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

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
device (K0554) and related supplies (K0553). 
 
You asked the Plan to pre-approve a Freestyle Libre CGM and related supplies. You say that the requested 
items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage 
for continuous glucose monitors and related supplies have 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 a 
Freestyle Libre CGM and related supplies have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) device (K0554) and related supplies 
(K0553).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on October 12, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health services. You say that the facility was responsible to obtain prior 
authorization and the service was rendered in good faith. The Plan denied your request. The Plan says the 
rendering provider is an OON provider and there was no referral from an in-network provider or an approved 
authorization. Also, the service rendered was not urgent or emergent. 
 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 the home health services provided on October 12, 
2021, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee from 
November 2, 2021, to November 30, 2021. 
 
You asked the Plan to pay for the services. You say that  The Plan denied your request. The Plan says this was 
billed with an invalid type of bill. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
 We find that the denied home health services are not supported, as a claim with the correct bill type must be 
submitted. Based on this information, we decided that Medicare rules for coverage of the services have not 
been met. Therefore, we decided that the Plan does not have to pay for home health services provided to the 
enrollee from November 2, 2021, to November 30, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the medical services (36415, 80053, 84443, 84484, 85025, 82948, 
93005) provided on December 9, 2021. 
 
You asked the Plan to pay for the medical services. You say that you would like this claim reprocessed based 
on medical records. The Plan denied your request. The Plan says that this claim has denied correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan has denied coverage for a variety of reasons but failed to 
support these denial reasons. There is no documentation of what criteria in a Local Coverage Determination or 
National Coverage Determination have not been satisfied. The Plan has not made reasonable and diligent 
efforts to support their denial by citing valid Medicare coverage rules that were not met. Therefore, we decided 
that the Plan has to pay for the medical services (36415, 80053, 84443, 84484, 85025, 82948, 93005) provided 
on December 9, 2021.  
 
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 copayment for a diagnostic colonoscopy provided on 
January 20, 2022. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that you feel you should not 
have to pay the additional $75. You say that the $250 seems to have been for ASC and not outpatient. The Plan 
denied your request. The Plan says you have been charged the correct copayment 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 $325 
copayment for surgery in an in-network outpatient hospital.  
 
You have been asked to pay a $325 copayment for a diagnostic colonoscopy. The diagnostic colonoscopy falls 
within the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers (ASC) 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 diagnostic 
colonoscopy provided on January 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is requesting LTACH to 
receive PT, OT and ST that will help the enrollee maintain their strength. The enrollee will also see a wound 
specialist weekly for assessment of the wounds. The Plan denied your request. The Plan says the enrollee can 
stay in the hospital until they are safe for transfer or discharge. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary. Our physician reviewer 
found the enrollee was admitted to the acute care hospital with acute respiratory failure (COPD) exacerbation 
and possible pneumonia requiring antibiotics, intubation, vasopressors complicated by seizure activity, and 
failure to thrive. The trach and PEG were placed. The enrollee received sacral wound debridement and tube 
feeds. Recent notes describe the enrollee as still having on-going hypotension and with poor neurological status 
requiring on-going aggressive pulmonary hygiene, IV antibiotics, and tube feeds. 
 The enrollee appears to be unstable and requires short-term additional acute care that can be safely completed 
at the current facility. Transfer to LTACH is not medically necessary as the enrollee is not yet stable enough. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) of the 
chest and spine provided on February 14, 2022. 
 
You asked the Plan to waive the copayment for the MRI. You say that you are on a fixed income and cannot 
afford the 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 $350 
copayment per visit for outpatient diagnostic and therapeutic services and supplies, such as MRI's.  
 
 
 
 
 
 You have been asked to pay a $350 copayment for the MRI. The MRI 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 imaging (MRI) of the chest and spine provided on February 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has multiple plausible 
pathologic sources of significant pain generation. Overall, documentation is lacking regarding reasonably 
detailed and/or evidenced findings supportive of spinal vertebral bodies as the overwhelming primary 
generators of the enrollee's chronic persistent pain. The documentation does not support actual formal surgical 
ablation of pre-designated basivertebral nerves as being medically necessary and/or reasonable at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a walker provided on November 24,2021. 
 
You asked the Plan to waive the coinsurance for a walker. You say that due to a previous appeal there is no 
coinsurance and that you are not responsible. 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 durable medical equipment (not advanced).  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay 
$11.01, which is 20% coinsurance of the allowed amount for a walker ($55.03 allowed amount x 20% 
coinsurance = $11.01). You have also been asked to pay $3.10, which is 20% coinsurance of the allowed 
amount for the walker seat attachment ($15.51 allowed amount x 20% coinsurance = $3.10). You have been 
asked to pay a total of $14.11 ($11.01 coinsurance + $3.10 coinsurance = $14.11). A walker 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 walker provided on November 24,2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a pacemaker evaluation (93294) provided 
on February 5, 2022. 
 
You asked the Plan to waive the copayment for the pacemaker evaluation. 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 $20 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
 
  You have been asked to pay a $20 copayment for the pacemaker evaluation. Pacemaker evaluations fall 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 pacemaker evaluation (93294) provided on February 5, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the insulin (J1815) and sodium polystyrene (A9270) 
provided in an outpatient setting on February 17, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that this was an emergency visit to the 
hospital. You say that you did not ask for this medicine. You say it was given to me on the doctor's orders. You 
also say that you did not have a choice. The Plan denied your request. The Plan says the drugs you received are 
considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D 
prescription drug plan. The Plan also says the drugs you received are not covered under Medicare Part B.  
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 pay for the insulin (J1815) and sodium 
polystyrene (A9270) provided in an outpatient setting on February 17, 2022.  
 
Benefits for the self-administered drugs 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the digital hearing aids (V5261) purchased on February 
15, 2022. 
 
You asked the Plan to pay more for the hearing aids. You say that you received a denial of payment in the mail 
which you think is unacceptable. The Plan denied your request. The Plan says your benefit for this type of 
service has been exhausted. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only up to a $750 allowance, and you are responsible any amount above the $750 allowance.  
 
We looked at this the file and the Plan's rules. The record shows that you received digital hearing aids (V5261) 
and the total cost that the Plan approved was $4,900.00. The Plan paid the $750.00 allowance, and you are 
responsible for the remaining balance of $4,150.00. Based on this information, we decided that the Plan's rules 
for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay 
more for the digital hearing aids (V5261) purchased on February 15, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an ultrasound of the extremity veins 
provided on January 19, 2022. 
 
You asked the Plan to reduce the copayment for an ultrasound. You say that you already paid a $20 copayment. 
You also say that you were never told how much the procedure would cost. 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 $120 
copayment for in-network radiology diagnostic services, including ultrasounds.  
 
 
 
 
 
 The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$120 copayment for an ultrasound. An ultrasound 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 reduce the copayment for an 
ultrasound of the extremity veins provided on January 19, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for physical therapy services provided on 
January 20, 2022. 
 
You asked the Plan to waive the deductible for the physical therapy services. You say that the services should 
be covered as you disagree with the charges. The Plan denied your request. The Plan says the deductible 
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. Your 
contract with the Plan says that there is a $750 deductible which applies to Outpatient rehabilitation services.  
 
 
  The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
rehabilitation services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 
$750 deductible which applies to Outpatient rehabilitation services. This cost sharing is a contractual obligation 
that had not been met at the time the physical therapy services was received on January 20, 2022. Therefore, 
we decided that the Plan does not have to waive the deductible for physical therapy services provided on 
January 20, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided from October 
25, 2021, to February 3, 2022.  
 
You asked the Plan to waive the copayment for ambulance services. You say that you do not think you can 
afford this member liability. 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 $250 
copayment for each one-way ambulance service.  
 
You have been asked to pay a $250 copayment for each ambulance service on October 25, 2021, October 30, 
2021, and February 3, 2022. You have been asked to pay a total of $750 ($250 copayment x 3 ambulance trips 
= $750).  Ambulance services fall within the Ambulance 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 ambulance services provided from October 25, 2021, to February 3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says based on Medicare guidelines, the Long-Term Acute Care 
Hospital (LTACH) services you are requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where he/she is currently receiving care, and all medically necessary care is being provided in the 
current acute care facility. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.