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

 
We decided that the Plan does not have to waive the copayments for the specialist office visit and urine flow 
measurement provided on October 17, 2022. 
 
You asked the Plan to waive the copayments for the specialist office visit and urine flow measurement. You 
say that if this had been done in the office you would only have a single office visit 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 $40 
copayment for each specialist office visit. Your contract with the Plan also clearly says that you must pay a 
$275 copayment for each outpatient hospital service. 
 
You have been asked to pay a $40 copayment for the specialist office visit. This item/service falls within the 
physician/practitioner services benefit category. You have also been asked to pay a $275 copayment for the 
urine flow measurement. This item/service falls within the 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 copayments for the specialist office visit and urine flow measurement 
provided on October 17, 2022.
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 a continuous glucose monitor (CGM). You say that you would like to 
request reconsideration of the denied authorization. The Plan denied your request. The Plan says the criteria for 
approval have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not have diabetes 
Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor 
(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 stay provided from 
January 24, 2023, to January 26, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you spoke to Medicare 
and were told there would be no cost for this 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 $245 
copayment per day for days 1-8 of each 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. 
 
You have been asked to pay a $245 copayment per day for days 1-2 of the inpatient hospital stay. This 
item/service falls within the inpatient hospital care benefit category. You have not been asked to pay after day 
two or for the day you were discharged. You have been asked to pay a total of $490 for the inpatient hospital 
stay ($245 copayment per day x 2 days = $490). This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
the inpatient hospital stay provided from January 24, 2023, to January 26, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a stress test provided on December 8, 2022. 
 
You asked the Plan to waive the copayment for a stress test. You say that you do not understand why the cost 
share was applied for the services rendered. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B drugs and 20% coinsurance for each Medicare-covered medical supply and an 
$85 copayment for Medicare-covered radiological diagnostic services, not including x-rays.  
 
You have been asked to pay $184.18 for a stress test. This total includes $49.18 for Medicare Part B drugs, $50 
for medical supplies, and an $85 copayment for the radiological diagnostic services. The Medicare Part B drugs 
fall within the Medicare Part B prescription drugs benefit category. The medical supply and radiological 
diagnostic service 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 copayment for a stress test provided on December 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve root canal for tooth #8 (D3310), post for tooth $8 
(D2950) and a resin-based composite (D2330). 
 
You asked the Plan to pre-approve root canal and post for tooth #8 and a resin-based composite. You say that 
this is medically necessary for the enrollee. The Plan denied your request. The Plan says the documentation 
submitted by the provider states that the prognosis for tooth #8 is not good and that acceptable alternative 
treatments would be either no treatment or extraction and replacement with the approved upper partial denture. 
 
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 root canal and 
post for tooth #8 and a resin-based composite 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 root canal and post for tooth #8 and a 
resin-based composite. Our reviewer says that the service is not medically necessary. Our physician reviewer 
found a review of the documentation indicates that tooth #8 presently has a root canal and post/crown in place. 
Due to the periodontal condition, the long-term prognosis after retreatment of the root canal and placement of a 
new post/core and crown is poor. Therefore, it is my opinion that the services indicated are not medically 
reasonable. 
 
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 root canal and post for tooth #8 and a resin-based composite have not been met. 
Therefore, we decided that the Plan does not have to pre-approve root canal for tooth #8 (D3310), post for 
tooth $8 (D2950) and a resin-based composite (D2330).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on November 05, 2022, to 
November 22, 2022. 
 
You asked the Plan to pay for home health services. You say that you are appealing the claim payment denial. 
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 health services 
provided on November 05, 2022, to November 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an implant maintenance procedure (D6080) provided on 
January 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 dental services were received from an out-of-
network provider and are not covered by your supplemental 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. 
 
 
  The record shows you received the requested 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 pay for an implant maintenance procedure (D6080) provided on January 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that claims for ventilators used to provide CPAP or bi-level 
CPAP therapy will be denied as not 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 a home ventilator. Our reviewer says 
that the enrollee does not need this item. Our physician reviewer found the records document that the home 
ventilator is being requested for use in average volume assured pressure support (AVAPS) mode with auto-
expiratory positive airway pressure (EPAP) (AE) which could be provided by a BiPAP device with AVAPS 
and a back-up rate. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on January 6, 2023, and January 
13, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for physical therapy provided by an OON provider. You say that you are appealing 
the claim payment denial. The Plan denied your request. The Plan says the services were provided out-of-
network and were not approved in advanced. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for physical therapy provided on January 6, 2023, and 
January 13, 2023, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve air ambulance services (A0430, A0435). 
 
You asked the Plan to pre-approve air ambulance services. You say that there is no clinic in the area that can 
support the enrollee's needs. The Plan denied your request. The Plan says this request does not meet Medicare 
coverage criteria. 
 The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air ambulance services. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the documentation does not 
support that the enrollee suffers from an illness or injury that contraindicates transportation by any means other 
than ambulance. The documentation does not support that the enrollees condition was such that the time 
needed to transport the enrollee by ground, or the instability of transportation by ground, posed a threat to the 
enrollee's survival or seriously endangered the enrollee's health. The enrollee was medically stable and could be 
reasonably transferred by ambulance to a facility closer to the admitting hospital in Texas, rather than 
transported by air ambulance to California.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of air ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve air ambulance services (A0430, A0435).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93970-26 and 93979 billed for date of 
service December 15, 2022. 
 
You asked the Plan to pay for the billed services. You say that the procedures were separately performed. The 
Plan denied your request. The Plan says the services are not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
In this case, we have confirmed that code 93979 is a column II code to column I code 93978. Code 93979 has 
not been billed with an appropriate modifier to bypass the edit. We find that CPT code 93970-26 is not payable 
when furnished to hospital patients. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 93970-26 and 93979 billed for 
date of service December 15, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the PET scan provided on January 24, 
2023. 
 
You asked the Plan to waive the copayment for PET scan. You say that you would like the claim paid for by 
insurance as this was a procedure related to cancer treatment. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $175 
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). You pay these 
amounts until you reach the out-of-pocket maximum. Your provider may need to obtain prior authorization.  
 
You have been asked to pay $175 copayment for the PET scan. This PET scan falls within the other outpatient 
diagnostic tests - radiological diagnostic services, not including x-rays 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 PET scan provided on January 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3. 
 
You asked the Plan to pre-approve the Freestyle Libre 3. You say that the alternative CGM is a Dexcom G7, 
but it's more expensive than the Freestyle Libre and the battery life is shorter. The Plan denied your request. 
The Plan says you are requesting a CGM product that does not meet Medicare's definition of durable medical 
equipment (DME) and therefore is not in a defined Medicare benefit category. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that a non-adjunctive continuous glucose monitor 
(CGM) must be billed with code E2103. The rules also say that only devices reviewed by the PDAC and 
assigned code E2103 may be billed using this code.  
 
We looked at the file and Medicare rules. The request at issue is for the Freestyle Libre 3 non-adjunctive CGM. 
However, this device has not been reviewed by the PDAC and has not been assigned code E2103. As such, this 
non-adjunctive CGM device is not eligible for coverage at this time. Therefore, we decided that the Plan does 
not have to pre-approve a Freestyle Libre 3.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the MRI provided on May 17, 2021. 
 
You asked the Plan to waive the copayment for the MRI. You say that you feel you should not be responsible 
for the billed amount because, the provider told you they contacted your insurance, they did not receive any 
notice saying you had to pay. You say that now after two years, you received a bill. 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  $250 
copayment for in-network diagnostic radiology other than computed tomography (CT) scans.  
 
You have been asked to pay $207.71, which is less than the standard $250 copayment for an MRI. This MRI 
falls within the diagnostic radiology 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 MRI provided on May 17, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need transportation 
to your medical appointments. The Plan denied your request. The Plan says you have utilized the maximum 
number of transportation trips allowed per year. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for manual wheelchair provided on September 21, 2022. 
 
You asked the Plan to pay for manual wheelchair. 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 manual wheelchair 
provided on September 21, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on August 27, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment is included in the inpatient facility 
payment. 
 
The Plan must follow Medicare rules. The rules say that the applicable payments made under the prospective 
payment systems are payment in full for all inpatient hospital services. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ambulance services have not been met. Specifically, the record shows that the enrollee was 
admitted as inpatient on the date of service at issue. Therefore, we decided that the Plan does not have to pay 
for the ambulance services provided on August 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Epifix Skin Substitute application (Q4186). 
 
You asked the Plan to pre-approve the Epifix Skin Substitute application. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the service 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 Epifix Skin Substitute application. 
Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the records do not show assessment of the enrollee's blood flow and correction of 
any amenable vascular problems, blood sugar control, or a proper diet with resultant proper nutritional status. 
 
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 Epifix Skin Substitute application have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the Epifix Skin Substitute application (Q4186).