Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for out-of-network chiropractic services 
provided on December 19, 2022. 
 
You asked the Plan to waive the coinsurance for out-of-network chiropractic 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 50% 
coinsurance for out-of-network chiropractic services. 
 
You have been asked to pay 50% coinsurance for out-of-network chiropractic services. This item/service falls 
within the out-of-network chiropractic 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 allowed amount for the chiropractic services is $38.32. 
You are being asked to pay $19.16 ($38.32 x 50% = $19.16). Therefore, we decided that the Plan does not have 
to waive the coinsurance for out-of-network chiropractic services provided on December 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repairs to foot orthotics.  
 
You asked the Plan to pre-approve repairs to foot orthotics. You say that you are in need of these medically 
necessary items to prevent from having surgery and the longer you wait for the orthotic item her health is 
worsening and might have to have surgery. 
  
The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve repairs to foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for duplex scan of extremity veins provided on June 12, 2023. 
 
You asked the Plan to pay for duplex scan of extremity veins. You say that the services were medically 
necessary. 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 duplex scan of extremity 
veins provided on June 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bath wipes. 
 
You asked the Plan to pre-approve bath wipes. You say that you would like the Plan to reconsider their denial. 
The Plan denied your request. The Plan says bath wipes are not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve bath wipes.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Methotrexate. 
 
You asked the Plan to pre-approve the medication. You say that the drug is medically necessary. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
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 Methotrexate.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic (D6245) for tooth #9 and retainer crowns 
(D6740) for tooth #8 and #10. 
 
You asked the Plan to pre-approve the dental services. You say that the clinical criteria for approving a bridge 
should be met. The Plan denied your request. The Plan says the denial of authorization for the bridge is correct, 
because there is fractured to the gum line, and it is non-restorable, and the panoramic x-ray shows moderate to 
severe periodontal bone loss around all remaining teeth. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the dental 
services when the services are medically necessary and reasonable.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the dental services. Our reviewer says 
that the pontic (D6245) for tooth #9 and retainer crowns (D6740) for tooth #8 and #10 is not medically 
necessary. Our physician reviewer found that there is severe bone loss around teeth #8 and #10. There was no 
periodontal charting included, and I cannot assess the stability and prognosis of the teeth and can only assess 
from the amount of bone loss around the teeth. The amount of bone loss around the teeth #8 and #10 makes 
these teeth have a guarded/poor prognosis, and teeth with this prognosis should not be crowned. A partial 
denture may be more beneficial for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a pontic (D6245) for tooth #9 and retainer crowns (D6740) for tooth #8 and #10.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each mental health visit provided on May 
18, 2023, to May 22, 2023. 
 
You asked the Plan to waive the copayment for each mental health visit. You say that you disagree with 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 $20 
copayment for outpatient mental health care. 
 
You have been asked to pay a $20 copayment for each mental health visit. This item/service falls within the 
outpatient mental health 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. The total amount you owe is $40 ($20 copayment x 2 visits = $40). Therefore, we decided 
that the Plan does not have to waive the copayment for each mental health visit provided on May 18, 2023, to 
May 22, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
January 3, 2023, to January 8, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were transferred to 
another location for the remainder of the stay. 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 $300 
copayment each time you are admitted to an acute care hospital. 
 
 You have been asked to pay a $300 copayment for the inpatient hospital stay. 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 the inpatient 
hospital stay provided from January 3, 2023, to January 8, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cimzia 
 You asked the Plan to pre-approve Cimzia. You say that the enrollee develops a rash and joint pain on Humira. 
The Plan denied your request. The Plan says the enrollee as not tried the preferred drugs.  
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Cimzia. Our physician reviewer found 
that the enrollee has a diagnosis of Rheumatoid arthritis without rheumatoid factor, multiple sites. It is noted 
that the enrollee developed a rash while taking Humira. The Plan requires a trial of two of adalimumab, 
Rinvoq, Skyrizi, Acetmra, Cosentyx, Otezla, Xeljanz, Xeljanz XR, Orencia, or Enbrel before they will approve 
the requested drug. The case file does not contain documentation of trial and failure of two of the required 
drugs. The documentation does not support that the Plan's required drugs would likely be less effective, and/or 
would likely have adverse effects for the enrollee 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 Cimzia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Cimzia
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse the coinsurance for an amalgam - two surfaces, primary or 
permanent (D2150), and posterior resin-based composite (D2392) provided on May 31, 2023. We also decided 
that the Plan does not have to reimburse for periodontal maintenance (D4910), a periodic oral evaluation 
(D0120), and vertical bitewings (D0277) provided on May 31, 2023.  
 
  You asked the Plan to reimburse the coinsurance for an amalgam - two surfaces, primary or permanent 
(D2150), and posterior resin-based composite (D2392). You also asked the Plan to reimburse for periodontal 
maintenance (D4910), a periodic oral evaluation (D0120), and vertical bitewings (D0277). You say you feel 
that multiple services on the claims did not process as they should have according to your Plan documents. The 
Plan denied your request. The Plan says this cost sharing  for the 30% coinsurance for an amalgam - two 
surfaces, primary or permanent (D2150), and posterior resin-based composite (D2392) was charged correctly. 
The Plan also says that the EOC states for all the services you will be responsible for paying the difference 
between the dentists fees and the Plans fee schedule for covered dental services performed by a dentist 
outside of the Plan dental network, even for services listed as $0 copayment. 
 
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 30% 
coinsurance for an amalgam - two surfaces, primary or permanent (D2150), and posterior resin-based 
composite (D2392). The contract also says that enrollees may be billed by the out-of-network provider for any 
charged amount greater than the payment made by the Plan.  
 
You have been asked to pay $88.88 in coinsurance, which is 30% of the allowed amount for an amalgam - two 
surfaces, primary or permanent (D2150), and posterior resin-based composite (D2392) ($296.29 allowed 
amount x 30% coinsurance = $88.88). These items/services fall within the dental services benefit category. 
You have been asked to pay the difference between the out-of-network providers charges, your cost share and 
the Plans payment for all the services. 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 reimburse the coinsurance for an 
amalgam - two surfaces, primary or permanent (D2150), and posterior resin-based composite (D2392) provided 
on May 31, 2023. We also decided that the Plan does not have to reimburse for periodontal maintenance 
(D4910), a periodic oral evaluation (D0120), and vertical bitewings (D0277) provided on May 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) 
sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre 2 CGM sensor. You say that the enrollee needs the 
receiver/reader. The Plan denied your request. The Plan says the enrollee does not meet criteria for approval of 
the requested CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia Based on this information, we decided that Medicare rules for 
coverage of a Freestyle Libre 2 CGM sensor have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient clinic visit provided on May 22, 2023. 
 
You asked the Plan to pay for an outpatient clinic visit. You say that you are requesting reconsideration of the 
denied claim. 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 outpatient clinic visit 
provided on May 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the radiation treatment provided on April 
26, 2023. 
 
You asked the Plan to reduce the coinsurance for the radiation treatment. You say that you cannot afford the 
treatment. 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 the radiation treatment. 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. The total amount you owe is $38.52 ($192.60 allowed amount x 20% = $38.52). 
Therefore, we decided that the Plan does not have to reduce the coinsurance for the radiation treatment 
provided on April 26, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the insertion of non-tunneled centrally inserted central 
venous catheter (36556) provided on March 4, 2023. 
 
You asked the Plan to pay for the surgical service. You say that the enrollee was seen twice on the same date of 
service at two different times and/or by two different providers. You also say that records have been included 
for review. The Plan denied your request. The Plan says this service was already paid for this date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the surgical service have been met. 
Specifically, the file does not support that the enrollee received this service by this provider on the date of 
service in this case. Therefore, we decided that the Plan does not have to pay for the insertion of non-tunneled 
centrally inserted central venous catheter (36556) provided on March 4, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oncology screening provided on June 28, 2023. 
 
You asked the Plan to pay for the oncology screening. You say that you are requesting reconsideration of the 
denied claim. 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 oncology screening 
provided on June 28, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B prescription drugs 
provided on January 11, 2023. 
 
You asked the Plan to waive the coinsurance for Medicare Part B prescription drugs. 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for Medicare Part B prescription 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. The total allowed amount for the prescription drugs is $10,191.16. You are 
being asked to pay $2,038.23 ($10,191.16 x 20% = $2,038.23). Therefore, we decided that the Plan does not 
have to waive the coinsurance for Medicare Part B prescription drugs provided on January 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B prescription drugs 
provided on September 20, 2021. 
 
You asked the Plan to waive the coinsurance for Medicare Part B prescription drugs. 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for Medicare Part B prescription 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. The total allowed amount for the prescription drugs is $365.74. You are 
being asked to pay $73.15 ($365.74 x 20% = $73.15). Therefore, we decided that the Plan does not have to 
waive the coinsurance for Medicare Part B prescription drugs provided on September 20, 2021.