Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to waive the coinsurance for a syringe for an insulin pump provided on December 
15, 2021. We also decided that the Plan does not have to waive the coinsurance for a CGM supply allowance 
provided on November 22, 2021. 
 You asked the Plan to waive the coinsurance for a CGM supply allowance and a syringe for an insulin pump. 
You say that Medicare covers the insulin pump and you have received a bill from the provider. The Plan says 
that you have charged the correct cost sharing amount. 
 
We decided that the Plan has to waive the coinsurance for a syringe for an insulin pump (code A4232) 
provided on December 15, 2021. 
 
The Plan says you must pay $17.40 for a syringe for an insulin pump. However, a syringe for an insulin pump 
(code A4232) is not payable by Medicare. Therefore, we decided that the Plan has to waive the coinsurance for 
a syringe for an insulin pump provided on December 15, 2021. 
 
We also decided that the Plan does not have to waive the coinsurance for a CGM supply allowance 
(K0553) provided on November 22, 2021. 
 
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 and supplies.   
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay 
$89.29, which is 20% coinsurance of the allowed amount for the CGM supply allowance ($446.44 allowed 
amount x 20% coinsurance = $89.29). The CGM supply allowance 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 CGM 
supply allowance. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Moh's micrographic surgery provided on February 21, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the Moh's micrographic surgery. You say that the service was medically 
necessary. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the Moh's micrographic surgery provided on February 21, 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 foot orthotics provided on December 15, 2021. 
 
You asked the Plan to pay for foot orthotics. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on December 
15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve twenty (20) occupational therapy (OT) (97140, 97110, 
97112, 97530, 97116) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve OT visits. You say that the requested OT visits are medically necessary. The 
Plan denied your request. The Plan says the requested OT visits do not meet criteria. 
 
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 
twenty (20) occupational therapy (OT) (97140, 97110, 97112, 97530, 97116) to be provided by an out-of-
network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for chemotherapy drugs and chemotherapy 
administration services provided on December 16, 2021. 
 
You asked the Plan to waive the cost-sharing for chemotherapy drugs and administration services. You say that 
this procedure was administered in a doctor's office, not a hospital. The Plan denied your request. The Plan says 
the cost-sharing amounts you are being charged are 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 20% 
coinsurance for chemotherapy drugs and $475 copayment for chemotherapy administration services provided 
in an outpatient hospital. The rendering facility is an outpatient hospital facility; therefore, the outpatient 
hospital copayment applies to this claim. The allowed amounts of the chemotherapy drugs total $4,115.72, 
resulting in a coinsurance amount of $823.15. You have also been asked to pay a $475 copayment amount for 
outpatient hospital services. Your total cost-sharing amount is therefore $1,298.15. 
 
You have been asked to pay 20% coinsurance for chemotherapy drugs and $475 copayment for chemotherapy 
administration services. Chemotherapy drugs and administration services fall within the "Medicare Part B 
Prescription Drugs" and "Outpatient Hospital Services" benefit categories. 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 cost-sharing for chemotherapy drugs and chemotherapy administration services provided on 
December 16, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says the requested continued SNF care does not 
meet criteria. 
 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 continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found records do not document the need 
for intravenous medications, new tube feeding, ostomy care or daily complex wound care. You are walking 
household distances with a front wheeled walker with supervision to contact guard assistance and is 
supervision to contact guard assist for transfers. Provided records do not document a significant decline in your 
functional status to necessitate further daily inpatient skilled therapy services. You do not require the services 
on an inpatient basis, only in a skilled nursing facility setting. Records do not document that services in the 
home with home health care or in a long-term care facility on a part time basis are not appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the flex and rotational components of foot and ankle 
(L5968 and L5986) and protective covering (L5964). 
 
You asked the Plan to pre-approve the flex and rotational components of foot and ankle and protective 
covering. You say that you would like reconsideration because the requested equipment is medically necessary. 
The Plan denied your request. The Plan says this equipment exceeds your needs. 
 
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 the flex and rotational components of 
foot and ankle and protective covering. Our reviewer says that With approved codes for flex and rotational 
components of foot and ankle, L5968 and L5986 are both duplicative and medically unnecessary. Our 
physician reviewer found L5964 is medically unnecessary. There are no documented special needs that would 
require this level of protection for the prosthesis. 
 
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 flex and rotational components of foot and ankle and protective covering 
have not been met. Therefore, we decided that the Plan does not have to pre-approve the flex and rotational 
components of foot and ankle (L5968 and L5986) and protective covering (L5964).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for infusion therapy injections (96374) 
provided from November 8, 2021, to November 29, 2021. 
 
You asked the Plan to waive the copayment for the infusion therapy injections. You say that the services should 
be covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing 
applied correctly based on the services provided. 
 
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 and Other Medical Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers.  
 You have been asked to pay a $207.77 copayment each for 4 infusion therapy injections ($207.77 x 4 = 
$831.08), which is less than the standard $250 each. Infusion therapy injections fall 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 infusion therapy injections 
(96374) provided from November 8, 2021, to November 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on January 5, 
2022. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you were advised that the 
COVID-19 test was free. You also say that you were not examined during this visit. 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 $15 
copayment for an urgent care visit at an urgent care center.  
 
The medical record shows you had an urgent care visit on January 5, 2022. You have been asked to pay a $15 
copayment for an urgent care visit. An urgent care visit falls within the Urgently Needed 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 urgent care visit provided on January 5, 
2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic exercises, manual therapy techniques and self-
care/home management training provided on July 7, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for therapeutic exercises, manual therapy techniques and self-care/home 
management training. You say that you are appealing with supporting records. The Plan denied your request. 
The Plan says a prior authorization was not obtained by the out-of-network provider for the services rendered, 
and the provider did not submit any documentation that the procedures were part of an emergency service. 
 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 therapeutic exercises, manual therapy techniques 
and self-care/home management training provided on July 7, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for group psychotherapy, and psychotherapy provided on July 
22, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for group psychotherapy, and psychotherapy. You say that to deny the Plan's 
obligation to pay for emergency services and admission due to lack of or no notification, shows an absence of 
good faith. The Plan denied your request. The Plan says this provider is not a network provider with the Plan, 
and based on the documentation submitted, they have determined that the services rendered to the member are 
not urgent or emergent, nor were they approved in advance by a network provider. 
 
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 group psychotherapy, and psychotherapy provided 
on July 22, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar fusion surgery. 
 
You asked the Plan to pre-approve lumbar fusion surgery. You say that you would like reconsideration because 
this surgery is medically necessary. The Plan denied your request. The Plan says the enrollee is a current 
smoker and has not tried to quit smoking, and there is no documentation of smoking cessation conversation or 
education. 
 
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 lumbar fusion surgery. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found smoking is a contraindication to elective lumbar fusion surgery. there is no 
documentation of smoking cessation in the records. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lumbar fusion surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve lumbar fusion surgery.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on October 
28, 2021. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you do not feel that you 
needed an ambulance to take you across the street after you had a procedure. 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 $300 
copayment for ground ambulance services.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$300 copayment for ambulance services. Ambulance services falls 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 28, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental crowns represented by code D2740. 
 
You asked the Plan to pre-approve the dental crowns. You say that your dental provider destroyed your teeth. 
You say that if your teeth are not fixed you cannot eat properly. The Plan denied your request. The Plan says 
the requested dental crowns are not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
dental crowns represented by code D2740.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam provided on December 1, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the eye exam. You say that you did not know the provider was out-of-network. 
You say you were unaware that she needed a referral or prior authorization. The Plan denied your request. The 
Plan says no prior authorization was obtained. 
 
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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the eye exam provided on December 1, 2021, by an out-of-
network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy and group therapy services provided on July 
8, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for psychotherapy and group therapy services. You say that to deny the Plan's 
obligation to pay for emergency services and admission due to lack of or no notification shows an absence of 
good faith. The Plan denied your request. The Plan says this provider s not a network provider with the Plan, 
and based on the documentation submitted, they have determined that the services rendered to the member are 
not urgent or emergent, nor were they approved in advance by a network provider. 
 
 
 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 psychotherapy and group therapy services 
provided on July 8, 2021, by an out-of-network (OON) provider.