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

 
We decided that the Plan does not have to pay for medication assisted treatment provided on January 12, 2021. 
 
You asked the Plan to pay for medication assisted treatment. The Plan denied your request. The Plan says prior 
authorization was not obtained by the provider or facility. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for medication assisted treatment provided on January 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an opioid treatment program provided on September 7, 2021. 
 
You asked the Plan to pay for the opioid treatment program. The Plan denied your request. The Plan says prior 
authorization was not obtained by the provider or facility. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an opioid treatment program provided on September 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for advanced care planning services provided 
on December 14, 2021. 
 
You asked the Plan to waive the copayment for the advanced care planning. You say that all you had was a 
wellness check and should not have a copayment. 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 no 
coinsurance, copayment, or deductible for annual wellness visits. Your contract with the Plan also clearly says that you must pay a $10 copayment per day for non-preferred PCP 
services. 
 
The file shows that during your wellness visit, additional counseling was provided in regard to future health 
and end of life planning. These advance care items go beyond the scope of the normal wellness visit. Therefore, 
you have been asked to pay a $10 copayment for the advanced care planning. The advanced care planning 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 advanced care planning services provided on December 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
September 28, 2020. We also decided that the Plan does not have to waive the copayment for physical therapy (PT) services provided on February 8, 2021. We also decided that the Plan does not have to waive the 
copayment for SPECT imaging provided on March 23, 2021. We also decided the Plan to waive the copayment 
for an emergency room (ER) visit provided on August 30, 2021. 
 
You asked the Plan to waive the copayments for the ER visits, PT services, and SPECT imaging. You say that 
you were informed that you would not have copayments when you enrolled in the Plan. 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 $50 
copayment for each emergency room visit. 
 
Your contract with the Plan also clearly says that you must pay a $15 copayment for physical therapy services 
provided at an outpatient hospital. 
 
Your contract with the Plan also clearly says that you must pay a $25 copayment for advanced imaging 
services provided at an outpatient hospital. 
 
You have been asked to pay a $50 copayment for each of the two ER visits. The ER visits fall within the 
Emergency Care benefit category. You have also been asked to pay a $15 copayment for the PT services. The 
PT services fall within the Outpatient Rehabilitation Services benefit category. You have also been asked to 
pay a $25 copayment for the SPECT imaging. The SPECT imaging falls within the Outpatient Diagnostic Tests 
and Therapeutic Services and Supplies benefit category. The total for all services is $140. 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 emergency room (ER) visit provided on September 28, 2020. We 
also decided that the Plan does not have to waive the copayment for physical therapy (PT) services provided on 
February 8, 2021. We also decided that the Plan does not have to waive the copayment for SPECT imaging 
provided on March 23, 2021. We also decided the Plan to waive the copayment for an emergency room (ER) 
visit provided on August 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a collagenase injection and a specialist 
office visit provided on April 5, 2021. 
 
You asked the Plan to waive the cost share for an injection and a specialist office visit. You say that this is a 
duplicate charge for the injection. 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 20% 
coinsurance for in-network Part B drugs, including a collagenase injection. The Plan contract also says that enrollees must pay a $35 copayment for an in-network specialist office visit.   
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay 
$1,959.84, which is 20% coinsurance of the allowed amount for an injection ($$9,799.20 allowed amount x 
20% coinsurance = $1,959.84). An injection falls within the Medicare Part B Prescription Drugs benefit 
category.  
 
You have also been asked to pay a $35 copayment for a specialist office visit. A specialist office visit falls 
within the Physician/Practitioner Services, Including Doctors Office Visits benefit category. You have been 
asked to pay a total of $1,994.84 ($1,959.84 coinsurance + $35 copayment = $1,994.84). 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 share for a collagenase injection and a specialist office visit provided on April 
5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable 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 follows Medicare rules. Medicare rules say that the Centers for Medicare & Medicaid Services 
(CMS) National Coverage Determinations Manual (CMS Pub. 100-03) in Chapter 1, Part 4, Section 280.1 
stipulates that ventilators (E0465, E0466, and E0467) are covered when specific criteria are met. 
 
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 portable ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the documentation does not 
support that the coverage criteria established by the LCD have been satisfied in this case. While you have 
respiratory failure due to chronic obstructive pulmonary disease (COPD), it is documented that you have not 
failed treatment with bilevel positive airway pressure (BiPAP) or continuous positive airway pressure (CPAP). 
Products classified as E0466 when used to provide CPAP or bi-level PAP shall not be paid in the FSS payment 
category, regardless of the underlying medical condition. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: Testing
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services. We decided that the Plan does not have to pay for 31255.  
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan says that the denied 
codes remain not supported. 
 
We decided that the Plan has to pay for 31296.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of CPT 31296 is "Nasal/sinus endoscopy, surgical, with dilation 
(eg, balloon dilation); frontal sinus ostium." 
 
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 for CPT 31296. Our reviewer says that this code is 
supported in the medical records. Our physician reviewer found that the operative report describes balloon 
dilation frontal sinus. This procedure should be covered. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
31296.  
 
We also decided that the Plan does not have to pay for 31255. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of CPT 31255 is "Nasal/sinus endoscopy, surgical with 
ethmoidectomy; total (anterior and posterior)." 
 
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 for CPT 31255. Our reviewer says that this code is not 
supported in the medical records. Our physician reviewer found that the operative report does not describe 
removal of the anterior posterior ethmoid air cells. Therefore, this procedure cannot be verified. The report 
describes poly removal, which would not be reported with total ethmoidectomy procedure code. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 31255 have not been met. Therefore, we decided that the Plan does not have to 
pay for 31255. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553, K0554). 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that the device is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor (K0553, K0554).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an opioid treatment program provided on July 14, 2021. 
 
You asked the Plan to pay for the opioid treatment program. The Plan denied your request. The Plan says prior 
authorization was not obtained by the provider or facility. 
 
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 
service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an opioid treatment program provided on July 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya injections. 
 
You asked the Plan to pre-approve Ilumya injections. You say that the requested Ilumya injections are 
medically necessary. The Plan denied your request. The Plan says the requested Ilumya injections are not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Ilumya injections. Our reviewer says 
that the requested Ilumya injections are not medically necessary. Our physician reviewer found the record 
indicates that the enrollee has a diagnosis of psoriasis vulgaris involving 8% body surface area. The record 
does not indicate that the enrollee has moderate to severe plaque psoriasis eligible for systemic therapy or 
phototherapy. 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 Ilumya injections have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Ilumya injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an influenza virus vaccine (90662) provided 
on November 2, 2021. 
 
You asked the Plan to waive the deductible for the influenza virus vaccine. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the services should be 
covered as you disagree with the charges. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $9,000 deductible which applies to Immunizations.  
 
 
  The item or service you asked the Plan to waive the deductible for falls within the benefit category 
Immunizations. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 
$9,000 deductible which applies to Immunizations. This cost sharing is a contractual obligation that had not 
been met at the time the influenza virus vaccine was received on November 2, 2021. Therefore, we decided that 
the Plan does not have to waive the deductible for an influenza virus vaccine (90662) provided on November 2, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a home specialist visit provided on 
December 13, 2021. 
 
You asked the Plan to waive the copayment for the home visit. You say that you are not sure why you were 
billed a specialist copayment. 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 per visit with a specialist.  
 
You have been asked to pay a $40 copayment for the home visit. The home visit 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 home specialist visit provided on December 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an opioid treatment program provided on February 9, 2021, 
and February 23, 2021. 
 
You asked the Plan to pay for an opioid treatment program. The Plan denied your request. The Plan says prior 
authorization was not obtained by the provider or facility. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an opioid treatment program provided on February 9, 2021, and 
February 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an opioid treatment program provided on August 30, 2021. 
 
You asked the Plan to pay for the opioid treatment program. The Plan denied your request. The Plan says prior 
authorization was not obtained by the provider or facility. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an opioid treatment program provided on August 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an urgent care visit provided on October 
24, 2021, ambulance services provided on October 25, 2021, and an inpatient hospital stay provided from 
October 25, 2021, to October 28, 2021. 
 
You asked the Plan to waive the copayments for an urgent care visit, ambulance services, and an inpatient 
hospital stay. You say that the doctor at the urgent care center prescribed you medicine that caused you to have side effects. You also say that because of those side effects you were transported to the hospital and were 
admitted. 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 $10 
copayment for an urgent care visit. The Plan contract also says that enrollees must pay a $200 copayment for 
ground ambulance services. The Plan contract also says that enrollees must pay a $75 copayment per day for 
days 1-5 for an inpatient hospital stay. The contract also says that there is a $0 copayment for days 6-90. 
 
You have been asked to pay a $10 copayment for an urgent care visit on October 24, 2021. An urgent care visit 
falls within the Urgently Needed Services benefit category. You have also been asked to pay a $200 copayment 
for ambulance services on October 25, 2021. Ambulance services fall within the Ambulance Services benefit 
category.  
 
You have also been asked to pay $225, which is a $75 copayment per day for a three-day inpatient hospital stay 
from October 25, 2021, to October 28, 2021 ($75 copayment x 3 days = $225). There is no charge for the day 
of discharge. An inpatient hospital stay 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 copayments for an urgent care visit provided on October 24, 2021, ambulance 
services provided on October 25, 2021, and an inpatient hospital stay provided from October 25, 2021, to 
October 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve the total electric hospital bed. You say that the hospital bed is medically 
necessary. The Plan denied your request. The Plan says this type of bed is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0265).