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

 
We decided that the Plan does not have to pre-approve Voltaren Gel. 
 
You asked the Plan to pre-approve Voltaren Gel. You say that the chart notes provided support that the 
requested drug is medically necessary. The Plan denied your request. The Plan says they do not administer 
pharmacy benefits for the enrollee. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Voltaren Gel.  
 
Benefits for Voltaren Gel 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for prefabricated brace provided on 
September 01, 2022. 
 
You asked the Plan to waive the coinsurance for prefabricated brace. You say that the Velcro on the brace fell 
off, and the brace does not work. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for durable medical equipment. 
 
You have been asked to pay 20% coinsurance for prefabricated brace. This item/service falls within the durable 
medical equipment 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 prefabricated brace 
provided on September 01, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided on June 25, 2022. 
 
You asked the Plan to pay for anesthesia services. You say that this was medically necessary and should be 
covered. 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 anesthesia services 
provided on June 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for office visit provided on January 10, 2022. 
 
You asked the Plan to waive the deductible for office visit. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $800 
deductible for Office visits. 
 
You have been asked to pay a $800 deductible for office visit. This item/service falls within the Office visits 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the deductible for office visit provided on January 
10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the custom foot orthotics (L3020 x 2) 
purchased from the out-of-network (OON) provider on May 18, 2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the items were purchased from an 
out-of-network provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that enrollees must pay a coinsurance upon a written prescription from a network provider to a 
network DME or Orthotics and Prosthetics supplier.  
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the items at issue in this appeal. The Plan did not pre-approve the items at issue. We 
found no exception that would require the Plan to issue reimbursement for these items. Therefore, we decided 
that the Plan does not have to issue reimbursement for the custom foot orthotics (L3020 x 2) purchased from 
the out-of-network (OON) provider on May 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral exams, x-rays, imaging, cleanings, fluoride 
treatments, resin-based composites, and a crown provided from June 30, 2021, to January 7, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that you have been seeing this provider for a couple 
of years and gave your coverage information to the billing office. You say you have not been reimbursed for 
services that were included in your dental coverage booklet. The Plan denied your request. The Plan says the 
dental services were received from an out-of-network provider and are not covered by your supplemental 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have to pay for the oral exams, x-rays, imaging, cleanings, 
fluoride treatments, resin-based composites, and a crown provided from June 30, 2021, to January 7, 2022, by 
an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Part B drugs provided on August 26, 
2022. 
 
You asked the Plan to waive the coinsurance for Part B drugs. You say that you thought this would be covered 
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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for Part B drugs. This item/service falls within the Medicare Part 
B prescription 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. You have been asked to pay $284.82 which is 20% of the allowed amount for the injection. 
Therefore, we decided that the Plan does not have to waive the coinsurance for Part B drugs provided on 
August 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341, D4342) 
provided on October 1, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the dental services were received from an out-of-network provider and are 
not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for periodontal scaling and root planing (D4341, D4342) provided on October 1, 2021, by an out-of-
network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided to the enrollee on June 15, 
2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the plan's policy covers non-emergency ambulance transportation when it is the only 
way to safely and adequately transport an enrollee or if other means of transporting an enrollee are unsafe due 
to a medical condition. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 pay for the services. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found that 
transportation via ambulance from dialysis back to the enrollees residence was not medically necessary. The 
enrollee did not require the expertise of trained personnel or the equipment available only on an ambulance in 
order to effectuate a safe transport. Transportation could have been provided by other means (stretcher van) 
without endangering the enrollees condition. A prudent layperson would not believe that immediate medical 
attention was required for someone who was attending regularly scheduled appointments. 
 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for ambulance services provided to the enrollee on June 15, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for pacemaker provided on July 11, 2022. 
 
You asked the Plan to waive the copayment for pacemaker. You say that you are disputing the share cost. 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 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $20 copayment for pacemaker. This item/service 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 pacemaker provided on July 11, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve gastrointestinal tract imaging, intraluminal (eg, capsule 
endoscopy), esophagus through ileum, with interpretation and report (91110). 
 
You asked the Plan to pre-approve a capsule endoscopy. You say that a capsule procedure is more 
advantageous because the doctor will be able to look both stomach and small with little risk. The Plan denied 
your request. The Plan says that your records do not show that you have had a recent 
esophagogastroduodenoscopy. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a capsule endoscopy. Our reviewer says 
that this service is medically reasonable and necessary. Our physician reviewer found that a capsule endoscopy 
in 2019 was abnormal, with multiple erosions in the stomach, gastritis, and duodenitis. A colonoscopy on 
January 26, 2022, was notable for a polyp in the rectum and a polyp in the transverse colon. The enrollee's 
medical history is notable for chronic obstructive pulmonary disease (COPD), mitral stenosis, and atrial 
fibrillation. The gastroenterologist states that an esophagogastroduodenoscopy is needed, but the enrollee is at 
risk due to cardiac and respiratory status. One of the primary indications for capsule endoscopy is the 
evaluation of suspected small bowel bleeding. The study is considered medically reasonable and necessary in 
this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a capsule endoscopy have been met. Therefore, we decided that the Plan has to 
pre-approve gastrointestinal tract imaging, intraluminal (eg, capsule endoscopy), esophagus through ileum, 
with interpretation and report (91110).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a physician visit and arthrocentesis provided on August 11, 
2022. 
 
You asked the Plan to pay for a physician visit and arthrocentesis. You say that you were not aware the 
provider was out-of-network and your provider advised you that no prior authorization was needed. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a physician visit and 
arthrocentesis provided on August 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 8, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the enrollee moved to Delaware and had a new 
patient visit with this provider, who is now their PCP. The Plan denied your request. The Plan says the provider 
is out-of-network and authorization was not obtained prior to services being 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 provider at issue in this case is not a network provider with the Plan. 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 pay for the office visit. Our reviewer says that the need for a primary care physician is a 
foreseeable event. Our physician reviewer found the record provided does not indicate that the enrollee was 
seen for an emergent or urgent visit. 
 
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 office visit have not been met.  
 
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 pay for the office visit. Therefore, we decided that the Plan does not 
have to pay for an office visit provided on March 8, 2022, 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 subsequent nursing care provided on May 20, 2022. 
 
You asked the Plan to pay for the subsequent nursing care. You say that the facility depends on hospital staff to 
obtain 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 subsequent nursing 
care provided on May 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for annual wellness visit provided on December 
14, 2021. 
 
You asked the Plan to waive the deductible for annual wellness visit. You say that you should not be 
responsible to pay this. 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 
$124.63 deductible for annual wellness visit. 
 
You have been asked to pay a $124.63 deductible for annual wellness visit. This item/service falls within the 
annual wellness visit 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 deductible for annual wellness visit 
provided on December 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve orthopedic shoes and inserts. 
 
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 for your condition. 
 
Medicare rules state that therapeutic shoes, inserts and/or modifications to therapeutic shoes are covered if all 
criteria are met. The Plan follows these same rules.     
 
The records do not show that you have requested orthopedic footwear for a covered condition.  
 
 Although orthopedic footwear may be appropriate for you, neither Medicare nor the Plan provides coverage of 
these items for your condition. Therefore, we decided that the Plan does not have to pre-approve orthopedic 
shoes and inserts.
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 a CGM. You say that you would like the Plan to reconsider their denial. The 
Plan denied your request. The Plan says you do not meet Medicare criteria for the requested 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 use insulin with at least 
three daily injections, and you do not 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 CGM have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor 
(CGM).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance supplies provided on March 28, 2022. 
 
You asked the Plan to pay for the ambulance supplies. You say that you were assured by the hospital that these 
would be covered by insurance. The Plan denied your request. The Plan says the routine disposable supplies 
and unlisted ambulance services are not covered by Original Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that ambulance supplies are considered part of the 
general ambulance service and payment for them is included in the payment rate for the transport. Therefore, 
we decided that the Plan does not have to pay for ambulance supplies provided on March 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing care provided on December 13, 2021. 
 
You asked the Plan to pay for the subsequent nursing care. You say that it is the hospital staffs responsibility 
to obtain 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 subsequent nursing 
care provided on December 13, 2021.