Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 26, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the enrollee did not have their insurance card at time 
of service. The Plan denied your request. The Plan says an authorization was not obtained prior to services 
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 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 May 26, 2022, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings. 
 You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says these items are not a covered benefit under your 
contractual policy or by Medicare for your condition. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings are covered only when 
they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and 
gradient compression wraps are covered only when they are used as dressings over a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve compression stockings.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ExoDx Prostate Test gene expression profile by RT-
PCR. 
 
You asked the Plan to pre-approve the test. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested service is not covered by Medicare or the health plan. 
 
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 test. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee does not meet the coverage criteria for ExoDx Prostate Test gene expression profile by 
RT-PCR. Coverage criteria require that the PSA is more than 3ng/ml and less than 10ng/ml. The records show 
that the enrollee has a PSA of 26.9 mL indicating high risk for prostate cancer and should proceed to MRI or 
prostate biopsy rather than ExoDx testing. 
 
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 test have not been met. Therefore, we decided that the Plan does not have to 
pre-approve ExoDx Prostate Test gene expression profile by RT-PCR.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve CGM. You say that you test your bloods sugar 9 times per day and use 2 
insulins. The Plan denied your request. The Plan says you do not meet criteria for a continuous glucose monitor 
(CGM). 
 
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 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 your 
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 CGM have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care provided on June 12, 2022. 
 
You asked the Plan to waive the copayment for emergency care. You say that you were advised by the Plan 
that this bill would be paid 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 $90 
copayment for emergency care.  
 
You have been asked to pay $90 copayment for emergency care. This item/service falls within the emergency 
care 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 emergency care provided on 
June 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on April 6, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says these services are not covered when provided OON 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 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 lab services provided on April 6, 2022, by an 
out-of-network (OON) provider.
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 need to check your insulin three 
times a day. The Plan denied your request. The Plan says the requirements 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 indicate that you perform blood glucose 
testing at least four times per day and 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 7, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that this should be covered. The Plan denied your 
request. The Plan says there was no preauthorization by a primary care provider (this is different than a 
referral) for an out-of-network (OON) provider or facility, and this was not an emergency. Therefore, the 
decision is upheld. 
 
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 July 7, 2022, by an out-
of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the records available do not support a health 
need for a higher level of care. 
 
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 office visit 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 the office visits provided from January 14, 2022, to April 13, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient services. You say that you have been taking care of family 
members out of state since October 2021. You say that you were not aware that you did not have coverage out 
of state. You also say that you cannot handle having to have this financial burden on you. The Plan denied your 
request. The Plan says the services in this case were not urgent or emergent.  
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Additionally, the record 
shows that the services were to establish care and an annual wellness exam, thus the services you received were 
not urgent or emergent. Therefore, we decided that the Plan does not have to pay for the office visits provided 
from January 14, 2022, to April 13, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for intravenous infusions provided on April 18, 
2022, to May 26, 2022. 
 
You asked the Plan to waive the copayment for intravenous infusions. You say that the charges seem 
unreasonably high, and the copayment is equally unreasonable. 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 $100 
copayment for 'outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers'.  
 
You have been asked to pay $100 copayment for each intravenous infusion. This item/service falls within the 
'outpatient surgery and other medical 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 intravenous infusions 
provided on April 18, 2022, to May 26, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Ondansetron tablet. 
 
You asked the Plan to pre-approve Ondansetron. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not, as prescribed, covered by Medicare Part 
B. Therefore, we decided that the Plan does not have to pre-approve treatment with Ondansetron tablet.  
 
Benefits for Ondansetron may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 17, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the services provided were medically necessary. 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 February 17, 2022, by 
an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on April 27, 2022, to 
April 29, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you want to appeal the 
amount being charged. 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 $375 
copayment per day, days 1 to 5 for inpatient hospital stay. Includes inpatient acute, inpatient rehabilitation, 
long-term care hospitals and other types of inpatient hospital services. Inpatient hospital care starts the day you 
are formally admitted to the hospital with a doctor's order. The day before you are discharged is your last 
inpatient day. There were two days. 2 x $375 = $750. Therefore, results in the total cost sharing amount of 
$750. 
 
 
 You have been asked to pay a $375 copayment per day for inpatient hospital stay. This item/service falls within 
the Inpatient hospital care 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 inpatient 
hospital stay on April 27, 2022, to April 29, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care provided on June 17, 2022. 
 
You asked the Plan to waive the copayment for emergency care. You say that she did not receive any care. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay $90 copayment for emergency care.  
 
The enrollee has been asked to pay $90 copayment for emergency care. This item/service falls within the 
emergency care 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 copayment for emergency 
care provided on June 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 28, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and the rules. We find that the code was not billed with a modifier suitable for payment. 
Based on this information, we decided that Medicare rules for coverage of the laboratory services have not 
been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on 
December 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 20, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that services were rendered in good faith and medically 
necessary. You say that you are requesting the Plan to reconsider the denial and process the claim for payment. 
The Plan denied your request. The Plan says an authorization was not obtained prior to services 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 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 June 20, 2022, by an 
out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient behavioral health visits to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve outpatient behavioral health visits. You say that you feel the services should 
be covered because the insurance Plan paid for services since March of 2022. You say that to interrupt 
treatment is unethical and dangerous to your physical and mental health. The Plan denied your request. The 
Plan says mental health services may only be covered when they are provided by a Medicare-qualified mental 
health care professional. The provider is not in the Plan's Medicare Preferred network or a Medicare-qualified 
mental health care professional. 
 
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 
outpatient behavioral health visits to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve total electric hospital bed. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says this device is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that total electric hospital beds are not covered by 
Medicare.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of total electric hospital bed have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a total electric hospital bed (E0265).