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

 
We decided that the Plan does not have to pay for self-administered drugs provided on February 16, 2023. 
 
You asked the Plan to pay for the medication. You say that you did not take any medication that the nurse did 
not give you. 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 pay for self-administered drugs provided 
on February 16, 2023.  
 
Benefits for the medication 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 the brake attachment (E0159). 
 
You asked the Plan to pre-approve the brake attachment. You say that the item is medically necessary. The 
Plan denied your request. The Plan says  the brake attachment may not be billed separately for a new walker 
 
The Plan follows Medicare rules. Medicare rules say that the brake attachment may not be billed separately for 
a new walker. 
 
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 brake attachment. Our reviewer 
says that this enrollee does not need this item. Our physician reviewer found the brake attachment may not be 
billed separately for a new walker. 
 
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 brake attachment have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the brake attachment (E0159).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services provided on January 16, 2023. 
 You asked the Plan to pay for the hospital services. You say that the coding is correct, and the claim should be 
paid. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for hospital services provided on January 16, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an outpatient diagnostic test provided on 
March 17, 2023 
 
You asked the Plan to waive the cost share for an outpatient diagnostic test. You say that you disagree with 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. Your 
contract with the Plan says that there is a $750 deductible which applies to outpatient diagnostic test.  
 
The item or service you asked the Plan to waive the cost share for falls within the outpatient diagnostic test 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 
deductible which applies to outpatient diagnostic test. You are being asked to pay $120.12 towards your $750 
deductible. This cost sharing is a contractual obligation that had not been met at the time an outpatient 
diagnostic test was received on March 17, 2023. Therefore, we decided that the Plan does not have to waive the 
cost share for an outpatient diagnostic test provided on March 17, 2023
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for Medicare Part B prescription drugs and 
outpatient hospital services provided on April 6, 2023. 
 
You asked the Plan to waive the cost share for Medicare Part B prescription drugs and outpatient hospital 
services. You say that you disagree with 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 20% 
coinsurance for Medicare Part B prescription drugs and a $130 copayment for outpatient hospital services.  
 You have been asked to pay a 20% coinsurance for Medicare Part B prescription drugs and a $130 copayment 
for outpatient hospital services. The total allowed amount for the prescription drugs is $1,361.88. You are 
being asked to pay $272.38 ($1,361.88 x 20% = $272.38). You are only being asked to pay $59.42 for the 
outpatient hospital services which is less than the required amount of $130. The total amount you are being 
asked to pay is $331.80 ($272.38 + 59.42 = $331.80). This item/service falls within the Medicare Part B 
prescription drugs and outpatient 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 
cost share for Medicare Part B prescription drugs and outpatient hospital services provided on April 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint injection.  
You asked the Plan to pre-approve the injection. You say that the enrollee is experiencing moderate to severe 
low back pain primarily over the right sacroiliac joint. You say that the enrollee has positive findings with 
proactive maneuvers for sacroiliitis on the exam and has started physical therapy. The Plan denied your 
request. The Plan says a sacroiliac joint injection 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 the injection. Our reviewer says that the 
enrollee does not meet the coverage criteria. Our physician reviewer found that the records do not show that the 
enrollee has at least 3 positive findings with proactive maneuvers of the sacroiliac joints. Additionally, the 
enrollee's clinical findings and imaging studies suggest lumbar spinal stenosis as a possible cause of their 
lumbosacral pain. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sacroiliac joint injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits (99203, 99213), electrical stimulation 
(G0283), manual therapy (97140), therapeutic exercises (97110), and the mechanical traction therapy (97012) 
provided from December 5, 2022, through March 7, 2023.  
 
You asked the Plan to pay for these dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the office visits (99203, 99213), electrical stimulation (G0283), manual 
therapy (97140), therapeutic exercises (97110), and the mechanical traction therapy (97012) provided from 
December 5, 2022, through March 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a limited oral evaluation - problem focused (D0140). 
 
You asked the Plan to pre-approve the limited oral evaluation - problem focused. You say that this is the only 
clinic and the only prosthodontist with the added license and an operating room to give you the health services 
you need. You also say that you have to have permanent implants, not snap-ons because you have no bone to 
screw the titanium screws in only soft tissue. The Plan denied your request. The Plan says dental services from 
an out-of-network provider are not covered by your supplemental benefits. Additionally, services from this 
type of provider are not covered per your 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. You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve a limited 
oral evaluation - problem focused (D0140).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Tetanus, Diphtheria Toxoids and Acellular Pertussis vaccine 
provided on April 14, 2023. 
 
You asked the Plan to pay for Tetanus, Diphtheria Toxoids and Acellular Pertussis vaccine. You say that it is 
medically necessary. The Plan denied your request. The Plan says the vaccine and its administration are 
covered under your Part D benefits, not your medical benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide Tetanus, Diphtheria 
Toxoids and Acellular Pertussis vaccine. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to Tetanus, 
Diphtheria Toxoids and Acellular Pertussis vaccine. Therefore, we decided that the Plan does not have to pay 
for Tetanus, Diphtheria Toxoids and Acellular Pertussis vaccine provided on April 14, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a CT scan and a chemical agent provided on 
September 19, 2022. 
 
You asked the Plan to waive the cost share for a CT scan and a chemical agent. You say that you do not feel 
you should be responsible for the cost share applied to this claim. The Plan denied your request. The Plan says 
the cost share applied is correct. 
 
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-covered medical supply, including chemical agents used in certain diagnostic 
procedures, and a $125 copayment for Medicare-covered radiological diagnostic services.  You have been asked to pay $127.04 for a CT scan and a chemical agent. This total includes a $125 copayment 
for a CT scan and $2.04 coinsurance, which is 20% of the allowed amount ($10.20 allowed x 20% = $2.04). 
These items/services fall within the outpatient diagnostic tests benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the cost share for a CT scan and a chemical agent provided on September 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain/ceramic tooth (D6245), and retainer crown 
(D6740). 
 
You asked the Plan to pre-approve a porcelain/ceramic tooth, and retainer crown. You say that the services are 
medically necessary. The Plan denied your request. The Plan says these are not covered services. 
 
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 a 
porcelain/ceramic tooth (D6245), and retainer crown (D6740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a porcelain crown (D2750) provided on February 6, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your 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 pay for a 
porcelain crown (D2750) provided on February 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation, cleaning, and application of 
fluoride (D1206, D0120, D1110) provided on May 17, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the charges. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider.  
 
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. 
 
 
  You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for a periodic oral evaluation, cleaning, and 
application of fluoride (D1206, D0120, D1110) provided on May 17, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse the full amount for magnetic resonance imaging (MRI) of 
the lumbar spine provided on March 24, 2023. 
 
You asked the Plan to reimburse the full amount for the MRI. You say that the amount reimbursed is not what 
you were told it would be. The Plan denied your request. The Plan says the claim was reimbursed 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 35% 
coinsurance for out-of-network (OON) radiological diagnostic services.  
 
 
  Your responsibility for the MRI is 35% of the contracted amount of $191.87, which is a total of $67.15. The 
Plans responsibility is the remaining 65%, for a total of $124.72. The file shows that the Plan reimbursed you 
$188.03. This item/service falls within the out-of-network (OON) radiological diagnostic services benefit 
category. This means that you have been reimbursed more than 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 full amount for magnetic resonance imaging 
(MRI) of the lumbar spine provided on March 24, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an IRF stay provided from February 22, 
2023, to February 28, 2023. 
 
You asked the Plan to waive the copayment for an IRF stay. You say that you were informed by the facility 
that there would be no cost share 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 $350 
copayment per day for days 1 to 5 for inpatient hospital care.  
 
 You have been asked to pay a $1,750 copayment for an IRF stay ($350 per day x 5 days = $1,750). 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 an IRF stay provided from February 22, 2023, to February 28, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for chemotherapy drugs and outpatient hospital 
services provided on January 19, 2023. 
 
You asked the Plan to waive the cost share for chemotherapy drugs and outpatient hospital services. You say 
that you do not understand why the cost share was not paid by the Plan. The Plan denied your request. The Plan 
says the cost sharing will be applied according to the Plan contract. 
 
 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 each Medicare-covered chemotherapy drugs and the administration of that drug.  
 
You have been asked to pay $571.66 for chemotherapy drugs and outpatient hospital services. This total 
includes $201.66 coinsurance, which is 20% of the allowed amount for chemotherapy drugs and the associated 
administration ($1,008.27 allowed x 20% = $201.66) and a $370 copayment for outpatient hospital services. 
The chemotherapy drugs fall within the Medicare Part B prescription drugs benefit category. The outpatient 
hospital services fall within the outpatient surgery and other medical 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 cost share for chemotherapy drugs and outpatient hospital services provided on 
January 19, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from November 
1, 2022, to November 15, 2022. 
 You asked the Plan to pay for SNF care. You say that the services are coverable under Medicare guidelines. 
The Plan denied your request. The Plan says the SNF services you are requesting do not meet the requirements 
for approval. 
 
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 pay for 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 the enrollee does not require skilled nursing or skilled therapy services that require 
the specialized skill, knowledge, and judgement of a skilled professional nurse or therapist. The enrollee does 
not require skilled services on a daily basis. The enrollee does not require skilled services on an inpatient basis 
in a SNF 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 pay for skilled nursing facility (SNF) care provided from November 1, 2022, to November 15, 2022.
Appeal type: Hospice
Decision: Favorable

 
We decided that the Plan has to pay for ambulance services provided on November 23, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that the Plan should be responsible due to the 
enrollee's Value-Based Insurance Design (VBID) coverage. The Plan denied your request. The Plan says that 
Original Medicare is responsible for payment. 
 
Medicare rules say that Plans that have elected to participate in the VBID Model are responsible for hospice 
related benefits.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Since the 
Plan has elected to participate in the VBID Model, they are responsible for the services. Therefore, we decided 
that the Plan has to pay for ambulance services provided on November 23, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675, E0673). 
 
You asked the Plan to pay for the pneumatic compression device. You say that the items are medically 
necessary. The Plan denied your request. The Plan says the items are not covered. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (E0675, E0673).