glycosylated (A1c) (83036) provided May 3, 2022.