Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device. 
 
You asked the Plan to pre-approve the Vertiflex device. You say that the Vertiflex procedure will be of great 
benefit to the enrollee. The Plan denied your request. The Plan says the Vertiflex device is considered 
experimental/investigational. 
 
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 the Vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is experimental, and more research is needed. 
 
  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 Vertiflex device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex device.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for home infusion services provided on April 
21, 2022. 
 
You asked the Plan to waive the coinsurance for the home infusion. You say that you are under financial 
hardship and cannot afford the costs. 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 Part B drugs, durable medical equipment (DME) and related supplies, and remote monitoring.  
 
You have been asked to pay $19.60, which is 20% of the allowed amount for the home infusion ($98.00 
allowed amount x 20% coinsurance = $19.60). The home infusion falls within the Home Infusion Therapy 
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 home infusion services 
provided on April 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $475 copayment for outpatient surgery on February 28, 
2022. 
 
You asked the Plan to waive the $475 copayment for outpatient surgery. You say that this was for a 
colonoscopy, and you should not be responsible for a copayment. The Plan denied your request. The Plan says 
You must pay a $475 copayment for each outpatient hospital facility visit. 
 
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 $475 
copayment for outpatient surgery provided at a hospital outpatient facility. 
 
You have been asked to pay a $475 copayment for an outpatient hospital visit. An outpatient hospital visit 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 $475 copayment for outpatient 
surgery on February 28, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayments for out-of-network (OON) physical therapy 
(PT) services provided from March 21, 2022, to April 13, 2022. 
 
You asked the Plan to reduce the copayments for the OON PT services. You say that the provider informed you 
the copayments would only be $5. 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 therapy visit with an out-of-network provider.  
 
The file shows that the Plan verified the provider is not a network provider. The contract says that there is a 
$50 copayment for each therapy visit with an out-of-network provider. However, the provider has only billed a 
$25 copayment per visit for the OON PT services. The total for all services is $200 ($25 copayment x 8 visits = 
$200). The OON PT services fall within the Outpatient Rehabilitation Services 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 copayments for out-of-network (OON) physical therapy (PT) services provided 
from March 21, 2022, to April 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on September 16, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says these services are 
not payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab services provided on September 16, 2021.
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 would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the enrollee does 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 the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on April 15, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on April 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair and accessories. 
 
You asked the Plan to pre-approve the power wheelchair and accessories. You say that the power wheelchair is 
medically necessary. The Plan denied your request. The Plan says the records do not support the use of the 
power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file does not include any record of an evaluation to determine if the enrollee can safely operate the power 
wheelchair in the home. The record shows the enrollee is bedbound with visual and motor weaknesses. This 
means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power wheelchair and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the new patient outpatient office visit (99202) provided on 
February 17, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that records attached support that this procedure was 
performed by your provider. The claim denied as duplicate in error. Please review and reprocess the claim for 
reimbursement. The Plan denied your request. The Plan says enrollees must receive their medical services 
from an in-network provider with the exception being urgent or emergent services. Non-emergent services with 
non-contracted providers require prior authorization before services being rendered. 
 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 referring provider indicated 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 new patient outpatient office visit (99202) provided on February 17, 2021 by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $35 copayment for a specialist office visit on April 7, 
2022. 
 
You asked the Plan to waive the $35 copayment for a specialist office visit. You say that you should not be 
responsible for this copayment. The Plan denied your request. The Plan says you must pay a $35 copayment for 
each in-person specialist visit. 
 
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 specialist office visit. A specialist office 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 $35 copayment for a specialist office visit on April 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an outpatient visit to be provided by an out-of-network 
(OON) audiologist. 
 
You asked the Plan to pre-approve an outpatient visit. The Plan denied your request. The Plan says the services 
were requested out-of-network and there are in-network providers available. 
 
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 
an outpatient visit to be provided by an out-of-network (OON) audiologist.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for lab test, outpatient surgery, and outpatient 
hospital visit on December 01, 2021, to January 05, 2022. 
 
You asked the Plan to waive the copayments for lab test, outpatient surgery, and outpatient hospital 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 $10 
copayment per day for Medicare-covered lab services. Covered services include but are not limited to: 
Laboratory tests. A $350 copayment for each Medicare-covered outpatient hospital surgery. Also, a $300 
copayment for each Medicare-covered outpatient hospital surgery visit. We cover medically necessary services 
you get in the outpatient department of a hospital for diagnosis or treatment of an illness or injury. Covered 
services include but are not limited to: Services in an emergency department or outpatient clinic, such as 
observation services or outpatient surgery.  
 
The provider billed in the amount of $557 and the allowed amount is $203.75, which is less than the copayment 
amount of $350. There were 3 visits, resulting in the amount of $611.25 for outpatient surgery. The provider 
also billed in the amount of $1,222 and the allowed amount is $241.09 for outpatient hospital visit. The Plan 
paid $81.09, resulting in the amount of $160, which is also less than the copayment amount of $300. $611.25 + 
$160 + $10 = $781.25. Therefore, results in the total cost-sharing amount of $781.25. 
 
You have been asked to pay a $10 copayment for lab test, $203.75 for each outpatient surgery, and $160 
outpatient hospital visit, which is less than the copayment amounts. Lab test, outpatient surgery, and outpatient 
hospital visit falls within the Outpatient diagnostic tests and therapeutic services and supplies, Outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers, and 
Outpatient hospital services 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 lab test, 
outpatient surgery, and outpatient hospital visit on December 01, 2021, to January 05, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xgeva. 
 
You asked the Plan to pre-approve Xgeva. You say that this drug is medically necessary. The Plan denied your 
request. The Plan says step therapy criteria have not been satisfied. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Xgeva. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the Plan requires a 
trial of intravenous pamidronate or zoledronic acid before they will approve the requested drug. In this case, the 
patient has not tried and failed the required drug(s). There is no documentation provided indicating that the 
plans required drug(s) likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Xgeva have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Xgeva.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cataract surgery performed on April 8, 
2022. 
 
You asked the Plan to waive the copayment for cataract surgery. You say that you were told you would not 
have to pay for this surgery. The Plan denied your request. The Plan says you must pay a $225 copayment per 
visit, per provider, per day for surgery performed at an in-network ambulatory surgical center. 
 
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 $225 
copayment for Outpatient Surgery, Including Services Provided At Hospital Outpatient Facilities and 
Ambulatory Surgical Centers.  
 
You have been asked to pay a $225 copayment for cataract surgery. Cataract surgery 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 cataract surgery performed on 
April 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuous glucose monitor (CGM) supplies. 
 
You asked the Plan to pre-approve CGM supplies. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says you do not meet criteria for the requested items. 
 
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 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 CGM supplies have not been met. Therefore, we 
decided that the Plan does not have to pre-approve continuous glucose monitor (CGM) supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuous glucose monitor (CGM) supplies. 
 
You asked the Plan to pre-approve these services. You say that you have to finger stick test multiple times per 
day. The Plan denied your request. The Plan says the criteria for coverage are not 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 you do not treat with insulin three 
or more times per day or use an insulin pump. 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 
continuous glucose monitor (CGM) supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 2, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received 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 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 an office visit provided on August 2, 2021, by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the $300 copayment for cataract laser surgery on February 
25, 2022. 
 
You asked the Plan to reduce the $300 copayment for cataract laser surgery. You say that you were not aware 
you would be responsible for a $300 copayment. The Plan denied your request. The Plan says you pay a $300 
copayment for surgery services performed in an outpatient hospital setting. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 
copayment for Outpatient Hospital Services.  
 
You have been asked to pay a $300 copayment for cataract laser surgery. Cataract laser surgery falls within the 
Outpatient Hospital Services 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 $300 copayment for 
cataract laser surgery on February 25, 2022.