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 a therapeutic CGM. You say that this device is medically necessary. The 
Plan denied your request. The Plan says the criteria for coverage 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 does not provide evidence that you use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic tests provided on January 13, 2022, by an 
OON provider. 
 
You asked the Plan to pay for the diagnostic tests. You say that you would like the claim reprocessed for 
payment. The Plan denied your request. The Plan says the rendering and referring providers are both OON 
providers and there was no approved authorization. Also, the services 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 diagnostic tests provided on January 13, 2022, 
by an OON provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the continuous glucose monitor (CGM) supplies provided on June 1, 
2021. 
 
You asked the Plan to pay for the CGM supplies. You say that the records clearly show that criteria are met. 
The Plan denied your request. The Plan says that the documentation submitted did not sufficiently support the 
billed code. 
 
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, though the Plan argues that the documentation is not sufficient to 
support payment for this code, no specific deficiency is cited. We reviewed the documentation, including the 
documentation submitted directly by the supplier, and we find no deficiency that would support denial of 
payment. The file contains a signed order/prescription, and the records submitted show that the enrollee 
performs more than three insulin injections per day with the dose being adjusted based on CGM readings. 
There is a proof of delivery showing that a month's supply was delivered. We find that the Plans' denial of 
payment is not supported. Therefore, we decided that the Plan has to pay for the continuous glucose monitor 
(CGM) supplies provided on June 1, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) provided on 
December 1, 2021, billed with codes E0675 and E0673. 
 
You asked the Plan to pay for the PCD as billed. You say that this is the most effective therapy for preventing 
deep vein thrombosis. These are not part of surgical facilities treatment and are separately payable. The Plan 
denied your request. The Plan says this is not billed with an appropriate place of service. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device (PCD) provided on December 1, 2021, billed with codes E0675 and 
E0673.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the removal of skin tags provided on 
January 6, 2022. 
 
You asked the Plan to waive the copayment for the removal of skin tags. You say that you were told by the 
provider that it would be covered. You also say it was done at the doctor's office and not at the hospital. 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 $325 
copayment for in-network outpatient surgery.  
 
The record shows the removal of skin tags (code 11200) is considered a surgical procedure and the outpatient 
surgery cost share applies. You have been asked to pay the allowed amount of $185.39, which is less than the $325 copayment for the removal of skin tags. The removal of skin tags falls within the Outpatient Surgery, 
Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for the removal of skin tags provided on January 6, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the post-cataract laser surgery services 
provided on January 7, 2022. 
 
You asked the Plan to waive the copayment for the post-cataract laser surgery services. You say that you were 
never told there would be a copayment charge for the use of the facility. The Plan denied your request. The 
Plan says the proper copayment was applied, and they confirmed with the provider's office that the claim was 
billed correctly and there was no double billing. 
 
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 $175 
copayment for ambulatory surgical center visits.  
 
  You have been asked to pay a $175 copayment for the post-cataract laser surgery services. The post-cataract 
laser surgery services falls within Outpatient surgery, including services provided at hospital outpatient 
facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for the post-cataract laser surgery services provided on January 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exam rendered on November 2, 
2021. 
 
You asked the Plan to waive the copayment for these services. You say that the services were a glaucoma 
screening and should have no copayment. The Plan denied your request. The Plan says the copayment was 
applied 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 each Medicare-covered vision care exam.  
 
Review of the file shows that you received a diagnostic eye exam on November 2, 2021. The exam was 
diagnostic in nature and not a glaucoma screening because the records show it was performed for diagnoses of 
age-related cataracts, puckering of left eye macula, and a retinal break of the left eye. You have been asked to 
pay a $25 copayment for these services. These services fall within the Medicare-covered vision care exam 
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 the eye exam rendered on 
November 2, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Mental Health provided on December 9, 2021 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for Outpatient Mental Health. You say that the provider was the only therapist in the 
area when the member was seen and he was the only therapist that could see him at that time. The Plan denied 
your request. The Plan says prior authorization is required for an out-of-network visit. 
 
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 Outpatient Mental Health provided on December 
9, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 15, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the testing is not covered.  
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on August 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fecal occult blood test you had on February 2, 2022. 
 
You asked the Plan to pay for the fecal occult blood test. You say that you did not know there was a limit for 
this test. The Plan denied your request. The Plan says you have exhausted your benefit for this test for 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that fecal occult blood tests are only covered once a 
year.  Your Evidence of Coverage also discloses that only one fecal occult blood test is covered every 12 
months.  You had already received a covered fecal occult blood test on January 18, 2022.  You will not be 
eligible for another fecal occult blood test until 12 months has passed after January 18, 2022. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the fecal occult blood test have not been met. Therefore, we decided that the Plan does not have to 
pay for the fecal occult blood test you had on February 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) rendered by 
the out-of-network (OON) provider on June 15, 2021 and September 23, 2021. 
 
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 the services were rendered by an out of 
network provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. 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 the chiropractic manipulative treatment (98941) rendered by the out-of-network 
(OON) provider on June 15, 2021 and September 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a Life vest on November 27, 2021 to 
December 27, 2021. 
 
You asked the Plan to waive the coinsurance for a Life vest. You say that you would like to appeal the cost 
share. The Plan denied your request. The Plan says the cost share applied 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 Life vest. The total allowed amount of the Life vest is $5,862.90, resulting in a total 
coinsurance amount of $1,172.58. 
 
You have been asked to pay a 20% coinsurance for a Life vest. A Life vest 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 Life vest on November 27, 2021 to December 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the outpatient procedures provided on 
December 6, 2021, and December 20, 2021. 
 
You asked the Plan to waive the copayments for the outpatient procedures. You say that the enrollee has had 
this procedure done before and it was covered. The Plan denied your request. The Plan says the proper 
copayments were applied for each date of service. 
  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $100 copayment for outpatient procedures and services, including, but not limited to, outpatient 
surgery performed in an outpatient hospital or ambulatory surgical center. On December 6, 2021, the total 
copayment amount for the procedure was $100. On December 20, 2021, the total copayment amount for the 
procedure was $100. For both dates of service, the total copayment amount was $200 ($100 copayment + $100 
copayment. 
 
The enrollee has been asked to pay a $200 copayment for the outpatient procedures. The outpatient procedures 
falls within the Outpatient hospital services benefit category. This means that the enrollee has been asked to 
pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the 
enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayments for the outpatient procedures provided on December 6, 2021, and December 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a Udenyca injection provided on March 4, 
2021. 
 
You asked the Plan to waive the coinsurance for an injection. You say that the insurance plan was reprocessing 
this claim and would pay 100%. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay 20% coinsurance for Part B drugs.  
 
The enrollee has been asked to pay $1,292.42, which is 20% coinsurance of the allowed amount for an 
injection ($6,462.11 allowed amount x 20% coinsurance = $1,292.42). An injection falls within the Medicare Part B Prescription Drugs benefit category. This means that the enrollee has been asked to pay the correct 
amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to 
pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for 
a Udenyca injection provided on March 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed with procedure code 85060 for date of 
service January 14, 2022. 
 You asked the Plan to pay for code 85060. You say that you billed these services with the correct date of 
interpretation and the service was medically necessary. The Plan denied your request. The Plan says this code 
is not payable with the place of service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for code 85060, no payment is recognized for 
this service when furnished to hospital outpatients or non-hospital patients. You billed this code with Place of 
Service 22, which indicates the patient was a hospital outpatient. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 85060 have not been met. Therefore, we decided that the Plan does not have to pay for lab 
services billed with procedure code 85060 for date of service January 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computerized axial tomography (CAT) 
scan provided on September 10, 2021. 
 
You asked the Plan to waive the copayment for the CAT scan. You say that you already paid the provider, and 
they should be billing for the copayment amount. The Plan denied your request. The Plan says the proper 
copayment was applied, and they reached out to the provider and there was no record of payment for the date 
of service. 
  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 Complex Radiology (MRI/MRA, CT scans, nuclear cardiology studies). The total allowed 
amount was $113.88 which is less than the copayment amount of $200. Therefore, only $113.88 was charged 
as the copayment. 
 
You have been asked to pay a $113.88 copayment for the CAT scan. The CAT scan 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 the computerized axial tomography (CAT) scan provided on September 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on November 30, 2021, billed 
with codes 36906, 76937-26, and 99152. 
 
You asked the Plan to pay for the medical services provided. You say that the enrollee had multiple exams on 
this date of service. The records show that both should be paid. The Plan denied your request. The Plan says 
this was correctly denied as a duplicate claim. Payment was made for these services on January 12, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that duplicate claims are to be denied but may be 
appealed.  
 
We looked at the file and Medicare rules. There is no evidence that these services were provided on two 
occasions on this date of service. The two records submitted as evidence are exact duplicates of one another. 
This was correctly denied.  
 
Based on this information, we decided that Medicare rules for coverage of the medical services provided have not been met. Therefore, we decided that the Plan does not have to pay for the medical services provided on 
November 30, 2021, billed with codes 36906, 76937-26, and 99152.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 14, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on April 14, 2021.