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

 
We decided that the Plan does not have to waive the coinsurance for the inpatient hospital services provided 
from October 3, 2022, to October 5, 2022. 
 
You asked the Plan to waive the coinsurance for the inpatient hospital services. You say that because the illness 
is contributed to COVID-19, it should be fully 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 10% 
coinsurance for in-network Medicare-covered inpatient hospital services. 
 
You have been asked to pay $19.93, which is 10% coinsurance of the allowed amount for the inpatient hospital 
services on October 3, 2022 ($199.32 allowed amount x 10% = $19.93 coinsurance). You have also been asked 
to pay $7.16, which is 10% coinsurance of the allowed amount for subsequent hospital care on October 4, 
2022, and October 5, 2022 ($71.59 allowed amount x 10% coinsurance = $7.16). These items/services fall 
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 coinsurance for 
the inpatient hospital services provided from October 3, 2022, to October 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebroplasty (22510), and percutaneous 
vertebral augmentation (PVA) (22513). 
 
You asked the Plan to pre-approve PVA. You say that the procedure is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the requested procedure is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that percutaneous vertebral augmentation (PVA) may be 
covered when certain criteria have been met. 
 
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 PVA. Our reviewer says that the 
requested PVA is not medically necessary. Our physician reviewer found the documentation does not support 
that the fracture is an acute fracture less than six weeks old on imaging. Therefore, the reviewer found that the 
requested procedure is not medically 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 PVA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve percutaneous vertebroplasty (22510), and percutaneous vertebral augmentation (PVA) (22513).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power seat elevation (E2300) and power standing 
feature (E2301). 
 
You asked the Plan to pre-approve power seat elevation and power standing feature. You say that this is 
medically necessary. The Plan denied your request. The Plan says this is not covered because they are not 
primarily medical in nature. 
 
The Plan must follow Medicare rules. Medicare rules say that power seat elevation and power standing features 
are non-covered because they are not primarily medical in nature.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of power seat elevation and power standing feature have not been met. Therefore, we decided that the 
Plan does not have to pre-approve power seat elevation (E2300) and power standing feature (E2301).
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to reduce the coinsurance for the bebtelovimab injection and post-administration 
monitoring provided on September 11, 2022. We also decided that the Plan does not have to fully waive the 
coinsurance for the bebtelovimab injection and post-administration monitoring provided on September 11, 
2022.  
 
You asked the Plan to waive the coinsurance for the bebtelovimab injection and post-administration 
monitoring.. You say that you were not charged in the past. The Plan denied your request. The Plan says that 
this cost sharing was charged correctly. 
 
We decided that the Plan has to reduce the coinsurance for the bebtelovimab injection and post-
administration monitoring provided on September 11, 2022. 
 
The Plan has asked you to pay $239.40 coinsurance for Medicare Part B drugs, which is more than 10% of the 
allowed amount. You cannot be asked to pay more than $235.09 coinsurance, which is 10% of the allowed 
amount ($2,350.91 allowed amount x 10% = $235.09). 
 
The Plan has asked you to pay $33.43 coinsurance for the outpatient hospital facility visit, which is more than 
10% of the allowed amount. You cannot be asked to pay more than $32.83 coinsurance, which is 10% of the 
allowed amount ($328.29 allowed amount x 10% = $32.83). Therefore, we decided that the Plan has to reduce 
the coinsurance for the bebtelovimab injection and post-administration monitoring provided on September 11, 
2022. 
 
We also decided that the Plan does not have to fully waive the coinsurance for the bebtelovimab injection 
and post-administration monitoring provided on September 11, 2022. 
 
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 the bebtelovimab injection and post-administration monitoring.  
 
You are responsible to pay 10% coinsurance for Medicare Part B drugs. This item/service falls within the 
Medicare Part B prescription drug benefit category. You are also responsible for 10% coinsurance for post-
administration monitoring. This item/service falls within the outpatient hospital services benefit category. 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 fully waive the coinsurance for the bebtelovimab injection and post-
administration monitoring provided on September 11, 2022. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and 
pelvis with and without contrast. 
 
You asked the Plan to pre-approve the CT scan of the abdomen and pelvis. You say that the services are 
medically necessary to follow up with findings on previous scans. The Plan denied your request. The Plan says 
the enrollee's records do not show results of a prior picture study such as an x-ray or ultrasound that support 
further imaging. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 the CT scan of the abdomen and pelvis. 
Our reviewer says that the CT scan is not medically necessary. Our physician reviewer found the medical 
records show that the enrollee has a history of lung cancer. Previous CT scans showed stable liver and splenic 
cysts. The last office visit on October 4, 2022, did not show any concerning needs for a CT of the abdomen and 
pelvis. 
 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 CT scan of the abdomen and pelvis have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and 
pelvis with and without contrast.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crowns (D2740) and core buildup (D2950) for tooth #21, 
#22, #23, #27, #28, and #29 provided on September 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that the Plan had the wrong address for the provider 
and the services were denied because of that. The Plan denied your request. The Plan says the denial of 
payment for these services is correct, because crowns and core buildup are not covered by the Plan. 
 
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 pay for crowns 
(D2740) and core buildup (D2950) for tooth #21, #22, #23, #27, #28, and #29 provided on September 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH can render services that will 
improve the enrollee's condition and avoid unnecessary readmission. The Plan denied your request. The Plan 
says the enrollee's care can be provided in the current inpatient hospital. 
 
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 the enrollee appears to still be unstable and requires additional acute care 
services that can safely be administered at the current facility until more stable for transfer. The enrollee does 
not require services at the LTACH that are not already available at the current facility. Transfer to the LTACH is not medically necessary at this time as the enrollee is not stable for transfer and as it would not be clinically 
advantageous. Completion of treatment at the current facility is recommended. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on December 25, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you should 
not owe for the service since you did not go to the hospital. The Plan denied your request. The Plan says these 
services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on December 25, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on December 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve glasses to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve the glasses. You say that you have tried several in-network optometrists, but 
they did not provide acceptable service and did not have the type of glasses you need. You also say that you are 
requesting to go to this OON provider because they are close to home, and you have been going to them for 
years. The Plan denied your request. The Plan says the vision center you have requested to go to is not an in-
network location with the Plan. The Plan also says your request to use an OON provider to obtain glasses is not 
a covered benefit.  
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 
glasses to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a nerve stimulator. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says a 
psychological clearance is needed. 
 The Plan follows Medicare rules. Medicare rules say that electrical nerve stimulators are only covered under 
certain medical indications.  
 
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 requested services. Our physician 
reviewer found that the enrollee is being treated for chronic pain syndrome. Detailed documentation is not 
evident regarding a trial and failure of recent, reasonable, comprehensive less invasive conservative care 
measures, including the recent physical therapy. The results from the stimulator trial were not clearly 
documented. The most recent exam is without findings corroborating a chronic pain syndrome diagnosis. 
Moreover, psychological clearance was not provided. No compelling rationale is presented, or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the records do 
not show that the electrical nerve stimulator is indicated for the enrollees condition. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a nerve stimulator.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for the etanercept injection (J1438) provided on August 16, 2022. 
 
You asked the Plan to pay for the etanercept injection (J1438). You say that the claim needs to be reprocessed. 
The Plan denied your request. The Plan says that drugs and biological coverage are only covered if they are of 
the type that are not usually self-administered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan says the etanercept injection (J1438) was denied as it is a self-
administered drug. The description of procedure code J1438 is injection, etanercept, 25 mg (code may be used 
for Medicare when drug administered under the direct supervision of a physician, not for use when drug is self-
administered). The medical records clearly show the etanercept injection (J1438) was provided under the 
supervision of a physician during an office visit and is not considered a self-administered drug. Therefore, we 
decided that the Plan has to pay for the etanercept injection (J1438) provided on August 16, 2022. 
 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre test strips. 
 
You asked the Plan to pre-approve Freestyle Libre test strips. You say that you disagree with the denial. The 
Plan denied your request. The Plan says only the preferred brand products listed in the EOC are covered. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for diabetic test strips. Therefore, we decided that the Plan does not have to pre-approve Freestyle Libre test 
strips.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the nivolumab and relatlimab injection 
provided on October 24, 2022. 
 
You asked the Plan to waive the coinsurance for the injection. You say that the doctor is charging too much for 
this injection. 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 Medicare Part B drugs.  The records show you met your out-of-pocket maximum during the processing of this claim. Therefore, you 
have been asked to pay $2,875.24, which is less than the standard 20% coinsurance for the injection. This 
item/service falls within the Medicare Part B drugs 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 the nivolumab and relatlimab injection provided on October 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided on November 9, 2021. You asked the Plan to pay for the supply allowance for the CGM. You say that you have provided medical 
records and would like the claim processed for payment. The Plan denied your request. The Plan says the 
Medicare criteria was 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 the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the supply allowance for the CGM have not been met. Therefore, we decided that the Plan does not have to pay 
for the supply allowance for a continuous glucose monitor (CGM) provided on November 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
December 26, 2022, to December 30, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that no one in your home 
could provide basic care for you. 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 $295 
copayment per day, for days 1-5 for in-network inpatient hospital care.  
 
 You have been asked to pay a $295 copayment per day for a three-day inpatient hospital stay. You have been 
asked to pay a total of $885 copayment ($295 copayment x 3 days = $885). You have not been charged for the 
last day. 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 the inpatient hospital stay provided from December 26, 2022, to December 30, 
2022.