Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine eyewear (V2020, V2199). 
 
You asked the Plan to pre-approve additional routine eyewear. You say that the requested items are necessary. 
The Plan denied your request. The Plan says the covered benefit has been exhausted. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers a $300 credit towards your purchase of frames and a $0 copayment for standard 
lenses. The covered benefit excludes Deluxe, Premium or Platinum progressive lenses. 
 
We looked at the file and the Plan's rules. You have exceeded your benefit limit. Based on this information, we 
decided that the Plan's rules for coverage of additional routine eyewear have not been met. Therefore, we 
decided that the Plan does not have to pre-approve additional routine eyewear (V2020, V2199).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the PT visits. You say that the additional PT visits are medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the PT visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the specialized skill, knowledge and judgment of a qualified therapist 
is not required to establish, design and/or deliver a program to maintain the patient's current condition or to 
prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the PT visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional physical therapy (PT) visits.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided by you on April 1, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. 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 Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 1, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided by you on April 
1, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on 
February 22, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you feel you should not 
be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan 
denied your request. The Plan says you received ambulance services on the date of service at issue in this 
appeal. The Plan says the correct copayment has applied per your contract with the Plan. 
 
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 $265 
copayment for Ambulance services.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received ambulance 
services on February 22, 2020. You have been asked to pay a $265 copayment for the ambulance services. The 
ambulance services fall 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 the ambulance services provided on February 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an influenza virus vaccine provided on October 23, 2019. 
 
You asked the Plan to pay for the influenza virus vaccine. The Plan denied your request. The Plan says you 
must receive your care from a network provider. In most cases, care you receive from an out-of-network 
provider will not be covered. If you need medical care that Medicare requires our plan to cover and the 
providers in our network cannot provide this care, you can get this care from an out-of-network provider. You, 
or your PCP, must obtain authorization from the plan prior to seeking care. In this situation, you will pay the 
same as you would pay if you got the care from a network provider. 
 
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 did not pre-approve the 
services 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 an influenza virus vaccine provided on October 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglasses provided. 
 
You asked the Plan to pay for the eyeglasses. You say that you would like reconsideration because you 
cancelled the order for these glasses. The Plan denied your request. The Plan says the provider has rendered a 
service and are not obligated to reinstate the benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to $150 once per calendar year toward the purchase and fitting of eyeglasses. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the eyeglasses have not been met. Specifically, the record indicates that the Plan paid $150 towards 
 
 
your eyeglasses and therefore, this benefit is exhausted. Therefore, we decided that the Plan does not have to 
pay for eyeglasses provided.
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 (denosumab, J0897). You say that you want the enrollee treated with 
this drug. The Plan denied your request. The Plan says the enrollee has not first tried and had a contraindication 
or intolerance to Zoledronic Acid. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 (denosumab, J0897). Our 
reviewer says that the drug is not medically necessary. Our physician reviewer found Medicare rules also allow 
the Plan to use step therapy. The review has determined that The Plan requires a trial of drug, Zoledronic Acid 
before they will approve the requested drug.  In this case, the patient has not tried and failed the required drug. 
There is no documentation provided indicating that the Plan's required drug would likely be less effective 
and/or likely have adverse effects for the enrollee. The enrollee does not have a history of an osteoporosis-
related fracture. 
 
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 (denosumab, J0897) have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the physical medicine office visit and the 
Botox injection you received on April 8, 2020. 
 
You asked the Plan to waive the cost sharing for the specialist visit and the Botox injection. You say that you 
had this procedure in the past and were not charged cost sharing. The Plan denied your request. The Plan says 
you were charged these cost sharing amounts 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 a separate $20 copayment for the specialist office visit.  
 
You have been asked to pay 20% coinsurance for the Botox injection and a $20 copayment for the office visit. 
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 sharing for the physical medicine office visit and the Botox injection 
you received on April 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular nerve block (64640). 
 
You asked the Plan to pre-approve the genicular nerve block. You say that you would like reconsideration 
because this service is medically necessary. The Plan denied your request. The Plan says there is not enough 
information to determine the medical necessity of this service. 
 
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 genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the effectiveness of genicular nerve blocks, including genicular nerve radiofrequency 
ablation, to treat knee pain has not been established. Genicular nerve blocks are considered 
experimental/investigational in nature. 
 
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 genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the genicular nerve block (64640).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve rituximab (J9312, 96413, 96415). 
You asked the Plan to pre-approve rituximab. You say that this is the best option for the enrollee's symptoms. 
The Plan denied your request. The Plan says that the use of this drug is not supported. 
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 rituximab. Our reviewer says that this 
drug is medically reasonable and necessary. Our physician reviewer found the use of rituximab for rheumatoid 
arthritis is supported in a Medicare-approved compendium. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of rituximab have been met. Therefore, we decided that the Plan has to pre-
approve rituximab (J9312, 96413, 96415).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Jacuzzi hot tub (E1399). 
 
You asked the Plan to pre-approve a Jacuzzi hot tub. You say that this is medically necessary. The Plan denied 
your request. The Plan says the records do not support the need for this item. 
 
The Plan must follow Medicare rules. Medicare rules say that whirlpool bath equipment is covered if patient is 
homebound and has a (standard)condition for which the whirlpool bath can be expected to provide substantial 
therapeutic benefit justifying its cost. Where patient is not homebound but has such a condition, payment is 
restricted to the cost of providing the services elsewhere. 
 
We looked at the file and Medicare rules. The records do not show that you are homebound or that the Jacuzzi 
will provide a substantial therapeutic benefit. Based on this information, we decided that Medicare rules for 
coverage of a Jacuzzi hot tub have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Jacuzzi hot tub (E1399).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on January 9, 
2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says prior authorization was not obtained, as required under the plan's benefits. 
 
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 has network providers 
available who can provide 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 laboratory services provided to the enrollee on 
January 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the complete upper and lower denture. 
 
You asked the Plan to pre-approve the complete upper and lower denture. You say that you are unable to eat 
and need your dentures fixed. The Plan denied your request. The Plan says the service is only covered one time 
in a 60-month period. 
 
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, you also have a maximum benefit of 
one complete or partial denture every 5 years. You received a complete upper and lower denture on February 
28, 2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve the 
complete upper and lower denture.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve physical therapy. You say that the documentation supports medical 
necessity. The Plan denied your request. The Plan says services could be provided by an in-network provider. 
 
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 
physical therapy to be provided by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 3, 2019. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Therefore, we decided that the Plan does not have to pay 
for the laboratory services provided on December 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-covered chiropractor services provided on August 
28, 2019, and August 29, 2019. 
 
You asked the Plan to pay for the non-covered chiropractor services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says they were unable to make a 
determination within the allotted time frame. 
 
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 service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the non-covered chiropractor services provided on August 28, 2019, and 
August 29, 2019.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a transthoracic echocardiography. 
 
You asked the Plan to pre-approve a transthoracic echocardiography. You say that the requested transthoracic 
echocardiography is medically necessary. The Plan denied your request. The Plan says that the enrollee does 
not meet criteria for the requested transthoracic echocardiography. 
 
 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 transthoracic echocardiography. Our 
reviewer says that the requested transthoracic echocardiography is medically necessary. Our physician reviewer 
found the enrollee has a non-ischemic cardiomyopathy and an EF on July 2020 echo of 25-30%. She was 
wearing a LifeVest to prevent sudden cardiac death while being treated with guideline directed medical 
therapy. This was done to see if her EF would improve over 3-6 months and obviate the need for an 
implantable ICD. However, at approximately 6 months since diagnosis in Oct 2020, repeat echocardiogram 
showed no change in EF despite continued medical therapy. This would make an ICD implant indicated but the 
enrollee refused. Although she refused ICD, reassessment of LV function after a prolonged period of 
appropriate medical therapy is necessary and indicated for the management of LV dysfunction and CHF and 
recommended in AHA/ACC published guidelines. This also meets CMS indications criteria for 
echocardiography  (1)-done to assess a response to a therapeutic intervention-(namely guideline directed 
medical therapy) and is both medically necessary and indicated in this clinical situation. 
 
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 transthoracic echocardiography have been met. Therefore, we decided that the 
Plan has to pre-approve a transthoracic echocardiography.  
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided on April 14, 2020. 
 
You asked the Plan to pay for the chiropractic services. You say that you would like the plan to reconsider their 
decision. The Plan denied your request. The Plan says the claim has been processed correctly per the enrollee's 
plan benefits. 
 
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 that the enrollee must pay out-of-pocket before the 
plan will pay their share for the enrollee's covered medical services. 
 
The item or service you asked the Plan to pay for falls within the benefit category out-of-network chiropractic 
services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is a $750 deductible that the enrollee must pay out-of-pocket before the plan will pay their share for the 
enrollee's covered medical services. This cost sharing is a contractual obligation that had not been met at the 
time the chiropractic services was received on April 14, 2020.  
 
Therefore, we decided that the Plan does not have to pay for the chiropractic services provided on April 14, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for outpatient surgery services (45378, 82962, 
00811, J2704) provided on January 10, 2020. 
 
You asked the Plan to waive the cost sharing for outpatient surgery services. You say that this should be 
processed as in-network. The Plan denied your request. The Plan says this processed 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 $500 
deductible for services from both in-network and out-of-network providers and a 25% coinsurance for in-
network and out-of-network outpatient surgery services provided in an outpatient hospital. 
 
You have been asked to pay a $500 deductible and a $372.63 coinsurance ($1,490.53 remaining allowed 
amount x 25% = $372.63) for outpatient surgery services. 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 sharing 
for outpatient surgery services (45378, 82962, 00811, J2704) provided on January 10, 2020.