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

 
We decided that the Plan does not have to waive the copayment for the colonoscopy provided on December 02, 
2022. 
 
You asked the Plan to waive the copayment for the colonoscopy. You say that you were not informed of the 
charges. 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 $325 
copayment for in-network outpatient surgery including services provided at ambulatory surgical centers. 
 
You have been asked to pay a $325 copayment for the colonoscopy. This item/service falls within the in-
network outpatient surgery including services provided at 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. However, since the 
allowed amount is less than the standard copayment, you only owe $270.57. Therefore, we decided that the 
Plan does not have to waive the copayment for the colonoscopy provided on December 02, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural neurostimulator implantation. 
 
You asked the Plan to pre-approve these services. You say that you are still having back pain and have seen 
many providers. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. There is no documentation to support that the services are medically 
necessary. The Plan requested medical records from your physician on three occasions and did not receive a 
response. 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 epidural neurostimulator 
implantation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the automatic external defibrillator 
provided on September 01, 2022. 
 
You asked the Plan to waive the coinsurance for the automatic external defibrillator. You say that you thought 
this was covered under your hospital visit since you needed this device in order to go home. 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 20% 
coinsurance for durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for the automatic external defibrillator. This item/service falls 
within the durable medical equipment 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. The total you owe is $540.99 ($2,704.94 allowed 
amount x 20% coinsurance = $540.99). Therefore, we decided that the Plan does not have to waive the 
coinsurance for the automatic external defibrillator provided on September 01, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the podiatry service provided on July 20, 
2022. 
 
You asked the Plan to waive the copayment for the podiatry service. You say that you disagree with the cost 
share. 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 $40 
copayment for podiatry services. 
 
You have been asked to pay a $40 copayment for the podiatry service. This item/service falls within the podiatry 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 podiatry service 
provided on July 20, 2022.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve a duplex scan (93880). 
 
You asked the Plan to pre-approve a duplex scan (93880). You say that the requested duplex scan (93880) is 
medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for 
the requested duplex scan (93880). 
 
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 a duplex scan (93880). Our reviewer 
says that the enrollee meets criteria for the requested duplex scan (93880). Our physician reviewer found the 
documentation meets the listed criteria for medical necessity. In this case the indication is planned carotid 
surgery for a medically necessary, Food and Drug Administration (FDA) approved device. Specific bullet 
points that are consistent with medical necessity include  the information is necessary for appropriate medical 
and/or surgical management, and the test is not redundant of another diagnostic procedure that must be 
performed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a duplex scan (93880) have been met. Therefore, we decided that the Plan has 
to pre-approve a duplex scan (93880).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a second opinion office visit provided on November 01, 
2022. 
 
You asked the Plan to pay for a second opinion office visit. You say that due to the seriousness of your 
condition, you chose to consult with this provider. 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 second opinion office 
visit provided on November 01, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the lumbar-sacral orthosis provided on 
November 28, 2022. 
 
You asked the Plan to waive the coinsurance for the lumbar-sacral orthosis. You say that you were told the 
Plan would pay in full. 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 10% 
coinsurance for prosthetic devices and related supplies. 
 
You have been asked to pay 10% coinsurance for the lumbar-sacral orthosis. This item/service falls within the 
prosthetic devices 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. The total you owe is $42.80 ($428 allowed amount x 10% = $42.80). Therefore, 
we decided that the Plan does not have to waive the coinsurance for the lumbar-sacral orthosis provided on 
November 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 15, 2022. 
 
You asked the Plan to pay for an office 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 an office visit provided 
on September 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a freestyle libre 2 kit. 
 
You asked the Plan to pre-approve the freestyle libre 2 kit. You say that the items should be covered as the 
enrolle disagrees with the denial. The Plan denied your request. The Plan says the items denied correctly as the 
enrollee does not meet the clinical requirements to be approved. 
 
  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 the freestyle libre 2 kit have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a freestyle libre 2 kit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extraction and bone replacement graft bone 
replacement graft (D7210, D7953). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says dental services from an out-of-network 
provider 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. 
 
 
 You are requesting 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 pre-approve an 
extraction and bone replacement graft bone replacement graft (D7210, D7953).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the additions to endoskeletal knee-shin system (L5856, 
L5828, L5845, L5848 and L5999). 
 
You asked the Plan to pre-approve the items. You say that the enrollee required transfemoral prosthesis to 
promote and restore independent, pain free ambulation with a safe return to home and community activities. 
The Plan denied your request. The Plan says a K3 microprocessor knee exceeds the enrollee's need and cannot 
be 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 items. Our physician reviewer 
found the enrollee has been authorized to have a K3 level lower extremity prosthesis. There is no indication the 
enrollee requires a microprocessor knee. 
 
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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the additions to endoskeletal knee-shin system (L5856, L5828, L5845, L5848 and L5999).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the telehealth visit with a specialist 
provided on October 14, 2022. 
 
You asked the Plan to waive the copayment for the telehealth visit with a specialist. You say that your visit was 
only a few minutes long and should not be charged 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 $40 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $40 copayment for the telehealth visit with a specialist. This item/service falls 
within the physician/practitioner services, including doctors office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the telehealth visit with a specialist provided on October 14, 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 December 29, 
2022. 
 
You asked the Plan to pay for a subsequent nursing facility care. You say that the provider had no prior 
knowledge of the the patients that were seen. 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 December 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 24, 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 August 24, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the nuclear stress test provided on October 
17, 2022. 
 
You asked the Plan to waive the copayment for the nuclear stress test. You say that you were not told about this 
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 $200 
copayment for outpatient diagnostic test, including stress tests. 
 
You have been asked to pay a $200 copayment for the nuclear stress test. This item/service falls within the 
outpatient diagnostic test, including stress tests 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 nuclear stress test provided on October 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a labial veneer (D2960). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your dental 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. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
labial veneer (D2960).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Coflex device (22867). 
 
You asked the Plan to pre-approve a Coflex device. You say that Coflex stabilization is required, given the 
finding of severe foraminal stenosis at L3 and L4. You say that the Coflex device will offer added stability and 
will help prevent further collapse, thereby helping prevent further degenerative change. The Plan denied your 
request. The Plan says the device in dispute is not medically necessary due to insufficient evidence of efficacy. 
 
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 a Coflex device. Our reviewer says that 
a Coflex device is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the Coflex device is experimental in spine surgery, as high failure rates have been reported. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Coflex device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Coflex device (22867).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the localized delivery of antimicrobial agents (D4381). 
 
You asked the Plan to pre-approve the localized delivery of antimicrobial agents (D4381). You say that the 
enrollee is on a very limited fixed income. You say this is a hardship for the enrollee financially to have to pay 
up front and out of pocket. The Plan denied your request. The Plan says benefits for this service cannot be 
determined until the dates of service and the enrollee's periodontal treatment history have been received. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services cannot 
be approved until the dental records are received. Based on this information, we decided that the Plan's rules 
for coverage of the localized delivery of antimicrobial agents (D4381) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the localized delivery of antimicrobial agents (D4381).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for the CGM system and supplies provided on 
November 28, 2022. 
 
You asked the Plan to reduce the cost share for the CGM system and supplies. You say that you were told you 
would only be charged $24.88. 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. Your 
contract with the Plan says that there is a $500 deductible which applies to durable medical equipment and 
related supplies. Your contract with the Plan also says that there is 4% coinsurance after the deductible has 
been met for durable medical equipment and supplies. 
 
 You have been asked to pay $171.96 towards your deductible for the CGM system. You have also been asked 
to pay $328.04 towards your deductible for the CGM supplies. The remaining allowed amount after the 
deductible was satisfied for the CGM supplies is $164.62 ($492.66 original allowed amount - $328.04 
deductible paid = $164.62 remaining allowed amount). The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $500 deductible which applies to durable medical equipment. This cost 
sharing is a contractual obligation that had not been met at the time the CGM system and supplies were 
received on November 28, 2022. 
 
You have also been asked to pay $6.58, which is 4% coinsurance of the allowed amount for the CGM supplies 
($164.62 remaining allowed amount x 4% coinsurance = $6.58). You have been asked to pay a total of $506.58 
($500.00 deductible + $6.58 coinsurance = $506.58). These items/services fall within the durable medical 
equipment 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 reduce the cost share for 
the CGM system and supplies provided on November 28, 2022.