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

 
We decided that the Plan does not have to pre-approve a CT scan of the heart. 
 
You asked the Plan to pre-approve a CT scan of the heart. You say that the test needs to be done to re-evaluate 
if the thrombus has resolved as well as pleural effusion. The Plan denied your request. The Plan says a CT scan 
of the heart is not medically necessary. 
 
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 CT scan of the heart. Our reviewer says 
that an CT scan of the heart is not medically necessary. Our physician reviewer found that that an 
echocardiogram and chest x-ray are planned to assess cardiac thrombus and pleural effusion. Based on review 
of the clinical documentation, guidelines for the use of a cardiac CT have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT scan of the heart have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CT scan of the heart.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye appointment provided on December 15, 2022. 
 
You asked the Plan to pay for an eye appointment. 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 an eye appointment 
provided on December 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an IRF stay provided from July 20, 2022, to 
August 3, 2022. 
 
You asked the Plan to waive the copayment for an IRF stay. You say that you should not have to pay a second 
copayment for the rehabilitation services. 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 $345 
copayment per day for days 1 to 5 and $0 copayment per day for days 6 to 90 for inpatient rehabilitation 
services.  
 You have been asked to pay a $1,725 copayment for an IRF stay ($345 per day x 5 days = $1,725). 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 an IRF stay provided from July 20, 2022, to August 3, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J3490 provided on December 13, 2022. 
 
You asked the Plan to pay for procedure code J3490. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment is included in the global surgery 
payment.  
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery. 
 
We looked at the file and Medicare rules. Payment for procedure code J3490 is included in the global surgery 
payment for procedure code 27096 provided on December 13, 2022. Separate payment cannot be made for 
procedure code J3490. Based on this information, we decided that Medicare rules for coverage of procedure 
code J3490 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
J3490 provided on December 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on September 30, 
2022. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says durable medical equipment for 
use outside the home is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the durable medical equipment provided on September 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 17, 2022. 
 
You asked the Plan to pay for an office visit. You say that the provider is in-network and no referral is 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 an office visit provided 
on October 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on July 8, 2022. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says durable medical equipment for 
use outside the home is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the durable medical equipment provided on July 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve osteogenesis stimulator. 
 
You asked the Plan to pre-approve osteogenesis stimulator. 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 a spinal electrical osteogenesis stimulator (E0748) is 
covered only if specific criteria are 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 osteogenesis stimulator. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the request does not meet the 
LCD criteria. Therefore, it is deemed not medically reasonable and 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 osteogenesis stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve osteogenesis stimulator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for out-of-network inpatient hospital care and 
an out-of-network computed tomography (CT) scan provided on February 14, 2022, to February 18, 2022. 
 
You asked the Plan to waive the copayment for out-of-network inpatient hospital care and an out-of-network 
CT scan. You say that you disagree with the cost share. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $650 copay per day for days 1-6 for out-of-network inpatient hospital care and a $250 copayment 
for and out-of-network outpatient diagnostic tests/ CT scan.  The enrollee has been asked to pay a $650 copay per day for days 1-6 for out-of-network inpatient hospital care 
and a $250 copayment for and out-of-network outpatient diagnostic tests/ CT scan. The total amount you are 
being asked to pay for inpatient care is $2,600 ($650 x 4 days = $2,600). You are being asked to pay $120 
copayment which is less than the required amount. The total amount you are being asked to pay is $2,720 
($2,600 + $120 = $2,720). This means that the enrollee has been asked to pay the correct amount based on the 
contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in 
the Plan. Therefore, we decided that the Plan does not have to waive the copayment for out-of-network 
inpatient hospital care and an out-of-network computed tomography (CT) scan provided on February 14, 2022, 
to February 18, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each hyperbaric oxygen procedure 
provided on August 04, 2022, to August 30, 2022. 
 
You asked the Plan to waive the copayment for each hyperbaric oxygen procedure. You say that the services 
did not start until August 22, 2022. 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 $25 
copayment for in-network outpatient hyperbaric oxygen services.  
You have been asked to pay a $25 copayment for each hyperbaric oxygen procedure. This item/service falls 
within the in-network outpatient hyperbaric oxygen 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. The total you owe is $450 ($25 copayment per 
service x 18 services = $450). Therefore, we decided that the Plan does not have to waive the copayment for 
each hyperbaric oxygen procedure provided on August 04, 2022, to August 30, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for computed tomography (CT) scan and 
medical supplies provided on November 18, 2022. 
 
You asked the Plan to waive the cost share for CT scan and medical supplies. You say that you disagree with 
the cost share. 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 a 20% coinsurance and a $750 deductible which applies to outpatient 
diagnostic tests//Medicare-covered medical supply/Medicare-covered radiological diagnostic services.  
 
The item or service you asked the Plan to waive the cost share for falls within the outpatient diagnostic 
tests//Medicare-covered medical supply/Medicare-covered radiological diagnostic services benefit category. 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 20% coinsurance and 
a $750 deductible which applies to outpatient diagnostic tests//Medicare-covered medical supply/Medicare-
covered radiological diagnostic services. You are being asked to pay $243.34 towards your $750 deductible. 
The total allowed amount for the medical supplies is $9. You are being asked to pay $1.80 ($9 x 20% =$1.80). 
The total amount you are being asked to pay is $245.14 ($243.34 + $1.80 = $245.14). This cost sharing is a contractual obligation that had not been met at the time CT scan and medical supplies was received on 
November 18, 2022. Therefore, we decided that the Plan does not have to waive the cost share for computed 
tomography (CT) scan and medical supplies provided on November 18, 2022.
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 the CGM. You say that the items should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the items denied correctly as the enrollee does not meet 
the clinical requirements to be approved. 
 
  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 the CGM have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an OON provider. 
 
You asked the Plan to pre-approve physical therapy. You say that the enrollee is unable to find in-network 
providers who make home visits and can provide the desired level of service on time, close to the enrollee's 
home. 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 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 
physical therapy to be provided by an OON provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of the abdomen and pelvis 
 
You asked the Plan to pre-approve a CT scan of the abdomen and pelvis. You say that you are appealing based 
on the records submitted. The Plan denied your request. The Plan says that the last scan was done on 
September 21, 2022, and this is only supported for surveillance once every 3 months for 2 years, then once 
every 6 months for 3 years. 
 
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 CT scan of the abdomen and pelvis. 
Our reviewer says that the enrollee has had metastatic melanoma to liver, multiple bones, and a transplanted 
kidney. The enrollees last CT scan was performed on September 21, 2022. Given the extent of treated 
metastatic disease, the request for a 6-month surveillance CT scan of the abdomen and pelvis is reasonable and 
should be approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT scan of the abdomen and pelvis have been met. Therefore, we decided that 
the Plan has to pre-approve a CT scan of the abdomen and pelvis  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on November 21, 2022. 
 
You asked the Plan to pay for laboratory testing. 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 laboratory testing 
provided on November 21, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for PT services provided from November 28, 
2022, to December 27, 2022. 
 
You asked the Plan to waive the copayment for PT services. You say that you were not advised the $25 
copayment for PT would be after the deductible was met. 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 a $675 deductible which applies to PT services. Your contract also says 
you will pay a $25 copayment for PT services after the deductible has been met. 
 
 
  The item or service you asked the Plan to waive the copayment for falls within the outpatient rehabilitation 
services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is a $675 deductible which applies to PT services. This cost sharing is a contractual obligation that had not 
been met at the time PT services was received on November 28, 2022, to December 27, 2022. Therefore, we 
decided that the Plan does not have to waive the copayment for PT services provided from November 28, 2022, 
to December 27, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs received on January 24, 2023. 
 
You asked the Plan to pay for the self-administered drugs. You say that the plan should pay for the self-
administered drugs. The Plan denied your request. The Plan says these may be covered under your Part D 
Prescription Drug benefit. 
 
 
 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 pay for the self-administered drugs 
received on January 24, 2023.  
 
Benefits for the self-administered drugs 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for laboratory services and a CT scan 
provided on October 24, 2022. 
 You asked the Plan to waive the copayments for laboratory services and a CT scan. You say that you have 
financial struggles and are unable to afford the copayments. 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 $10 
copayment for laboratory services and a $250 copayment for a CT scan.  
 
You have been asked to pay a total copayment of $128.66 for laboratory services and a CT scan. This total 
includes a $10 copayment for laboratory services and $118.66 for a CT scan, which is less than the standard 
$250 copayment. These items/services fall within the outpatient diagnostic 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 laboratory services and a CT scan provided on October 24, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis - adult (D1110) provided on November 23, 
2022. 
 
You asked the Plan to pay for the dental services. You say that it was your understanding that cleanings were 
covered without being deducted from the annual maximum allowance. 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. This benefit includes the 
requested prophylaxis - adult (D1110) but is limited to an annual maximum of $1,000. After the annual 
maximum is exhausted, any remaining charges are your responsibility. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your annual maximum of $1,000 was exhausted on date of service April 12, 2022. Therefore, we 
decided that the Plan does not have to pay for prophylaxis - adult (D1110) provided on November 23, 2022.