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

 
We decided that the Plan does not have to waive the copayment for the electrocardiogram (EKG) provided on 
February 01, 2023. 
 
You asked the Plan to waive the copayment for the electrocardiogram (EKG). You say that you were charged 
separately from the emergency room, and you disagree with how this was processed. 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 $30 
copayment for outpatient diagnostic tests, including EKGs. 
 
You have been asked to pay a $30 copayment for the electrocardiogram (EKG). This item/service falls within 
the outpatient diagnostic tests, including EKGs 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. However, since the allowed amount is less than the standard 
copayment, you only owe $15.08. Therefore, we decided that the Plan does not have to waive the copayment 
for the electrocardiogram (EKG) provided on February 01, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on October 05, 2022. 
 
You asked the Plan to pay for nursing facility care. You say that this is supported in the records. 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 nursing facility care 
provided on October 05, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve new eyeglasses. 
 
You asked the Plan to pre-approve the glasses. You say that this was medically necessary. The Plan denied 
your request. The Plan says that you are not eligible for another pair of glasses until 10/7/23. 
 
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 $350 worth of eyeglasses per year. 
 
We looked at the file and the Plan's rules. The plan's vision benefit rules are too vague to support the denial. 
The benefit says that $350 worth of eyeglasses are covered every year. This does not specify that if it's covered 
every 12 months specifically or every calendar year. As the eyeglasses were last received in 2022, the benefit 
as written would allow for eyeglasses again the next year in 2023. Based on this information, we decided that 
the Plan's rules for coverage of the glasses have been met. Therefore, we decided that the Plan has to pre-
approve new eyeglasses.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says you do not have 
complex medical; nursing and rehabilitation needs. Your needs may be met at an alternative level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve topical hyperbaric oxygen therapy to be provided by an 
out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the treatment with an out-of-network provider. You say that the requested 
provider is the exclusive provider of topical oxygen therapy. The Plan denied your request. The Plan says there 
are network provider's available. 
 
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 
topical hyperbaric oxygen therapy to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on April 16, 2022. 
 
You asked the Plan to pay for laboratory services. You say that the services 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 services 
provided on April 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) device.  
You asked the Plan to pre-approve the CGM device. You say that you prick your finger twice a day and you 
don't want to prick your finger since you feel really anxious and desperate. The Plan denied your request. The 
Plan says you do not meet the medical necessity criteria. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
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 CGM device. Our reviewer says 
that the CGM is not medically necessary. Our physician reviewer found the criteria for a CGM coverage 
includes low blood glucose sugar and insulin treated. Neither is present in these records and hence coverage 
criteria are not 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 the CGM device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a continuous glucose monitor (CGM) device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Mis Reader. 
 
You asked the Plan to pre-approve the FreeStyle Mis Reader. You say that the medical records submitted 
support the need for the CGM. The Plan denied your request. The Plan says a  continuous glucose monitor is 
not covered under Medicare if the enrollee does not have documentation of history of problematic 
hypoglycemia. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
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 FreeStyle Mis Reader. Our reviewer 
says that the CGM is not medically necessary. Our physician reviewer found the criteria for coverage of a 
CGM include signs and symptoms of hypoglycemia or insulin use. There does not appear to be either of these 
in the case to justify CGM coverage. 
 
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 FreeStyle Mis Reader have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a FreeStyle Mis Reader.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the specialist office visit and the steroid 
injection provided on February 15, 2023. 
 
You asked the Plan to waive the cost share for the specialist office visit and the injection. You say that you 
have not been charged for both the specialist office visit and the procedure in the past. 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 $45 
copayment per visit, for each covered in person visit or consultation in an outpatient location with a specialist. 
Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B non-
chemotherapy prescription drugs. 
 
You have been asked to pay a $45 copayment for the specialist office visit. This item/service falls within the 
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. 
 
You have also been asked to pay $4.84, which is 20% coinsurance of the allowed amount for the injection 
($24.18 allowed amount x 20% = $4.84). 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. 
Therefore, we decided that the Plan does not have to waive the cost share for the specialist office visit and the 
steroid injection provided on February 15, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 28, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 
70496. 
 
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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for each dialysis service provided on January 
02, 2023, to January 20, 2023. 
 
You asked the Plan to waive the coinsurance for each dialysis service. You say that you have never had to pay 
for this service in the past. 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 services to treat kidney disease. 
 
You have been asked to pay 20% coinsurance for each dialysis service. This item/service falls within the 
services to treat kidney disease 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 
each dialysis service provided on January 02, 2023, to January 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on February 21, 
2023. 
 
You asked the Plan to waive the copayment for the office visit. You say that this should be waived as it was a 
part of the surgery. 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 physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $10 copayment for the office visit. This item/service falls within the 
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. The record shows the office visit was outside of 
the global period for the surgery. Therefore, we decided that the Plan does not have to waive the copayment for 
the office visit provided on February 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each laboratory service provided on 
January 05, 2023, to January 20, 2023. 
 
You asked the Plan to waive the copayment for each laboratory service. You say that you did not know your 
provider ordered flu testing as well. 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 
copayment for outpatient diagnostic lab tests. 
 
You have been asked to pay a $20 copayment for each laboratory service. This item/service falls within the 
outpatient diagnostic lab tests 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 a total of $40 ($20 copayment + $20 copayment = $40). 
Therefore, we decided that the Plan does not have to waive the copayment for each laboratory service provided 
on January 05, 2023, to January 20, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service November 
22, 2022. 
 You asked the Plan to pay for procedure code 71045. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 71045 is bundled into payment for code 
36556. 
 
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, we have confirmed that code 71045 
is a column II code to column I code 36556. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 71045 billed for date of service November 22, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for a standard wheelchair purchased on 
January 24, 2023. 
 
You asked the Plan to provide reimbursement for a standard wheelchair. You say that you are requesting 
reimbursement for the wheelchair. The Plan denied your request. The Plan says that the provider does not 
participate in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
A review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to provide reimbursement for a standard 
wheelchair purchased on January 24, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 17, 
2023. 
 You asked the Plan to pay for procedure code 70450. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 
70496. 
 
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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 17, 
2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
You asked the Plan to pre-approve Aranesp. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Aranesp. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has a diagnosis of normocytic anemia. The Food and Drug Administration has not 
stated that the requested drug is indicated for the enrollee's condition. The Medicare approved  drug compendia 
do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. 
Therefore, the enrollee does not meet criteria for the requested drug.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the nuclear medicine heart study and drug 
injection provided on June 7, 2022. 
 
You asked the Plan to waive the cost share for the nuclear medicine heart study and drug injection. You say 
that this charge can be resolved if the bookkeeper would reconcile her records with the office manager. 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 $40 
copayment for in-network diagnostic procedures and tests. Your contract with the Plan also clearly says that you must pay 20% coinsurance for in-network Medicare Part B drugs. 
 
You have been asked to pay a $40 copayment for the nuclear medicine heart study. This item/service falls 
within the outpatient diagnostic tests and therapeutic services benefit category. You have also been asked to 
pay $34.44, which is 20% coinsurance of the allowed amount for the drug injection ($172.20 allowed amount x 
20% coinsurance = $34.44). This item/service falls within the Medicare Part B drugs benefit category. You 
have been asked to pay a total of $74.44 ($40 copayment + $34.44 coinsurance = $74.44). 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 cost share for the nuclear medicine heart study and drug injection provided on June 
7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair and accessories (K0823, E2397, 
E0973). 
 
You asked the Plan to pre-approve the power wheelchair and accessories. You say that this item is medically 
necessary. The Plan denied your request. The Plan says the enrollee resides in a skilled nursing facility. 
Durable Medical Equipment is not eligible for separate coverage. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the power wheelchair and accessories is being requested for use in a SNF or hospital. 
Therefore, we decided that the Plan does not have to pre-approve a power wheelchair and accessories (K0823, 
E2397, E0973).