Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Partially Favorable

 
We decided that the Plan has to reduce the coinsurance for the denosumab injections provided on June 20, 
2022, and December 22, 2022. We also decided that the Plan does not have to waive the coinsurance for the 
office visits provided on June 20, 2022, and December 22, 2022.  
 
You asked the Plan to waive the coinsurance for the injections and the office visits. You say that you have prior 
authorization; therefore, you should have no out-of-pocket expense. The Plan says that this cost sharing was 
charged correctly. 
 
We decided that the Plan has to reduce the coinsurance for the denosumab injections.  
 
The Plan follows Medicare rules. Medicare rules say that 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.  
 
The file shows that you have a medical indication for which Medicare will cover denosumab injections. You 
have been asked to pay 30% coinsurance for the denosumab injections. Based on the Plan contract, you cannot 
be asked to pay more than 20% coinsurance for Medicare Part B drugs. Therefore, we decided that the Plan has 
to reduce the coinsurance for denosumab injections provided on June 20, 2022, and December 22, 2022.  
 
We also decided that the Plan does not have to waive the coinsurance for the office visits. 
 
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 each out-of-network office visit. 
 
You have been asked to pay 30% coinsurance of the allowed amount for each office visit. These services falls 
within the physician/practitioner 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 the office visits provided on June 20, 2022, and December 22, 2022 
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that you would like to continue therapy with your 
provider. The Plan denied your request. The Plan says this is available in-network. 
 
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 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest radiological examination (71046) provided on 
January 27, 2023. 
 
You asked the Plan to pay for the chest radiological examination (71046). You say that the service was 
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 the chest radiological 
examination (71046) provided on January 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6530 that 
were issued on December 16, 2022, to December 19, 2022. 
 
You asked the Plan to pay for the compression stockings. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the service is not a covered 
benefit. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code A6530 that were issued on December 16, 2022, to December 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drugs (J3490) provided on January 6, 2023. 
 
You asked the Plan to pay for the drugs. 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 the requested services (J3490) is included in the global 
surgery payment for the procedure (27096) provided on the same date of service. Based on this information, we 
decided that Medicare rules for coverage of the drugs have not been met. Therefore, we decided that the Plan 
does not have to pay for the drugs (J3490) provided on January 6, 2023.
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 the CGM. You say that it is medically necessary that the enrollee gets a 
CGM. The Plan denied your request. The Plan says the Medicare criteria was not met. 
  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 use insulin 
with at least three daily injections. 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stays provided from 
December 4, 2022, to December 14, 2022 
 
You asked the Plan to waive the copayment for the inpatient hospital stays. You say that you were discharged 
too soon, and this should be considered a single 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 $325 
copayment per day for days 1-6 of each in-network inpatient hospital stay. Your contract with the Plan also clearly says that you then pay a $0 copayment per day for any additional days of the same inpatient hospital 
stay. Your contract with the Plan also clearly says that this copayment applies each time you are admitted as an 
inpatient. 
 
You have been asked to pay a $325 copayment per day for days 1-3 of the inpatient hospital stay provided from 
December 4, 2022, to December 7, 2022. You have not been asked to pay for the day you were discharged. 
You have been asked to pay a total of $975 for this inpatient hospital stay ($325 copayment per day x 3 days = 
$975). 
 
You have also been asked to pay a $325 copayment per day for days 1-6 of the inpatient hospital stay provided 
from December 8, 2022, to December 14, 2022. You have not been asked to pay after day six or for the day 
you were discharged. You have been asked to pay a total of $1,950 for this inpatient hospital stay ($325 
copayment per day x 6 days = $1,950). These items/services fall 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 stays provided from 
December 4, 2022, to December 14, 2022
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the emergency room (ER) services. 
 
You asked the Plan to pay for the ER services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that the provider is not enrolled with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The physician does show up as a Medicare provider in the Medicare provider 
search. The Plan has not submitted any documentation showing otherwise. Therefore, we decided that the Plan 
has to pay for the emergency room (ER) services.  
 
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: ER
Decision: Favorable

 
We decided that the Plan has to pay for the emergency room (ER) services. 
 
You asked the Plan to pay for the ER services. You say that the service was medically necessary. The Plan 
denied your request. The Plan says that the provider is not enrolled with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The physician does show up as a Medicare provider in the Medicare provider 
search. The Plan has not submitted any documentation showing otherwise. Therefore, we decided that the Plan 
has to pay for the emergency room (ER) services.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implant 
(D6010 x9). 
 
You asked the Plan to pre-approve the surgical placement of implant body: endosteal implants. You say that 
your mouth is very bad and needs this treatment. You also say that you are biting too much, cannot chew and it 
is difficult to eat. The Plan denied your request. The Plan says these services are not covered under your Plan's 
dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 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 pre-approve 
surgical placement of implant body: endosteal implant (D6010 x9).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the inpatient hospital stay provided from 
December 12, 2022, to January 6, 2023, and the chemotherapy drug and administration provided on January 
18, 2023. 
 
You asked the Plan to waive the cost share for the inpatient hospital stay and the chemotherapy drug and 
administration. You say that you cannot afford 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). Your contract with the Plan clearly says that you must pay a $250 
copayment per day, for days 1 to 3 and a $0 copayment for each additional day of inpatient hospital care. Your 
contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B drugs. 
 
You have been asked to pay a $250 copayment per day, for days 1 to 3 of the inpatient hospital stay. You have 
been asked to pay a total of $750 ($250 copayment x 3 days = $750). You have not been charged for any 
additional days. This item/service falls within the inpatient hospital coverage benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. You have also been asked 
to pay up to 20% coinsurance for the chemotherapy drug. You have been asked to pay $3,353.47, with is less 
than 20% of the allowed amount for the chemotherapy drug. You have also been asked to pay $16.53, which is 
20% coinsurance of the allowed amount for the chemotherapy administration ($82.65 allowed amount x 20% = 
$16.53). These items/services fall within the Medicare Part B drugs benefit category. 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 inpatient hospital stay provided from December 12, 2022, to 
January 6, 2023, and the chemotherapy drug and administration provided on January 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve white glass with high gold content crown for tooth 30 
(D2750). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. 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 March 4, 2022. 
Therefore, we decided that the Plan does not have to pre-approve white glass with high gold content crown for tooth 30 (D2750).
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 should be eligible for this benefit. 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy (PT) services provided on August 10, 
2022. 
 
You asked the Plan to pay for the PT services. You say that the enrollee continues to benefit from PT 
interventions to increase strength, mobility, and endurance. The Plan denied your request. The Plan says the 
submitted clinical documentation does not demonstrate progressive meaningful functional progress within a 
reasonable and predictable time period.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 PT services. Our reviewer says that 
skilled services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee is stable and able to continue with a home exercise 
program. The enrollee is not likely to gain because they have limited neurological recovery 9 months post 
stroke. The enrollee no longer requires unique input from a skilled therapist. 
 
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 PT services have not been met. Therefore, we decided that the Plan does not 
have to pay for the physical therapy (PT) services provided on August 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with codes K1024 and 
K1033. 
 
You asked the Plan to pre-approve the compression stockings. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the services are not 
covered benefits. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by codes K1024 and 
K1033 are noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with codes K1024 and K1033.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to waive the coinsurance for the specialist office visits provided from November 
4, 2022, to December 29, 2022, and the ultrasound provided on December 7, 2022. We also decided that the 
Plan does not have to waive the deductible for the specialist office visit provided on November 4, 2022.  
 
You asked the Plan to waive the cost share for the specialist office visits and an ultrasound. You say that you 
have never been charged for these services in the past. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
We decided that the Plan has to waive the coinsurance for the specialist office visits provided from 
November 4, 2022, to December 29, 2022, and the ultrasound provided on December 7, 2022.  
 
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 does not say in clear and accurate terms 
how much you should expect to pay for a specialist office visit or an ultrasound after the deductible has been 
met.  
 
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay 20% 
coinsurance for a specialist office visit. We also did not see where the contract says enrollees must pay 20% 
coinsurance for an ultrasound. The Plan contract does not clearly say how much enrollees must pay for a 
specialist office visit or an ultrasound after the deductible has been met. This means that the Plan did not follow 
Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the 
for coinsurance for the specialist office visits provided from November 4, 2022, to December 29, 2022, and the 
ultrasound provided on December 7, 2022.  
 
We also decided that the Plan does not have to waive the deductible for the specialist office visit provided 
on November 4, 2022. 
 
The item or service you asked the Plan to waive the deductible for falls within the physician/practitioner 
services, including doctors office visits benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $203 deductible which applies to the physician/practitioner services, 
including doctors office visits. This cost sharing is a contractual obligation that had not been met at the time 
the specialist office visit was received on November 4, 2022. Therefore, we decided that the Plan does not have 
to waive the deductible for the specialist office visit provided on November 4, 2022. 
 
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.