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

 
We decided that the Plan does not have to pre-approve an intracept procedure. 
 
You asked the Plan to pre-approve an intracept procedure. You say that the service is medically necessary. The 
Plan denied your request. The Plan says this service is considered experimental. 
 
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 an intracept procedure. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found this service is considered experimental and more research is needed to show its safety and 
efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an intracept procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic x-ray (D0330) provided on October 13, 2022. 
 
You asked the Plan to pay for 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 your benefit for the requested item or service has 
already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 27, 2021. 
Therefore, we decided that the Plan does not have to pay for a panoramic x-ray (D0330) provided on October 
13, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visits provided on July 18, 
2022, to August 22, 2022. 
 
You asked the Plan to pay for the domiciliary or rest home visits. You say that the assisted living facility is 
responsible for obtaining authorization. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the domiciliary or rest 
home visits provided on July 18, 2022, to August 22, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for home infusion therapy provided on 
February 2, 2022, to February 16, 2022. 
 
You asked the Plan to waive the coinsurance for home infusion therapy. You say that you disagree with the 
coinsurance. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for home infusion therapy.  
 
You have been asked to pay a 20% coinsurance for home infusion therapy. The total allowed amount for the 
infusion therapy is $5,988.76 ($5,988.76 x 20% =$1,197.75). However, you are only being asked to pay 
$1,197.74 which is less than the required amount. This item/service falls within the home infusion therapy 
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 home infusion therapy provided 
on February 2, 2022, to February 16, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital services provided on 
August 30, 2022. 
 
You asked the Plan to waive the copayment for outpatient hospital services. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment for outpatient hospital services.  
 
You have been asked to pay a $325 copayment for outpatient hospital services. This item/service falls within 
the outpatient hospital 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 
outpatient hospital services provided on August 30, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on July 20, 
2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for ambulance services.  
 
You have been asked to pay a $250 copayment for ambulance services. This item/service falls within the 
ambulance services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services 
provided on July 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chronic care management services provided on March 
22, 2022. 
 
You asked the Plan to pay for the chronic care management services. You say that the enrollee was in a nursing 
home and authorization could not be obtained. The Plan denied your request. The Plan says that unauthorized, 
out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the chronic care 
management services provided on March 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic CGM. 
 
You asked the Plan to pre-approve CGM. You say that it would be beneficial for the enrollee to have a CGM. 
The Plan denied your request. The Plan says the enrollee does not require insulin three or more times daily. 
 
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 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve therapeutic CGM.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit, x-ray and injections provided on August 18, 
2022, and September 2, 2022. 
 
You asked the Plan to pay for the office visit, x-ray and injections. You say that you had no idea you would be 
charged for the services, and you thought your insurance would pay the whole claim. 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 intravenous, subcutaneous and biological part b drugs, a $20 copayment for each x-ray service 
from an in-network provider and a $40 copayment for an in-network specialty care physician..  
 
  You have been asked to pay $112.53 for the office visit, x-ray and injections.  
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
August 18, 2022 Office Visit $104.91 $40 $40 
August 18, 2022 Methylprednisolone 
Acetate Injection 
$20.89 20% $4.18 
August 18, 2022 X-Ray $82.63 $20 $20 
September 2, 2022 Tendon Sheath 
Injection 
$46.49 $40 $40 
September 2, 2022 Methylprednisolone 
Acetate Injection 
$41.77 20% $8.35 
TOTAL:    $112.53 
 
This item/service falls within the Medicare Part B drug, Outpatient diagnostic tests and therapeutic services and 
supplies, 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 pay for the office visit, x-ray and injections provided on August 18, 2022, and September 2, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 15, 2022, to 
April 13, 2022. 
 You asked the Plan to pay for the home health services. The Plan denied your request. The Plan says the NOA 
was not received. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services.  
 
We looked at the file and the rules. The documentation does not show that a valid NOA was received. Based on 
this information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided 
that the Plan does not have to pay for the home health services provided from March 15, 2022, to April 13, 
2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an office visit and ultrasound provided on 
March 28, 2022. 
 
You asked the Plan to waive the cost share for an office visit and ultrasound. You say that this should be 
covered. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $1000 deductible which applies to ultrasounds and a $45 copayment for 
a specialist office visit. 
 
The item or service you asked the Plan to waive the cost share for falls within the Outpatient Diagnostic Tests 
and Therapeutic Services and Supplies benefit category and the Physician/Practitioner Services, Including 
Doctors Office Visits benefit category. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is $1000 deductible which applies to ultrasounds. This cost sharing is a contractual 
obligation that had not been met at the time an office visit and ultrasound was received on March 28, 2022. Therefore, we decided that the Plan does not have to waive the cost share for an office visit and ultrasound 
provided on March 28, 2022.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for outpatient services provided from July 13, 2022, through August 19, 
2022. 
 
You asked the Plan to pay for outpatient services. You say that you want the Plan to pay for the services. The 
Plan denied your request. The Plan says that they cannot pay the line of service for July 13, 2022, as they were 
not the primary payer until July 15, 2022. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 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 met its obligation with regards to coordination of benefits for date of service, July 13, 2022. 
Specifically, the record does not show that the Plan has sent the bill directly to the primary insurer for payment, 
directed the provider to send the bill to the primary insurer or paid for the services and submitted a bill for 
reimbursement to the primary insurer. Furthermore, for dates July 15, 2022, through August 19, 2022, 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 did not forward the appropriate information to verify if the other services were 
paid for services from July 15, 2022, through August 19, 2022. Therefore, we decided that the Plan has to pay 
for outpatient services provided from July 13, 2022, through August 19, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) and 
ground mileage (A0425) provided on July 11, 2022. 
 
  You asked the Plan to pay for the non-emergency ambulance transportation and ground mileage. You say that 
the patient was not enrolled in hospice on the date of transport. The Plan denied your request. The Plan says 
Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to 
the enrollees terminal condition. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on July 7, 2022. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the non-emergency 
ambulance transportation (A0428) and ground mileage (A0425) provided on July 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay more for frames (V2025), lenses (V2782), progressive lenses 
(V2781), and ultraviolet lenses (V2755), anti-reflective coating (V2750), and photochromatic tint (V2744) 
provided on August 18, 2022. 
 
You asked the Plan to pay more for frames (V2025), lenses (V2782), progressive lenses (V2781), and 
ultraviolet lenses (V2755), anti-reflective coating (V2750), and photochromatic tint (V2744). You say that you 
returned home and thought about your experience, and realized the frames you selected were not what you had 
asked for but rather guided to. You also say that you were told that they could not stop the order. The Plan 
denied your request. The Plan says the allowance of $175 was applied. The Plan also says that the remaining 
amount, the member is liable for. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when the Plan has a $175 allowance for supplemental eyewear every 
year. 
 
We looked at the file and the Plan's rules. The Plan rules say there is a $175 allowance for supplemental 
eyewear every year. The Plan rules also say that members are responsible for all costs over and above the 
allowance amount. The record shows the benefit was exhausted on August 28, 32022. Based on this 
information, we decided that the Plan's rules for coverage of frames (V2025), lenses (V2782), progressive 
lenses (V2781), and ultraviolet lenses (V2755), anti-reflective coating (V2750), and photochromatic tint 
(V2744) have not been met. Therefore, we decided that the Plan does not have to pay more for frames (V2025), 
lenses (V2782), progressive lenses (V2781), and ultraviolet lenses (V2755), anti-reflective coating (V2750), 
and photochromatic tint (V2744) provided on August 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a comprehensive oral evaluation and intraoral x-rays 
(D0150, D0210) provided on February 25, 2022. 
 
You asked the Plan to pay more for 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 you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for a comprehensive oral evaluation and 
intraoral x-rays (D0150, D0210) provided on February 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 12, 2022, by an OON 
provider. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration and have 
submitted supporting records. The Plan denied your request. The Plan says the enrollee must receive care from 
a network provider. 
 
 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 item/service 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 this item/service. Therefore, 
we decided that the Plan does not have to pay for an office visit provided on September 12, 2022, by an OON 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a rollator walker purchased on July 30, 2022. 
 
You asked the Plan to pay for a rollator walker. You say that the item was medically necessary. The Plan 
denied your request. The Plan says a walker falls under the durable medical equipment (DME) benefit and 
would have needed to be obtained through a DME provider that is in-network with the plan. 
 
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. 
Specifically, this item does not qualify under the wallet benefit and would have had to have been purchased 
through a DME provider in the Plans network to be covered under the DME benefit. Therefore, we decided 
that the Plan does not have to pay for a rollator walker purchased on July 30, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intracept procedure (64628). 
 
You asked the Plan to pre-approve an intracept procedure. You say that the service is medically necessary. The 
Plan denied your request. The Plan says this service is considered experimental. 
 
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 an intracept procedure. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found this service is considered experimental and more research is needed to show safety and 
efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an intracept procedure (64628).