Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the therapeutic continuous glucose monitor (CGM). You say that the 
enrollee has severe diabetic retinopathy. You also say that the enrollee has health literacy concerns and you feel 
that long acting insulin may drop his blood glucose too quickly. The Plan denied your request. The Plan says 
the enrollee does not require insulin three or more times daily. 
 
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. Based on this information, we decided that Medicare rules for coverage of 
the therapeutic continuous glucose monitor (CGM) have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient mental health on February 22, 
2022, to April 12, 2022. 
 
You asked the Plan to waive the copayment for outpatient mental health. You say that you want to appeal the 
amount being charged. 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 $40 
copayment for each individual/group therapy session. Covered services include mental health services provided 
by a state-licensed psychiatrist or doctor, clinical psychologist, clinical social worker, clinical nurse specialist, 
nurse practitioner, physician assistant, or other Medicare-qualified mental health care professional as allowed 
under applicable state laws. There were 3 visits. 3 x $40 = $120. Therefore, results in the total cost sharing 
amount of $120.  
 
 
 
 You have been asked to pay a $40 copayment for each outpatient mental health visit. This item/service falls 
within the Outpatient mental health 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 waive the copayment 
for outpatient mental health on February 22, 2022, to April 12, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on May 12, 2022, 
to May 13, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you disagree with copayment. 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 $100 
copayment for outpatient diagnostic tests/Medicare-covered ultrasound.  
 
You have been asked to pay a $100 copayment for an ultrasound. However, you are only being asked to pay 
$23.16 which is less than the required amount. This item/service falls within the outpatient diagnostic 
tests/Medicare-covered ultrasound 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 ultrasound provided on May 12, 2022, to May 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
July 3, 2022, to July 11, 2022. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the 
copayment charged for the inpatient stay. 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 $205 
copayment per day for days 1-6 of each Medicare-covered inpatient, including the day of admission and day of 
discharge of an inpatient hospital stay.  
 
 
  You have been asked to pay a $1,230 copayment for an inpatient hospital stay ($205 per day x 6 days = 
$1,230). This item/service falls within the Inpatient Hospital 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 waive the copayment for an inpatient hospital stay provided from July 3, 2022, to July 11, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit with surgical 
services of the neck (64616) and the coinsurance for an incobotulinumtoxin a injection (J0588) received on 
June 21, 2021. 
 
You asked the Plan to waive the copayment for a specialist office visit with surgical services of the neck 
(64616) and the coinsurance for an incobotulinumtoxin a injection (J0588). You say that you were assessed a 
lower coinsurance for previous these injections. 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 20% 
coinsurance for Medicare Part B prescription drugs and a $15 copayment for a specialist office visit.   
You have been asked to pay a $15 copayment for an office visit with surgical services of the neck (64616). 
This item/service falls within the specialist office visit benefit category. You have also been asked to pay  
$349.11, which is 20% coinsurance of the allowed amount for an incobotulinumtoxin injection (J0588). 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 copayment for a specialist office visit with surgical services of the neck (64616) and the 
coinsurance for an incobotulinumtoxin a injection (J0588) received on June 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a telehealth mental health visit provided on 
June 29, 2022. 
 
You asked the Plan to waive the copayment for a telehealth mental health visit. You say that you have never 
been charged a copayment for a telehealth visit. 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 $25 
copayment for physician/practitioner service. 
 
You have been asked to pay a $25 copayment for a telehealth mental health visit. This item/service falls within 
the physician/practitioner service 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 
telehealth mental health visit provided on June 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatments (97813, 97814) provided on 
August 18, 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 payable as they were 
rendered by an ineligible provider. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare.  
 
 However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the acupuncture services in this case were not 
rendered under the supervision of a physician, physicians assistant, nurse practitioner, or clinical nurse 
specialist. Therefore, we decided that the Plan does not have to pay for the acupuncture treatments (97813, 
97814) provided on August 18, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Tyrvaya. 
 
You asked the Plan to pre-approve the Tyrvaya. You say that the item is medically necessary. The Plan denied 
your request. The Plan says this is a self-administered drug. 
 
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 the Tyrvaya.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fluoride carriers. 
 
You asked the Plan to pre-approve dental services. You say that this service is a covered medical benefit. The 
Plan denied your request. The Plan says this service is not covered by Medicare or the Plan. 
 
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 or the Medicare dental benefit. Therefore, we decided that the Plan 
does not have to pre-approve fluoride carriers.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interim complete denture (D5810), implant/abutment 
supported removable denture for edentulous arch (D6110) and semi-precision abutment placement  
(D6191 x 5). 
 
You asked the Plan to pre-approve the dental services. You say that your current dentures cannot be cleaned, 
causing you irritation and nausea. The Plan denied your request. The Plan says these services are not covered 
by the Plan's dental 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 pre-approve an 
interim complete denture (D5810), implant/abutment supported removable denture for edentulous arch 
(D6110) and semi-precision abutment placement (D6191 x 5).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) provided on 
February 26, 2021, to March 15, 2021. 
 
You asked the Plan to waive the copayment for SNF. You say that you disagree with the copayment. 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 $0 
copayment for days 1-20 a $184 copayment per day for days 21-57 for skilled nursing facility (SNF) care.  
 
You have been asked to pay a $0 copayment for days 1-20 a $184 copayment per day for days 21-57 for SNF. 
The total allowed amount for the SNF is $3,128 ($184 x 17days = $$3,128). However, you are only being 
asked to pay $964.98 which is less than the required amount. 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 skilled nursing facility (SNF) provided on February 26, 2021, to March 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for imaging provided on August 13, 2021. 
 
You asked the Plan to waive the copayment for imaging. You say that you want to appeal the amount being 
charged. 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 $50 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $50 copayment for imaging. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for imaging provided on August 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on September 19, 
2022. 
 
You asked the Plan to pay for the evaluation. You say that you did not know what the frequency limitation was. 
The Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 4, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
September 19, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on April 25, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
enrollee was treated at home and was not transported to the hospital. You also say that you were informed the 
insurance would pay 80% of the service. 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 Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 25, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on April 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility care visit provided on September 21, 2022. 
 
You asked the Plan to pay for a nursing facility care visit. You say that you are requesting a review and 
reconsideration for the denied payment. 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 a nursing facility care 
visit provided on September 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation - per site 
tooth #20 (D7953), and guided tissue regeneration - resorbable barrier, per site tooth #20 (D4266). 
 
You asked the Plan to pre-approve a bone replacement graft for ridge preservation - per site tooth, and guided 
tissue regeneration - resorbable barrier, per site. You say that these procedures should be covered because the 
procedures are required in order for you to get an implant. The Plan denied your request. The Plan says these 
services are not covered under the benefit package. 
 
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 a 
bone replacement graft for ridge preservation - per site tooth #20 (D7953), and guided tissue regeneration - 
resorbable barrier, per site tooth #20 (D4266).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for computed tomography (CT) scan on 
August 31, 2022. 
 
You asked the Plan to waive the copayment for CT scan. You say that you want to appeal the amount being 
charged. 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 $300 
copayment depending on the Medicare-covered diagnostic radiology services (not including X-rays) for CT 
scans, MRIs, myelography, PET scans, MRA, SPECT, CTA, nuclear cardiology, and stress tests. Covered 
services include but are not limited to other outpatient diagnostic tests. The provider billed in the amount of 
$390.40 and the allowed amount is $106.53. This is less than the copayment amount. Therefore, results in the 
total cost sharing amount of $106.53. 
 
 You have been asked to pay a $106.53 copayment, which is less than the copayment for CT scan. This 
item/service falls within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for computed tomography (CT) scan on August 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service April 8, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that medical records were provided. The Plan 
denied your request. The Plan says procedure code 99100 is considered bundled and not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99100 billed for date of service April 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crown, porcelain fused to high noble metal (D2750) tooth 
#24 and core buildup, including any pins when required (D2950) tooth #24 provided on February 23, 2022. 
 
You asked the Plan to pay for dental services. You say that these services should have been covered by the 
Plan. The Plan denied your request. The Plan says this service is not covered under your Plan. 
 
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. Crown, porcelain fused to high 
noble metal (D2750) and core buildup, including any pins when required (D2950) are not covered under the 
Plans dental benefits. 
 
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 crown, 
porcelain fused to high noble metal (D2750) tooth #24 and core buildup, including any pins when required 
(D2950) tooth #24 provided on February 23, 2022.