Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gradient compression stockings (A6530). 
 
You asked the Plan to pre-approve gradient compression stockings. You say that the requested items are 
necessary. The Plan denied your request. The Plan says the item is not a covered benefit. 
 The Plan must follow Medicare rules. Medicare rules say that wound care items are covered when specific 
criteria are met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of gradient compression stockings have not been met. Therefore, we decided that the Plan does not 
have to pre-approve gradient compression stockings (A6530).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc One. 
 
You asked the Plan to pre-approve Synvisc One. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that the patient's medical record should contain 
documentation that fully supports the medical necessity for intra-articular injections of sodium hyaluronate 
(Hyalgan, Supartz or Visco-3TM, EuflexxaTM, MonoviscTM, GelSyn-3TM, GenVisc 850, Durolane, 
TriViscTM, SynojoyntTM, TriluronTM), hylan G-F 20 (Synvisc, Synvisc-One TM), hyaluronic acid (Gel-One), 
high molecular weight hyaluronan (Orthovisc) and high molecular weight viscoelastic hyaluronan 
(Hymovis). 
 
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 Synvisc One. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the use of any intraarticular hyaluronic acid 
formulation for hip osteoarthritis is generally not recommended due to lack of robust evidence demonstrating 
benefit. The review has determined that you do not meet the coverage criteria detailed in the LCA. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc One have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc One.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) of the 
pelvis provided on March 30, 2022. 
 
You asked the Plan to waive the copayment for the MRI. You say that the copayment is too expensive. The 
Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment per day for diagnostic radiology services, including MRI's.  
 
You have been asked to pay a $325 copayment for the MRI. The MRI falls within the Outpatient Diagnostic 
Tests and Therapeutic Services and 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 waive the copayment 
for a magnetic resonance imaging (MRI) of the pelvis provided on March 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for urgent care visits provided on March 14, 
2022, and March 17, 2022. 
 
You asked the Plan to waive the copayments for urgent care visits. You say that the copayment should be $15 
not $30. The Plan denied your request. The Plan says the copayment applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for urgently needed services.  
 
You have been asked to pay a $60 copayment for urgent care visits ($30 x 2 visits = $60). Urgent care visits 
fall within the Urgently Needed Services benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments 
for urgent care visits provided on March 14, 2022, and March 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
SSBCI benefits. 
 
You asked the Plan to pre-approve special supplemental benefits for the chronically ill SSBCI benefits. You 
say that you qualify for these benefits due to your bipolar disorder and attention deficit disorder diagnosis. The 
Plan denied your request. The Plan says according to the attestation form received from your physician, only 
the diagnosis field was checked, however there was no indication that you required intensive care management 
or are a high risk for hospitalization. The criteria is not met for coverage of Special Supplemental Benefits for 
the Chronically Ill SSBCI benefits. 
 The Plan contract covers Special Supplemental Benefits for the Chronically Ill SSBCI benefits. The Plan says 
that to qualify for these benefits, you must meet specific criteria, including being under care management for a 
qualifying chronic condition and determined to be a high-risk for hospitalization. 
  
We looked at the file and the Plans rules. The file shows that the attestation form received from your physician 
only had the diagnosis field checked, however there was no indication that you required intensive care 
management or you are a high risk for hospitalization. Based on this information, we decided that the Plans 
rules for coverage of special supplemental benefits for the chronically ill SSBCI benefits have not been met. 
Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits for the 
chronically ill SSBCI benefits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an automatic external defibrillator (AED) 
vest provided on December 14, 2021. 
 
You asked the Plan to waive the coinsurance for the AED vest. You say that you were informed that insurance 
would cover the costs. The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for durable medical equipment (DME) items.  
 
You have been asked to pay $586.29, which is 20% of the allowed amount for the AED vest ($2,931.45 
allowed amount x 20% coinsurance = $586.29). The AED vest falls within the Durable Medical Equipment 
(DME) 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 waive the coinsurance for an 
automatic external defibrillator (AED) vest provided on December 14, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided April 1, 2022. 
 
You asked the Plan to pay for the ambulance response. You say that the enrollee was feeling better and did not 
require transport. The Plan denied your request. The Plan says this service is not covered when there is no 
transport. 
 
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 April 1, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The trip report in this case shows that the enrollee refused transport to the hospital and thus the wavier criteria 
is not met. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, 
no transport (A0998) provided April 1, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided December 23, 2021. 
 
You asked the Plan to pay for the ambulance response. You say that this was a reasonable use of ambulance 
services. The Plan denied your request. The Plan says this service is not covered when there is no transport. 
 
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 23, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The trip report in this case shows that the enrollee refused transport to the hospital and thus the wavier criteria 
is not met. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, 
no transport (A0998) provided December 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) of a 
lower extremity provided on March 19, 2022. 
 
You asked the Plan to waive the copayment for the MRI. You say that you feel you should not have to pay 
since the MRI was done in the same building as your PCP's office. The Plan denied your request. The Plan says 
you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $220 
copayment for diagnostic radiology services, other than CT scans, performed by a provider other than your 
PCP.  
 
You have been asked to pay $214.62, which is less than the $220 copayment for the MRI. The MRI falls within 
the Outpatient Diagnostic Tests and Therapeutic Services and 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 waive the copayment for a magnetic resonance imaging (MRI) of a lower extremity provided 
on March 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab work provided on March 1, 2022. 
 
You asked the Plan to waive the copayment for lab work. You say that you should not have to pay this 
copayment. The Plan denied your request. The Plan says the copayment applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copayment for in-network labs.  
 
You have been asked to pay the allowed amount of $8.46 which is less than the $10 copayment for lab work. 
Lab work falls within the In-Network Labs 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 lab work provided on March 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a specialist visit provided on February 16, 
2022. 
 
You asked the Plan to waive the deductible for a specialist visit. You say that you should not have to pay this 
deductible, since the office told you they accepted your Plan. The Plan denied your request. The Plan says the 
deductible applied was correct. 
 
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 $575 deductible for out-of-network physicians which applies to 
physician/practitioner services. You are being asked to pay $173.53. 
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category 
Physician/Practitioner Services - POS (Out-Of-Network). The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $575 deductible for out-of-network physicians which applies to 
Physician/Practitioner Services - POS (Out-Of-Network). This cost sharing is a contractual obligation that had 
not been met at the time a specialist visit was received on February 16, 2022. Therefore, we decided that the 
Plan does not have to waive the $173.53 deductible for a specialist visit provided on February 16, 2022.  
 Your complaint about the office mistaking your Plan for a different one is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the FreeStyle Libre 14-day sensor kit. 
 
You asked the Plan to pre-approve the FreeStyle Libre. You say that you do not want to have to prick your 
fingers all the time. You would like this Freestyle Libre so you could have a better quality of life. The Plan 
denied your request. The Plan says the enrollee is not on insulin and does not meet the Medicare criteria. 
 
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 FreeStyle Libre have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the FreeStyle Libre 14-day sensor kit.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a retreatment of previous root canal therapy (D3347) and an 
amalgam (D2140). 
 
You asked the Plan to pre-approve a retreatment of previous root canal therapy and an amalgam. You say that 
your plan pays for services rendered by in-network and out-of-network providers. You also say that nowhere in 
the documentation does it state that the Plan might pay for services provided out-of-network. The Plan denied 
your request. The Plan says that a root canal is not a covered benefit under the dental plan. The Plan also says 
that a resin composite restoration on a posterior tooth is not a benefit of the dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a retreatment 
of previous root canal therapy and an amalgam when the services are medically necessary and reasonable. 
 
We looked at the file and Medicare rules. The Plan's 2022 Optional Supplemental Dental 
Program clearly lists retreatment of previous root canal therapy (D3347) and amalgam (D2140) as covered 
services. The contract also says endodontics (D3347) may require routine review or diagnostic information 
such as radiographs or patient treatment records. There is no evidence that the Plan made any efforts to receive 
any dental records or x-rays for the case. Based on this information, we decided that the Plan's rules for 
coverage of a retreatment of previous root canal therapy and an amalgam have been met. Therefore, we decided 
that the Plan has to pre-approve a retreatment of previous root canal therapy (D3347) and an amalgam 
(D2140).  
 
  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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crown - porcelain fused to high noble metal (code 
D2750) for tooth #14, and for tooth #2 and core buildup (code D2950). 
 
You asked the Plan to pre-approve the crowns and core buildup. The Plan denied your request. The Plan says 
tooth #2 has already been pulled out, and the x-ray shows there is a cavity below the bone of tooth #14, and the 
tooth will not last long. 
 
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 Plan covers the crowns 
and core buildup when the services are medically necessary and reasonable.  
 
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 crowns and core buildup. Our 
reviewer says that neither tooth #2 nor tooth #14 meet the criteria for crowns at this time. Our physician 
reviewer found that the Plan does not routinely allow for crown restorations where other materials would 
restore contour and function of the tooth. Our physician reviewer found that in this instance, the restoration of 
tooth #2 is apparently allowing the tooth to function properly and does not have a need for replacement with a full coverage crown. Tooth #14 has a deep carious lesion on the mesial aspect, the extent of which is unknown.  
Our physician reviewer also found if the decay does not reach the bone, then the mesial aspect would appear to 
be restorable with a conventional restorative material. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crowns and core buildup have not been met. Therefore, we decided that the 
Plan does not have to pre-approve crown - porcelain fused to high noble metal (code D2750) for tooth #14, and 
for tooth #2 and core buildup, including any pins when required (code D2950).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urinalysis services coded 81001 provided on June 24, 2021. 
 
You asked the Plan to pay for the urinalysis services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 In this case, the CPT Code Manual definition of code 81001 is urinalysis, by dip stick or tablet reagent for 
bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any 
number of these constituents; automated, with microscopy. 
 
We find that CPT code 81001 is not supported in the medical record. Specifically, the documentation submitted 
did not include documentation of Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, 
ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; 
automated, with microscopy; therefore, the billed service cannot be verified. Based on this information, we 
decided that Medicare rules for coverage of the urinalysis services have not been met. Therefore, we decided 
that the Plan does not have to pay for the urinalysis services coded 81001 provided on June 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pharmacogenomic testing services provided on February 
11, 2022. 
 
You asked the Plan to pay for the testing services. You say that the medical records support the billed charges. 
The Plan denied your request. The Plan says one code must be submitted for the panel. 
 
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 find that the gene panel was not billed with a single code as required. Based on this information, we 
decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that 
the Plan does not have to pay for the pharmacogenomic testing services provided on February 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 30, 2021, billed 
with codes 81241, 81335, 81230, 81240, 81408 and 81291. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has not been billed as required 
by Medicare billing regulations. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code.  
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
November 30, 2021, billed with codes 81241, 81335, 81230, 81240, 81408 and 81291.