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

 
We decided that the Plan does not have to waive the deductible for echocardiography provided on August 17, 
2020. 
 
You asked the Plan to waive the deductible for echocardiography. You say that you disagree with the charges 
because you feel that you should only 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. Your 
contract with the Plan says that there is a $750 deductible for outpatient diagnostic tests and therapeutic 
services and supplies.  
 
You received echocardiography on August 17, 2020. The record shows that you had only paid $97.60 toward 
the $750 deductible. Therefore, you are responsible to pay the total allowed amount of $437.72.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient 
diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $750 deductible for outpatient diagnostic tests and therapeutic services 
and supplies. This cost sharing is a contractual obligation that had not been met at the time echocardiography 
was received on August 17, 2020. Therefore, we decided that the Plan does not have to waive the deductible 
for echocardiography provided on August 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the established patient assisted living visit and annual 
wellness visit (99336, G0439) provided on May 28, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the established patient assisted living visit and annual wellness visit. You say 
that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan 
says prior authorization was not obtained by the facility or the provider; therefore, payment has been correctly 
denied. 
 
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 the established patient assisted living visit and 
annual wellness visit (99336, G0439) provided on May 28, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture. 
 
You asked the Plan to pre-approve the maxillary partial denture. You say that the provider glued your last 
denture back together and that it broke again. You say that it was the provider's responsibility to make and 
repair the dentures properly, and that he did not. You say that you want new dentures and for them to be done 
right this time. The Plan denied your request. The Plan says the benefit for dentures is currently exhausted. 
 
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 coverage for dentures is limited to 
once every 5 years. The records show that the Plan paid for dentures provided on May 13, 2019. This means 
that your request for coverage of dentures would exceed the benefit allowance. Therefore, we decided that the 
Plan does not have to pre-approve a maxillary partial denture.  
 
Our decision is in regards to the request for authorization of dentures. Your complaint regarding the care you 
received from the dentist who previously provided and repaired your dentures is considered a grievance and 
must be addressed by the Plan separately. Medicare does not permit us to make decisions about these types of 
complaints.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a 
participating provider on May 12, 2020. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you were told to go here 
from your doctor to have some tests run. The Plan denied your request. The Plan says the correct copayment 
has been 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 a $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for an emergency room visit. The correct copayment has been 
applied to the services that were provided. An emergency room visit falls within the emergency 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 emergency room visit provided by a 
participating provider on May 12, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio. 
 
You asked the Plan to pre-approve Entyvio. The Plan denied your request. The Plan says the enrollee has not 
had prior therapy, or cannot use Remicade or Inflectra; and Stelara. 
 
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 Entyvio. Our physician reviewer found 
that the enrollee has a history of Crohn's disease. The Plan requires a trial of Remicade or Inflectra; and Stelara 
before they will approve the requested drug. In this case, the enrollee has not tried and failed the required 
drugs. There is no documentation provided indicating that the Plan?s required drugs would likely be less 
effective, or likely have adverse effects for the enrollee. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Entyvio.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hydroxyzine HCL for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
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 Hydroxyzine HCL for the 
enrollee.  
 
Benefits for this drug 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 Otezla. 
 
You asked the Plan to pre-approve Otezla. The Plan denied your request. The Plan says this drug is not covered 
for the enrollee's condition by Medicare Part B. 
 
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 Otezla.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital bed (E0301) provided on March 31, 2020, by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the hospital bed. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained by the 
facility or the provider; therefore, payment has been correctly denied. 
 
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 the hospital bed (E0301) provided on March 31, 
2020, by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 25, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained by the 
facility or the provider; therefore, payment has been correctly denied. 
 
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 the laboratory services provided on February 25, 
2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary and mandibular denture 
 
You asked the Plan to pre-approve the denture. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
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. The Plan covers dentures once 
every five years. 
 
Dentures were last received on July 10, 2019. Based on this information, we decided that the Plan's rules for 
coverage of the denture have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
complete maxillary and mandibular denture
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation (D9310) on May 14, 2020. 
 
You asked the Plan to pay for the consultation (D9310). You say that they did a necessary assessment. You say 
that this visit was a referral for an exam, not a consult. The Plan denied your request. The Plan says the service 
is not a covered benefit. 
 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
consultation (D9310) on May 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ultra-lightweight manual wheelchair with accessories 
(K0005, E0973, K0108, E0978, E0971, E2601). 
 
You asked the Plan to pre-approve the wheelchair. You say that the new wheelchair is medically necessary. 
The Plan denied your request. The Plan says the record shows you have a power scooter that is less than 5 
years old. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee has a power scooter. a power scooter serves the same purpose as the 
wheelchair. Therefore, we decided that the Plan does not have to pre-approve a ultra-lightweight manual 
wheelchair with accessories (K0005, E0973, K0108, E0978, E0971, E2601).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a neurostimulator (L8679). 
 
You asked the Plan to pre-approve a neurostimulator. You say that the nerve stimulator is medically necessary. 
The Plan denied your request. The Plan says the nerve stimulator is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that auricular nerve stimulators are not covered.  
 
We looked at the file and Medicare rules. The requested device is considered an electro-acupuncture device and 
is non-covered. Based on this information, we decided that Medicare rules for coverage of a neurostimulator 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a neurostimulator 
(L8679).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine chiropractic services. 
 
You asked the Plan to pre-approve routine chiropractic services. You say that you would like reconsideration 
because these services are medically necessary to treat your condition. The Plan denied your request. The Plan 
says you have reached your benefit limit for non-manipulative chiropractic treatment. 
 
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 Plan rules say that up to 6 supplemental routine 
chiropractic visits are covered every year. 
 
The records show that the service at issue is not manual manipulation of the spine. The records also show that 
you have exhausted this benefit. Therefore, we decided that the Plan does not have to pre-approve routine 
chiropractic services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Myrbetriq tablets. 
 
You asked the Plan to pre-approve Myrbetriq. You say that this is necessary because the enrollee has failed 
other treatments. The Plan denied your request. The Plan says coverage of this medication is the responsibility 
of the enrollee's prescription drug 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 pre-approve Myrbetriq tablets.  
 
Benefits for Myrbetriq 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for screening laboratory tests provided on January 25, 2020. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with records. The Plan denied your 
request. The Plan says the denial of payment for these services is correct, because these tests are not covered 
for screening purposes. The Plan also says that they approved payment for some of the tests billed on this 
claim, so the denial is only for testing codes 84270, 84402, and 84403. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The tests at issue in this appeal, lab tests, were requested for screening purposes. Medicare does not cover these 
tests for screening purposes. Therefore, we decided that the Plan does not have to pay for screening laboratory 
tests provided on January 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the requested services. You say that you cannot travel to where the services 
are approved. The Plan denied your request. The Plan says the service requested is available within the plan 
network. 
 
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 for transplant services. The Plan has 
network providers available who can provide the services at issue in this appeal. We found no exception that 
would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-
approve the medical services to be provided by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay fornursing facility care provided on January 8, 2020.You asked the Plan to pay fornursing facility care. You say that the provider cannot deny any medical services that are essential for health treatment. You say that the claim should be reprocessed for payment.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 fornursing facility care provided on January 8, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for myocardial perfusion imaging provided on 
June 26, 2019. 
 
You asked the Plan to waive the copayments for myocardial perfusion imaging. You say that you disagree with 
the charges because you were misdiagnosed and had a heart attack. 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 $225 
copayment for nuclear medicine services provided in an outpatient hospital facility.  
 
You have been asked to pay a $225 copayment for myocardial perfusion imaging. Myocardial perfusion 
imaging 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 copayments for myocardial perfusion imaging provided on June 26, 2019.  
 
We note your complaint that you were misdiagnosed. Your complaint is a grievance that must be answered by 
the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 6, 2020. 
 
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 a physician order is not required to be signed, 
however, the physician must clearly document, in the medical record, his or her intent that the test be 
performed. 
 
We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the 
medical record. We find that the issue of intent is not clear. There are no medical records in the case file in 
regards to the physicians intent that the test be performed prior to services taking place. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on January 6, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hydroxychloroquine Sulfate 200MG tablets. 
 
You asked the Plan to pre-approve Hydroxychloroquine Sulfate 200MG tablets. You say that the medication is 
necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D 
benefit or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the 
criteria for coverage. 
 
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 Hydroxychloroquine 
Sulfate 200MG tablets.  
 
Benefits for Hydroxychloroquine Sulfate 200MG tablets may be available under Medicare Part D. Contact the 
Plan that administers Part D benefits for further information concerning any benefits and appeal rights.