Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review indicates that the enrollee does not require services at the LTACH that are 
not available at the acute care hospital where they are currently receiving care. There are no services available 
at the LTACH that the enrollee requires that are not available at the health care setting being offered by the 
health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the 
diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 
basis. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that the requested Botox is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for Botox. 
 
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 Botox. Our reviewer says that the 
enrollee does not meet criteria for Botox. Our physician reviewer found the review indicates that the enrollee is 
diagnosed with hypertension and lumbar degenerative disc disease. Treatment for her back pain has consisted 
of analgesics, TENS, physical therapy, facet blocks as well as radiofrequency ablation. 
 
Botulinum toxin is indicated for disorders associated with spastic conditions and dystonia, Blepharospasm, 
Achalasia, Anal Fissure, Hyperhidrosis, Sialorrhea, Urinary Incontinence, and Headache/Migraine. The wide 
range of botulinum toxin dosages used in a treatment session is determined by patient age, degree of spasticity, 
number of injections made into each muscle and number of muscles treated. Documentation of the medical 
necessity for Botox injections for spastic conditions other than upper limb spasticity, blepharospasm, 
hemifacial spasm, cervical dystonia or other focal dystonias, should include a statement that the spastic 
condition has been unresponsive to conventional treatment; a covered diagnosis; dosage(s), site(s) and 
frequency(ies) of injection(s). 
 
In this case, the enrollee does not meet LCD criteria for the requested Botox. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve coverage for special supplemental benefits. 
 
You asked the Plan to pre-approve coverage for the special supplemental benefits. You say that you feel that 
you have a condition for which this should be covered. The Plan denied your request. The Plan says your 
doctor has not diagnosed you with any of the eligible chronic conditions. 
 
The Plan must follow Medicare rules. Medicare rules say that MA plans may offer additional special 
supplemental benefits for the chronically ill. Your contract describes this benefit and provides a list of the 
covered chronic conditions. 
 
In this case, a signed document from your physician indicates that you do not have any of the eligible chronic 
conditions required to access these benefits. Therefore, we decided that the Plan does not have to pre-approve 
coverage for special supplemental benefits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vyzulta 0.024%. 
 
You asked the Plan to pre-approve Vyzulta. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Vyzulta 0.024%.  
 
Benefits for Vyzulta 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ubrelvy. 
 
You asked the Plan to pre-approve Ubrelvy. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ubrelvy.  
 
Benefits for Ubrelvy 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 Dexcom G6 Continuous Glucose Monitor (CGM) 
sensors. 
 
You asked the Plan to pre-approve Dexcom G6 Continuous Glucose Monitor (CGM) sensors. You say that the 
item is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage 
criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that CGM devices are covered when specific criteria is 
met. 
 
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 Dexcom G6 Continuous Glucose 
Monitor (CGM) sensors. Our reviewer says that the item is not medically necessary. Our physician reviewer 
found you are not taking insulin and hence do not meet the criteria. Furthermore, Dexcom is not approved for 
use in enrollees with end-stage renal disease (ESRD) and HD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Dexcom G6 Continuous Glucose Monitor (CGM) sensors have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Dexcom G6 Continuous Glucose Monitor 
(CGM) sensors.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for electrocardiogram, complete (93000) 
provided June 15, 2020. 
 
You asked the Plan to waive the copayment for the diagnostic services. You say that the plan share of 80% was 
not paid by the plan to your provider. The Plan denied your request. The Plan says the claim was processed 
with the correct copayment applied.  
 
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 
copayment for non-radiological diagnostic services. 
 
You have been asked to pay $30 copayment for the diagnostic services. Because the plan allowed less than the 
$30 copay, you are responsible for $12.90 instead of $30. The diagnostic services fall within the Outpatient 
diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for electrocardiogram, complete (93000) provided June 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on July 24, 2020. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you were not aware that you would 
owe a copayment. The Plan denied your request. The Plan says the claims were processed correctly, and you 
are being charged the correct amount. 
 
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 $200 
copayment for CT scans.  
 
You have been asked to pay a $200 copayment for a CT scan. A CT scan falls within the outpatient diagnostic 
tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for a CT scan provided on July 24, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services provided on March 17, 2020. 
 
You asked the Plan to pay for moderate sedation services. You say that the Plan should pay this claim. The 
Plan denied your request. The Plan says the documentation submitted did not indicate the presence of 
independent trained observer to assist in the monitoring of the enrollee. 
 
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, the CPT Code Manual definition of code 99152 is Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older.  
 
We find that CPT code 99152 is not supported in the medical record. Specifically, there is no record of a 
trained observer. Based on this information, we decided that Medicare rules for coverage of moderate sedation 
services have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation 
services provided on March 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve carpal tunnel gloves. 
 
You asked the Plan to pre-approve the gloves. You say that this is medically necessary. The Plan denied your 
request. The Plan says these are not medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve carpal tunnel gloves.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the knee x-ray provided on June 10, 2020. 
 
You asked the Plan to waive the copayment for the knee x-ray. You say that your doctor's office was under 
staffed so you were send to the hospital for the x-ray and shouldn't have to pay. The Plan denied your request. 
The Plan says you were charged this copayment 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 $100 
copayment for outpatient diagnostic tests at an outpatient hospital.  
 
You have been asked to pay a $100 copayment for the knee x-ray. The knee x-ray falls within the outpatient 
diagnostic tests at an outpatient hospital 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 knee x-ray provided on June 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from May 23, 
2020, to May 29, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that the stay was due to 
COVID-19. The Plan denied your request. The Plan says the claims were processed correctly and you are being 
charged the correct amount. 
 
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 $290 
copayment for days 1-5 for inpatient hospital care.  
 
You had an inpatient hospital stay from May 23, 2020, to May 29, 2020. Inpatient hospital copayments are not 
included in the COVID-19 waiver. Therefore, you are responsible to pay a $290 copayment for days 1-5 (May 
23, 2020, to May 27, 2020). $290 (copayment) x 5 (inpatient days) = $1,450.  
 
You have been asked to pay the total copayment amount of $1,450 for an inpatient hospital stay. An inpatient 
hospital stay 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 inpatient hospital stay from May 23, 2020, 
to May 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve specialist services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve specialist services. You say that you would like approval to see this out-of-
network provider. The Plan denied your request. The Plan says there are in-network providers available for 
these services. 
 
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 
specialist services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on July 21, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that authorization is not needed in this case. The 
Plan denied your request. The Plan says unauthorized, non-plan 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 in this case is not a network provider with the Plan. The Plan did not pre-approve the service at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the medical services provided on July 21, 2020 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the life vest rendered from March 
10, 2020 to May 10, 2020. 
 
You asked the Plan to waive the coinsurance for these services. You say that you should not be responsible 
because the vest didn't work. The Plan denied your request. The Plan says the coinsurance was applied 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 in-network Medicare-covered durable medical equipment and related supplies.  
 
Review of the file shows that you received a life vest from March 10, 2020 to May 10, 2020. You have 
been asked to pay a 20% coinsurance for these services. These services fall within the in-network Medicare-
covered durable medical equipment and related supplies benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the coinsurance for the life vest rendered from March 10, 2020 to May 10, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services rendered on June 
22, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The 
Plan denied your request. The Plan says the copayment was applied 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 $30 
copayment for Medicare-covered lab services and diagnostic procedures/tests performed in an outpatient 
hospital facility.  
 
Review of the file shows that you received laboratory services on June 22, 2020. You have been asked to pay a 
$30 copayment for these services. These services fall within the Medicare-covered lab services and diagnostic 
procedures/tests performed in an outpatient hospital facility 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 laboratory services rendered on June 22, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Amitiza. 
 
You asked the Plan to pre-approve Amitiza. You say that the enrollee has done very well with Amitiza. The 
Plan denied your request. The Plan says Amitiza to be taken at home is not covered under the Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Amitiza.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) and a urine analysis (81002) on March 
9, 2020. 
 
You asked the Plan to pay for an office visit and a urine analysis. You say that an urgent care clinic or 
emergency room at a hospital was not close to where you were traveling. The Plan denied your request. The 
Plan says the provider of these services only employs nurse practitioners. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of an NP may be covered if they are 
performed in collaboration with a physician. 
 
We looked at the file and Medicare rules. There is no information or medical records to show that the providing 
NP is working in collaboration with a physician. Based on this information, we decided that Medicare rules for 
coverage of an office visit and a urine analysis have not been met. Therefore, we decided that the Plan does not 
have to pay for an office visit (99214) and a urine analysis (81002) on March 9, 2020.  
 
Your complaint about receiving erroneous or misleading information about your benefit from a representative 
of the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be 
answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5213) and a partial lower 
denture (D5214). 
 
You asked the Plan to pre-approve the dental items. You say that the enrollee originally received dentures in 
March 2020. You say that they do not fit. You say that the enrollee cannot eat. You also say that the enrollee 
have been going through this process for a month without making any process. The Plan denied your request. 
The Plan says dentures are covered once every 5 plan years. The Plan says that it does not matter what code is 
being used as long as it is for the same tooth. The Plan also says that the frequency limit for dentures has been 
reached. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the frequency limit for dentures has 
been reached. The record shows that the Plan paid for partial dentures that the enrollee received on March 26, 
2019. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5213) and a 
partial lower denture (D5214).