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

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on July 29, 
2022, to July 30, 2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged 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 $275 
copayment for ambulance services.  
 
You have been asked to pay a $275 copayment for ambulance services. The amount you are being asked to pay 
for ambulance services on ambulance services provided on July 29, 2022 is for $248.65 which is less than the 
required amount. The total amount you are being asked to pay is $523.65 ($275 + $248.68 = $523.65). This 
item/service falls within the ambulance 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 
copayment for ambulance services provided on July 29, 2022, to July 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0220), a limited oral evaluation 
(D0140), and a core build-up (D2950), provided on May 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that these were covered and now they are being 
denied. The Plan denied your request. The Plan says the dental services were received from an out-of-network 
provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for intraoral imaging (D0220), a limited oral evaluation (D0140), and a core build-up (D2950), provided 
on May 11, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve additional service image guidance. 
 
You asked the Plan to pre-approve additional service image guidance. You say that the services are necessary. 
The Plan denied your request. The Plan says that medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 additional service image guidance. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found while image guided radiotherapy (IGRT) may not always be used in this 
situation, a possible benefit is plausible. Ensuring accurate set-up can ensure sparing of the esophagus and 
targeting the spine properly. IGRT could be considered plausibly beneficial and therefore in accordance with 
accepted standards of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional service image guidance have been met. Therefore, we decided that 
the Plan has to pre-approve additional service image guidance.  
 
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 pre-approve ultrasound to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve ultrasound. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says the enrollee must receive their care from a network provider (for more 
information about this, see Section 2 in Chapter 3). In most cases, care the enrollee receives from an out-of-
network provider (a provider who is not part of the plans network) will not be covered. This means that the 
enrollee will have to pay the provider in full for the services furnished. 
 
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 
ultrasound to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services provided on June 24, 2022. 
 
You asked the Plan to pay for telehealth services. You say that the records attached support the services 
provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for telehealth services 
provided on June 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a primary care visit provided on December 
19, 2022. 
 
You asked the Plan to waive the copayment for a primary care visit. You say that you think that this visit 
should be covered. The Plan denied your request. The Plan says this cost sharing was charged 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 $20 
copayment for each in and out-of-network primary care doctor office visit. 
 
You have been asked to pay a $20 copayment for a primary care visit. This item/service falls within the each in 
and out-of-network primary care doctor office visit 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 primary care visit provided on December 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a subsequent nursing facility care provided on September 29, 
2022. 
 
You asked the Plan to pay for a subsequent nursing facility care. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a subsequent nursing 
facility care provided on September 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services provided on December 01, 2022. 
 
You asked the Plan to pay for the chiropractic services. You say that you have seen this provider before and 
had no issues. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the chiropractic services 
provided on December 01, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit provided on September 28, 
2022. 
 
You asked the Plan to pay for domiciliary or rest home visit. You say that the records attached support the 
services provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for domiciliary or rest home 
visit provided on September 28, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital outpatient clinic visit provided on October 11, 2022. 
 
You asked the Plan to pay for hospital outpatient clinic visit. You say that these services should have been 
authorized. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for hospital outpatient clinic 
visit provided on October 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 transmitter. 
 
You asked the Plan to pre-approve a Dexcom G6 transmitter. You say that you disagree with the Plan's 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. Based on this information, we decided that Medicare rules for 
coverage of a Dexcom G6 transmitter have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a Dexcom G6 transmitter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an esophagogastroduodenoscopy (EGD) 
with biopsy provided on August 23, 2022. 
 
You asked the Plan to waive the copayment for an esophagogastroduodenoscopy (EGD) with biopsy. You say 
that you think that you were billed incorrectly for this service. The Plan denied your request. The Plan says this 
cost sharing was charged 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 $100 
copayment for in and out-of-network Medicare-covered surgery or services provided at an outpatient hospital 
or ambulatory surgical center. 
 
You have been asked to pay a $100 copayment for an esophagogastroduodenoscopy (EGD) with biopsy. This 
item/service falls within the in and out-of-network Medicare-covered surgery or services provided at an 
outpatient hospital or ambulatory surgical center 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 an esophagogastroduodenoscopy (EGD) with biopsy provided on August 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the lateral sacral 
branches. 
 
You asked the Plan to pre-approve RFA of the lateral sacral branches. You say that the services are necessary. 
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 RFA of the lateral sacral branches. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this is considered an experimental/investigational procedure because of the 
wide variation in efficacy reported in the literature. Therefore, the request is deemed not medically reasonable 
and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of RFA of the lateral sacral branches have not been met. Therefore, we decided 
that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the lateral sacral branches.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on September 
9, 2022. 
 
You asked the Plan to waive the copayment for the lab services. You say that you disagree with the cost 
sharing amount. The Plan denied your request. The Plan says this cost sharing was charged 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 $10 
copayment for each laboratory and non-radiological diagnostic test.  
 
You have been asked to pay a $10 copayment for the lab services. These items/services fall within the 
outpatient diagnostic tests and therapeutic 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 
copayment for laboratory services provided on September 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services provided on September 26, 2022. 
 
You asked the Plan to pay for the chiropractic services. You say that the provider is not out-of-network. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the chiropractic services 
provided on September 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
November 17, 2022. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you should not have to 
pay the copayment because the provider is a physician's assistant (PA). The Plan denied your request. The Plan 
says this cost sharing was charged 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 $35 
copayment for each specialist office visit.  
 
You have been asked to pay a $35 copayment for the specialist office visit. This item/service falls within the 
physician/practitioner 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 copayment for 
the specialist office visit provided on November 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation (D0120), and prophylaxis 
(D1110), provided on November 28, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you thought this provider was in-network. 
The Plan denied your request. The Plan says you are responsible for any charged amount above the Plans cost-
sharing amount when your services are received from an out-of-network provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for a periodic oral evaluation (D0120), and 
prophylaxis (D1110), provided on November 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on November 01, 2022. 
 
You asked the Plan to pay for laboratory services. You say that the records attached support the services 
provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on November 01, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets LTACH admission 
criteria, and their ongoing medical needs warrant an LTACH level of care to achieve a safe and sustainable 
discharge. The Plan denied your request. The Plan says criteria for admission to the LTACH have not been 
met. 
 
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 that there are no services available at the LTACH that the enrollee requires that are 
not available at the health care setting being offered by the Plan. The Plan has approved ongoing care in the 
current acute care setting.  
 
The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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.