Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acoustical wave treatments provided on January 29, 2020 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the acoustical wave treatments. You say that the services should be covered as 
you disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they 
were non-emergent and prior authorization was not 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 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 acoustical wave treatments provided on January 
29, 2020 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam computed tomography (CT) capture (D0364) 
provided on April 27, 2022. 
 
You asked the Plan to pay for cone beam computed tomography (CT) capture (D0364). You say that you were 
not informed by the provider that this service was not a covered procedure. The Plan denied your request. The 
Plan says this service is not covered under the member's contract under any normal circumstances. 
 
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 cone 
beam computed tomography (CT) capture (D0364) provided on April 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for thoracic lumbar sacral orthosis (TLSO) 
brace on May 02, 2022. 
 
You asked the Plan to waive the coinsurance for thoracic lumbar sacral orthosis (TLSO) brace. You say that 
you want to appeal the amount being charged. The Plan denied your request. The Plan says the cost sharing 
amount 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 20% 
coinsurance for Medicare-covered equipment and supplies. Covered items include, but are not limited to 
wheelchairs, crutches, powered mattress systems, diabetic supplies, hospital beds ordered by a provider for use 
in the home, IV infusion pumps, speech generating devices, oxygen equipment, nebulizers, and walkers, 
wound care supplies, and insulin pumps and continuous glucose monitors (CGM). The provider billed in the 
amount of $1,786 and the allowed amount is $1,568.23. $1,568.23 x 20% = $313.65. Therefore, results in the 
total cost sharing amount of $313.65. 
 
 You have been asked to pay a 20% coinsurance for thoracic lumbar sacral orthosis (TLSO) brace. Thoracic 
lumbar sacral orthosis (TLSO) brace 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 thoracic lumbar sacral orthosis 
(TLSO) brace on May 02, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 a home ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. You have a diagnosis of chronic obstructive pulmonary disease (COPD), but there are no pulmonary 
function tests to confirm or assess severity. There is no arterial blood gases (ABG), done while stable as an 
outpatient, to confirm chronic carbon dioxide (CO2) retention. If you do have chronic CO2 retention, you may 
benefit from bilevel positive airway pressure (BiPAP) with average volume-assured pressure support (AVAPS) during sleep. But Medicare does not cover a home ventilator when used as BiPaP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a dermatology appointment provided on 
May 3, 2022, and May 5, 2022. 
 
You asked the Plan to waive the copayment for a dermatology appointment. You say that you feel it is 
excessive to have two copayments in a row for the same specialist. The Plan denied your request. The Plan says 
the copayments that were applied were 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 Physician/Practitioner services, including doctor's office visits.  
 
You have been asked to pay a $35 copayment for a dermatology appointment. A dermatology appointment falls 
within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category.  This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for a dermatology appointment provided on May 3, 2022, and 
May 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve the office visits. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they are non-
emergent and can be provided in-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 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 
office visits to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for Part B drugs and office visit on April 06, 
2022. 
 
You asked the Plan to waive the cost sharing for Part B drugs and office visit. You say that you want to appeal 
the amount being charged. 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 20% 
coinsurance for Medicare Part B covered drugs at specialists office. These drugs are covered under Part B of 
Original Medicare. Members of our plan receive coverage for these drugs through our plan. Covered drugs 
Include drugs that usually aren't self-administered by the patient and are injected or infused while you are 
getting physician, hospital outpatient, or ambulatory surgical center services. You must pay a $45 copayment 
for provider and professional services at specialists office. Covered services include consultation, diagnosis, 
and treatment by a specialist. The provider billed in the amount of $28 and the allowed amount is $10.52. 
$10.52 x 20% = $2.10. $2.10 + $45 = $47.10. Therefore, results in the total cost sharing amount of $47.10. 
 
You have been asked to pay a 20% coinsurance for Part B drugs and a $45 copayment for office visit. Part B 
drugs and office visits fall within the Medicare Part B prescription drug and Physician/Practitioner services, 
including doctor's office visits benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost sharing for Part B 
drugs and office visit on April 06, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the breast. 
 
You asked the Plan to pre-approve an MRI of the breast. You say that the services are necessary. The Plan 
denied your request. The Plan says that based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that breast MRI studies are to be used very selectively. 
 
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 of the breast. Our reviewer says 
that the services are medically necessary. Our physician reviewer found the palpable abnormality appears to be 
apparent at different body positioning of the enrollee. This makes biopsy very difficult and even a negative 
result would carry with it the concern that the abnormal area was not included in the sample. The enrollee has 
had the usual extensive conventional imaging workup with negative results. In an enrollee with a positive 
physical finding the next and final step in imaging is a breast MRI which should be approved 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 an MRI of the breast have been met. Therefore, we decided that the Plan has to 
pre-approve a magnetic resonance imaging (MRI) of the breast.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a podiatry office visit and an ultrasound 
study of extremity arteries provided on March 3, 2022. 
 
You asked the Plan to waive the copayments for the podiatry visit and ultrasound. You say that the cost is 
exorbitant for the services provided. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for each podiatry visit. 
 
Your contract with the Plan also clearly says that you must pay a $105 copayment for radiological diagnostic services, such as ultrasounds. 
 
You have been asked to pay a $40 copayment for the podiatry visit. The podiatry visit falls within the Podiatry 
Services benefit category. You have also been asked to pay a $105 copayment for the ultrasound. The 
ultrasound falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. 
The total for the visit is $145. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayments for a podiatry office visit and 
an ultrasound study of extremity arteries provided on March 3, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc. 
 
You asked the Plan to pre-approve Synvisc. You say that the requested Synvisc is medically necessary. The 
Plan denied your request. The Plan says the requested Synvisc is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Synvisc. Our reviewer says that the 
requested Synvisc is not medically necessary. Our physician reviewer found the record indicates that the 
enrollee has a diagnosis of osteoarthritis of the shoulder. The Food and Drug Administration has not stated that 
the requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia do not 
contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. The elements 
of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Synvisc.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repatha Push. 
 
You asked the Plan to pre-approve Repatha Push. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Repatha Push.  
 
Benefits for Repatha Push may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a FreeStyle Libre CGM. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says you do not meet criteria for the requested device. 
 
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 you do 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 have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre continuous 
glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient services provided March 12, 2020, to March 20, 
2020. 
 
You asked the Plan to pay for the inpatient services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the billed DRG is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with A41.9, defined as sepsis unspecified organism. 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 the inpatient services. Our reviewer says that 
the documentation does not support the DRG billed. Our physician reviewer found the enrollee presented to the 
Emergency Department with shortness of breath and dyspnea. Vital signs on arrival were temp 99.3, blood 
pressure 172/73, heart rate 112, respiratory rate 28 and Oxygen saturation 95% on six liters per minute 
supplemental oxygen via nasal cannula. Chest X-ray showed left basilar opacity. While enrollee presentation 
warranted consideration of sepsis as a diagnosis, there was no evidence of life-threatening organ dysfunction 
due to a dysregulated host response to infection. Platelet count was 213-376. Total bilirubin was 0.4 milligrams 
per decilitre and creatinine was 0.44- 0.70 milligrams per decilitre. The enrollee remained alert and oriented 
and mean arterial pressure remained greater than 70. There was no evidence of significant physiologic 
instability. Therefore, the principal diagnosis code assignment of A41.9 (sepsis unspecified organism) was not 
supported by the documentation.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient services provided March 12, 2020, to March 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an automatic external defibrillator (AED) 
device provided on March 14, 2022. 
 
You asked the Plan to waive the coinsurance for the AED device. You say that you feel the claim should be 
covered in full. The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
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 durable medical equipment (DME) items.  
 
You have been asked to pay $554.57, which is 20% of the allowed amount for the AED device ($2,772.86 
allowed amount x 20% coinsurance = $554.57). The AED device 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 an 
automatic external defibrillator (AED) device provided on March 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve exercise pedals (A9300). 
 
You asked the Plan to pre-approve exercise pedals (A9300). You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says exercise equipment is not covered by Medicare or the 
Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
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 exercise pedals (A9300).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance angiography (MRA) 
provided on November 2, 2021. 
 
You asked the Plan to waive the copayment for the MRA. You say that your employer denied reimbursement. 
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 $200 
copayment for diagnostic radiology services other than CT scans.  
 
You have been asked to pay a $200 copayment for the MRA. The MRA 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 a magnetic resonance angiography (MRA) provided on November 2, 2021.