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

 
We decided that the Plan does not have to waive the copayment for an out-of-network ambulance ride provided 
on May 03, 2022. 
 
You asked the Plan to waive the copayment for an out-of-network ambulance ride. You say that you have an 
agreement with your case worker for this service. 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 
$1,326.51 copayment for ambulance services. 
 
You have been asked to pay a $1,326.51 copayment for an out-of-network ambulance ride. This item/service 
falls within the ambulance 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 out-of-network ambulance ride provided on May 03, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the science supporting the safety and 
efficacy of the Intracept procedure is robust. The Plan denied your request. The Plan says the Intracept 
procedure is not medically necessary. The medical records do not include 6 months of non-surgical treatment. 
 
The Plan follows Medicare rules. Medicare rules say that the Intracept procedure is only coverable for patients 
with documented failure to respond to greater than or equal to 6 months of non-surgical management. 
 
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 Intracept procedure. Our reviewer 
says that the patient does not meet criteria for the Intracept procedure. Our physician reviewer found more 
conservative measures are needed for back pain treatment prior to the Intracept procedure being appropriate.  
The patient needs to have at least six months of such conservative measures, and that is not noted in the 
medical records. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve additional acupuncture treatments.  
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says that your request exceeds the allowable acupuncture 
benefit.  
 
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. Specifically, the Plan has stated that your request exceeds the Medicare 
acupuncture benefit as only 20 visits are allowed per year. However, the Plan provides supplemental coverage 
for 12 in-network acupuncture treatments per year. The Plan has not indicated why the enrollee does not meet 
criteria for coverage of the requested services under the supplemental acupuncture benefit policy. The Plan has 
not substantiated their denial; therefore, we must find in your favor. Therefore, we decided that the Plan has to 
pre-approve additional acupuncture treatments.   
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for colonoscopy provided on March 06, 2023. 
 
You asked the Plan to waive the copayment for colonoscopy. You say that you say this was a screening and 
disagree with the charge. 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 for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. 
 
You have been asked to pay a $250 copayment for colonoscopy. This item/service falls within the outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 colonoscopy provided on March 06, 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 
October 7, 2022, to October 11, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were not aware of 
the inpatient hospital care 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 a $275 
copayment per day for days 1-5 of each inpatient hospital stay. Your contract with the Plan also clearly says you then pay a $0 copayment per day for any additional days of the same inpatient hospital stay. 
 
You have been asked to pay a $275 copayment per day for days 1-4 of the inpatient hospital stay. This 
item/service falls within the inpatient hospital care benefit category. You have not been asked to pay for the 
day you were discharged. You have been asked to pay a total of $1,100 ($275 copayment per day x 4 days = 
$1,100). 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 
October 7, 2022, to October 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 14 day sensor. 
 
You asked the Plan to pre-approve the FreeStyle Libre 14 day sensor. The Plan denied your request. The Plan 
says the member is not receiving insulin and has not had a documented hypoglycemic episode so the 
continuous glucose monitor is not medically necessary. 
 
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 Libre 14 day sensor. Our 
reviewer says that the requested FreeStyle sensor is not medically necessary. Our physician reviewer found the 
patient is not taking insulin and is not having low blood glucose sugar that have documented in the CGM or by 
the medical provider, 
 
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 Libre 14 day sensor have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a FreeStyle Libre 14 day sensor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the deep gum and root cleaning (D4341) for all 4 
quadrants. 
 
You asked the Plan to pre-approve the dental services. You say that you are in a lot of pain, and you need the 
dental services approved. The Plan denied your request. The Plan says there was no noticeable bone loss, or 
any hard substance built up on the root of the tooth. 
 
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 requested dental services do not meet the criteria for coverage. Our physician reviewer found that the 
documentation did not reveal any bone loss or evidence of subgingival calculus. Also, there was no charting 
record of pathological periodontal pockets. 
 
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 the deep gum and root cleaning (D4341) for all 4 quadrants.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on January 10, 2023. 
 
You asked the Plan to pay for drug testing. 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 drug testing provided on 
January 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and related services provided on January 24, 
2023. 
 
You asked the Plan to pay for an office visit and related 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 an office visit and 
related services provided on January 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block. 
 
You asked the Plan to pre-approve a genicular nerve block. You say that the requested genicular nerve block is 
medically necessary.  The Plan denied your request. The Plan says the requested genicular nerve block is not 
medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 a genicular nerve block. Our reviewer 
says that the requested genicular nerve block is not medically necessary.  Our physician reviewer found this is 
considered an experimental therapy at this time. There are ongoing clinical trials in patients with persistent 
knee pain status post arthroplasty to examine the role of genicular blocks and radiofrequency ablation.  
Therefore, at this time, the request is deemed not medically reasonable and necessary.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the cataract surgery provided on January 
10, 2023. 
 
You asked the Plan to waive the copayment for the cataract surgery. You say that you are not satisfied with the 
surgery and want a refund. 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 for outpatient surgery. 
 
You have been asked to pay a $325 copayment for the cataract surgery. This item/service falls within the 
outpatient surgery 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 cataract surgery 
provided on January 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 07, 2023. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and should be covered. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on February 07, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for abdominal paracentesis provided on November 18, 2022. 
 
You asked the Plan to pay for abdominal paracentesis. You say that you are requesting the submitted 
documentation be reviewed. 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 abdominal paracentesis 
provided on November 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CXbladder detect test (0012M) provided on December 
19, 2022. 
 
You asked the Plan to pay for the CXbladder detect test (0012M). You say that this service was medically 
necessary.  The Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-
covered.  
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the CXbladder detect test (0012M) have not been met. Therefore, 
we decided that the Plan does not have to pay for the CXbladder detect test (0012M) provided on December 
19, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance image (MRI) 
provided on June 09, 2022. 
 
You asked the Plan to waive the copayment for a magnetic resonance image (MRI). You say that you do not 
believe you should be responsible for the cost share applied but should be covered by the Plan. 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 $180 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $180 copayment for a magnetic resonance image (MRI). This item/service falls 
within the outpatient diagnostic test benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. The total you owe is $106.29, which is less than the standard $180 copayment 
for an MRI. Therefore, we decided that the Plan does not have to waive the copayment for a magnetic 
resonance image (MRI) provided on June 09, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from February 10, 
2021, to February 28, 2021. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you do not agree with the cost share 
assessed for the SNF 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 $0 
copayment for days 1 to 20, a $184 copayment per day for days 21 to 40, and $0 copayment per day for days 
41 to 100 for SNF care.  
 
You have been asked to pay a $2,392 copayment for a SNF stay. The cost share applied is less than the 
standard copayment because the maximum out-of-pocket was met with the processing of this claim. This 
item/service falls within the SNF 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 a 
SNF stay provided from February 10, 2021, to February 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on August 25, 
2022. 
 
You asked the Plan to pay for subsequent nursing facility care. 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 subsequent nursing 
facility care provided on August 25, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia 
 
You asked the Plan to pre-approve Prolia. You say that the requested Prolia is medically necessary.  The Plan 
denied your request. The Plan says the requested Prolia is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that the 
requested Prolia is not medically necessary.  Our physician reviewer found the enrollee is with a diagnosis of 
osteoporosis. The documentation indicates that the enrollees DEXA scan from April 12, 2023, indicates 
femoral neck T-Score of 1.0 (no FRAX 10-year provided), 1.2 on L1-4, and left forearm T-score of -2.7.  Her 
provider has requested medical therapy with Prolia. 
 
Denosumab (Prolia) is a humanized monoclonal antibody directed against the receptor activator of the nuclear 
factorkappa B ligand (RANKL), which is a key mediator of the resorptive phase of bone remodeling. It 
decreases bone resorption by inhibiting osteoclast activity.  Denosumab was approved by the US Food and 
Drug Administration in June 2010. It has been studied in cancer patients, patients with postmenopausal osteoporosis, and men with low bone mineral density (BMD). The approved dosage is 60 mg given 
subcutaneously every 6 months. Denosumab may be considered in certain patients with renal insufficiency, as 
impaired renal function does not significantly affect the metabolism or excretion of the drug.  According to 
DrugDex, a Medicare-approved compendium:  "High-risk of fracture was defined as a BMD T-score of less 
than or equal to -2.5 at the spine, hip, or femoral neck, a T-score of less than or equal to 2 with at least one 
BMD-independent risk fracture (eg, fracture after age 50, parental hip fracture after age 50 years, previous 
hyperthyroidism, inability to rise from a chair with arms elevated, or current smoking), or a T-score of less than 
or equal to -1 at the spine, hip, or forearm with a history of 1 or more fragility fractures." 
 
The review has determined that the documentation does not support that Prolia is medically reasonable and 
necessary for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia