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

 
We decided that the Plan does not have to waive the copayment for ultrasound on February 21, 2023. 
 
You asked the Plan to waive the copayment for ultrasound. You say that you want to know why you were 
charged for this procedure and not the other. 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 $150 
copayment for other Medicare-covered radiological diagnostic services, not including X-rays, performed in a 
physicians office or at a free-standing facility (such as a radiology center or medical clinic). Covered services 
include but are not limited to other outpatient diagnostic tests - Radiological diagnostic services, not including 
x-rays. The provider billed in the amount of $243.20 and the allowed amount is $109.59. This is less than the 
copayment amount. Therefore, resulsts in the total cost sharing amount of $109.59. 
 
You have been asked to pay a $109.59 copayment, which is less than the copayment for ultrasound. 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 ultrasound on February 21, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient mental health visit provided on March 27, 
2023. 
 
You asked the Plan to pay for an outpatient mental health visit. You say that the provider you saw was an in-
network provider. 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 mental 
health visit provided on March 27, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not require daily skilled nursing or therapy services. The 
enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a skilled 
nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-rays provided on May 10, 2022. 
 
You asked the Plan to pay for x-rays. You say that you are requesting reconsideration for the services provided. 
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 x-rays provided on May 
10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a portible x-ray provided on August 08, 2022. 
 
You asked the Plan to pay for a portible x-ray. You say that the patient is bedridden and could not leave to get 
this done in an in-network facility. 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 portible x-ray provided 
on August 08, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite provided on March 7, 2023. 
 
You asked the Plan to pay for the dental services. You say that this crown had to be re-done multiple times and 
you are being taken advantage of by your dental providers. The Plan denied your request. The Plan says your 
benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 29, 2021. 
Therefore, we decided that the Plan does not have to pay for the resin-based composite provided on March 7, 
2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continued acute inpatient psychiatric services rendered from 
July 14, 2022, to October 24, 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 records do not show continued thoughts about harming oneself. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 
requested services are not medically reasonable or necessary. Our physician reviewer found that based on the 
provided records, it was not expected that this enrollee would improve in a reasonable period of time for the 
dates in question as the enrollee did not have suicidal or homicidal ideation, auditory or visual hallucinations. 
The enrollee was compliant with treatment while not showing any acute threats to safety. It did not appear 
medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather 
than a lower level of care beyond the dates in question. The health plans denial of continued inpatient 
psychiatric services is appropriate. 
 
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 continued acute inpatient psychiatric services rendered from July 14, 2022, to October 24, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on January 3, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your $2,000 annual maximum has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted. Therefore, we decided that the Plan does 
not have to pay for dental services provided on January 3, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Gamunex-C infusion, diagnostic 
injection, and diphenhydramine hcl injection provided on February 9, 2023, and March 16, 2023. 
 
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that the claims are for 
infusion not injections. 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 chemotherapy drugs and 20% coinsurance for all other drugs covered under Medicare Part B 
drugs. 
 
  You have been asked to pay a total of $574 for the Gamunex-C infusion, diagnostic injection, and 
diphenhydramine hcl injection. The total amount allowed to be billed for the Gamunex-C infusion provided on 
February 9, 2023, was $2,868.00. You have been asked to pay a $573.60 coinsurance for this service, which is 
20% of the total allowed amount. The total amount allowed to be billed for the diagnostic injection provided on 
February 9, 2023, was $1.00. You have been asked to pay a $.20 coinsurance for this service, which is 20% of 
the total allowed amount. The total amount allowed for the diphenhydramine hcl injection provided on March 
16, 2023, was $1.00. You have been asked to pay a $.20 coinsurance for this service, which is 20% of the total 
allowed amount. These items fall 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 coinsurance for the Gamunex-C infusion, diagnostic injection, and 
diphenhydramine hcl injection provided on February 9, 2023, and March 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for application of caries arresting medicament  per tooth 
(D1354) provided on March 29, 2023. 
 
You asked the Plan to pay for the application of caries arresting medicament  per tooth . You say that you feel 
these services should be covered. The Plan denied your request. The Plan says application of caries arresting 
medicament is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
application of caries arresting medicament  per tooth (D1354) provided on March 29, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ubrelvy tablets. 
 
You asked the Plan to pre-approve Ubrelvy tablets. 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 Ubrelvy tablets.   
Benefits for Ubrelvy tablets 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 pre-approve a group 2 standard power operated vehicle (POV) 
(K0806). 
 
You asked the Plan to pre-approve a group 2 standard POV. You say that it would be better for you to have a 
power scooter instead of a power wheelchair. You also say that with a power chair there is no basket that you 
can use to place your fan, and with a power scooter you will have a place for the fan and your portable oxygen. 
The Plan denied your request. The Plan says the requested power operated vehicle (scooter) is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if a Group 2 POV (K0806, K0807, K0808) is 
provided it will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a group 2 standard POV have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a group 2 standard power operated vehicle (POV) (K0806).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI).  
 
You asked the Plan to pre-approve SSBCI benefits. You say that you are at high risk for hospitalization and 
have an upcoming surgery on both of your feet. The Plan denied your request. The Plan says the criteria for 
eligibility have not been met.  
 
 
 The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supply 
allowance. 
 
You asked the Plan to pre-approve the CGM and supply allowance. You say that the requested CGM and 
supply allowance is medically necessary for the enrollee. The Plan denied your request. The Plan says the 
Medicare coverage criteria was not met. 
 
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 and supply allowance. Our 
reviewer says that the CGM coverage criteria was not met. Our physician reviewer found that the provided 
records in this case do not document the enrollee is on insulin. Provided records in this case do not document 
recurrent level 2 hypoglycemic events that persist despite multiple attempts to adjust medication(s) and/or 
modify the diabetes treatment plan or a history of one level 3 hypoglycemic event characterized by altered 
mental and/or physical state requiring third-party assistance for treatment of hypoglycemia. 
 
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 and supply allowance have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supply allowance.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network acute inpatient stay provided 
from May 28, 2022, to June 8, 2022. 
 
You asked the Plan to waive the copayment for an in-network acute inpatient stay. You say that this is the 
second time you were hospitalized, both for the same diagnosis. Due to this you feel you should not have to 
pay this large payment. 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 $150 
copayment per day for days 1-5 for inpatient hospital services.  
 
You were in the hospital for 5 days, resulting in a $750 total copayment ($150 x 5 = $750). 
 You have been asked to pay $750 copayment per day for days 1-5 for an in-network acute inpatient stay. This 
item/service falls within the inpatient hospital services benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for an in-network acute inpatient stay provided from May 28, 2022, to June 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit for evaluation provided on February 24, 2023. 
 
You asked the Plan to pay for home visit for evaluation. You say that the assisted living facility is responsible 
to obtain prior authorization for all patients. 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 home visit for 
evaluation provided on February 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for magnetic resonance imaging (MRI), office 
visit and injection on October 28, 2022. 
 
You asked the Plan to waive the cost share for MRI, office visit and injection. You say that you want appeal the 
amount being charged. The Plan denied your request. The Plan says this cost sharing was charged correctly.  
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for all other Medicare-covered diagnostic radiology services (not including x-rays). Covered 
services include, but are not limited to other diagnostic radiology services, which may include CTs, MRIs and 
PET scan. You must pay a $25 copay for each Medicare-covered specialist visit. You must pay a 20% 
coinsurance for injections or durable medical equipment and prosthetic/orthotics if supplied by the physician, 
in addition to office visit copay. Covered services include medically necessary medical care or surgery services 
furnished in a physicians office, certified ambulatory surgical center, hospital outpatient department, or any 
other location and consultation, diagnosis, and treatment by a specialist. The provider billed in the amount of 
$1,842 and the allowed amount is $223.94 for the service. $223.94 x 20% = $44.79. The provider also billed in 
the amount of $40 and the allowed amount is $9.61 for the service. $9.61 x 20% = $1.92. For the services, it's 
$44.79 + $25 + $1.92 = $71.71. Therefore, results in the total cost sharing amount of $71.71. 
 
You have been asked to pay a 20% coinsurance for MRI, a $25 copayment for office visit and a 20% 
coinsurance for injection. This item/service falls within the outpatient diagnostic tests and therapeutic services 
and supplies and physician/practitioner services, including doctors office visits benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the cost share for magnetic resonance imaging (MRI), office visit and injection on 
October 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient earwax removal provided on December 29, 
2022. 
 
You asked the Plan to pay for an outpatient earwax removal. You say that you say that you are in-network with 
this plan. There is no reason for this being denied. 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 earwax 
removal provided on December 29, 2022.