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

We decided that the Plan does not have to pay for a cardiovascular risk assessment panel provided to the 
enrollee on September 1, 2020. 
 
You asked the Plan to pay for the testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says Medicare denies coverage for all cardiovascular risk assessment testing/panels. 
 
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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there are no provider records available for review. Therefore, there is no evidence to support that the 
provided testing was medically necessary to diagnosis or treat the enrollee's condition(s). In general, panel 
testing which is inclusive of testing that is not related to a specific symptom or diagnosis, or for which there are 
no associated therapies, is not medically necessary or reasonable. The documentation does not support that the 
provided panel testing was medically necessary or reasonable. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for a cardiovascular risk assessment panel provided to the enrollee on September 1, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis. 
 
You asked the Plan to pre-approve the Eliquis. You say that it would be most beneficial for the enrollee to start 
taking Eliquis rather than going with an alternative medication. The appellant says that the enrollee has been on 
samples since he was diagnosed, and it has shown a great outcome. The Plan denied your request. The Plan 
says the enrollee's Medicare Advantage plan does not cover outpatient prescription drugs. The Plan says that 
the enrollee may have a separate commercial pharmacy benefit or Medicare Part D benefit managed by another 
carrier. 
 
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 Eliquis.  
 
Benefits for the Eliquis 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 waive the copayment for the fecal occult blood test provided on 
September 14, 2020. 
 
You asked the Plan to waive the copayment for the fecal occult blood test. You say that you should not have to 
pay a $10 copayment since your handbook states it is 100% covered. The Plan denied your request. The Plan 
says you have been charged the correct cost sharing 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 $10 
copayment per in-network provider per day for Medicare-covered laboratory services.  
 
You have been asked to pay a $10 copayment for the fecal occult blood test. The fecal occult blood test falls 
within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. The record 
shows you were charged code 88274 which is for an assay test for fecal blood. 
 
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 fecal occult blood test provided on September 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for preventative procedure equipment (D1999) provided on July 
23, 2020. 
 
You asked the Plan to pay for preventative procedure equipment. You say that the service should be covered. 
The Plan denied your request. The Plan says this not a covered service. 
 
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. Specifically, the service is not listed in the Plan's benefit chart. This 
means the service is not covered. Therefore, we decided that the Plan does not have to pay for preventative 
procedure equipment (D1999) provided on July 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care (99309) received on February 20, 2019. 
 
You asked the Plan to pay for nursing facility care. You say that you should not be penalized for delays in 
receipt of the enrollee's coverage information from the nursing facility. The Plan denied your request. The Plan 
says rules for payment have not been met. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for nursing facility care was not filed until September 2, 2020. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for nursing facility care (99309) received on February 20, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan Supartz to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve Hyalgan Supartz. You say that you are in pain. The Plan denied your 
request. The Plan says that there are network provider available. 
 
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 
Hyalgan Supartz 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 pre-approve medical services to be provided by a tertiary provider. 
 
You asked the Plan to pre-approve the requested provider. You say that you would like to continue to see the 
requested provider. The Plan denied your request. The Plan says the services can be provided by a community 
level specialist. 
 
Medicare rules say that plans can require enrollees to get care from network providers.  
 
The file shows that a follow up visit was requested at a tertiary level of care provider. The medical records do 
not indicate that the services you need require an advance level of care. The Plan has network providers 
available who can provide the services at a lower level of care. 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 
medical services to be provided by a tertiary provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services provided on October 8, 2020, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and 
paid. The Plan denied your request. The Plan says prior authorization was not obtained by the provider or the 
facility the services were rendered in. 
 
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 skilled nursing services provided on October 8, 
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 additional routine transportation trips. 
 
You asked the Plan to pre-approve routine transportation. You say that you need more rides for dialysis and 
appointments. The Plan denied your request. The Plan says the denial of authorization for additional routine 
transportation is correct, because routine transportation beyond 60 one-way trips per calendar year is not 
covered. 
 
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 Plan?s coverage rules apply in this 
case. The Plan covers a maximum of 60 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.  
 
Please note that this decision is regarding your routine transportation benefits for the 2020 calendar year. Please 
contact your health plan regarding your benefits for the 2021 calendar year.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lead wires provided on September 14 2020. 
 
You asked the Plan to pay for the lead wires. You say that code A4557 is separately reimbursable. The Plan 
denied your request. The Plan says a TENS unit has been purchased in the previous 12 months. 
 
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 CPT code A4557 is not supported in the medical record. The records show that a TENS device 
was provided within the last 12 months. In this case, there are insufficient medical records to show that 
replacement wires are were necessary for the enrollee. Based on this information, we decided that Medicare 
rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the lead 
wires provided on September 14 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH is the appropriate level of 
care, which will decrease the risks of readmission and promote health improvement. The Plan denied your 
request. The Plan says the guidelines for coverage of LTACH care have not been met. The Plan says that the 
enrollee needs to stay in the hospital until he is better. 
 
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 enrollee was hospitalized due to low oxygen levels and lung infection due to 
COVID-19 infection. He needed intubation and mechanical ventilatory support to be placed on a breathing 
machine on January 18, 2021. He currently requires ventilatory support with FiO2 at .75 (75%) and positive 
end expiratory pressure (PEEP) at 8. There is no documentation provided necessitating admission to a LTACH. 
The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require 
services at the LTACH that are not available at the acute care hospital where he is 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 long-term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skin seal protect moisturizer. 
 
You asked the Plan to pre-approve the moisturizer. You say that this is medically necessary. The Plan denied 
your request. The Plan says Medicare does not cover non-reusable disposable supplies for home use, such as 
bandages, gauze, tape, antiseptics, latex gloves or dressings. 
 
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 skin seal protect moisturizer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a prosthetic limb volume management system identified 
with code L5781. 
 
You asked the Plan to pre-approve a prosthetic limb volume management system. You say that you would like 
the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a prosthetic limb volume management system is only 
covered for certain indications. 
 
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 prosthetic limb volume management 
system. Our reviewer says that the documentation does not support that the requested item is medically 
reasonable or necessary. Our physician reviewer found the documentation supports that your current prosthesis 
is loose and the liner slips causing the prosthesis to fall off. The documentation does not reveal objective 
physical exam evidence of your residual limb from your treating medical practitioner with evidence of excess 
volume or skin breakdown or issues that indicate a need for this request. Therefore, you do not meet criteria for 
the requested item. 
 
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 prosthetic limb volume management system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a prosthetic limb volume management system identified 
with code L5781.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical assistant services provided on July 28, 2020. 
 
You asked the Plan to pay for the assistant services. You say that the procedure is payable to the assistant 
surgeon. The Plan denied your request. The Plan says the services denied correctly. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the surgical assistant services 
provided on July 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for optometry services provided. 
 
You asked the Plan to pay for the optometry services. You say that you should be refunded $59 for these 
services. The Plan denied your request. The Plan says the benefit was correctly applied. 
 
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. 
 
We looked at the file and the Plan's rules. The record shows you paid the allowed amount for an eye exam. You 
paid the $4 that exceeded the $380 contact lens benefit. The plan properly applied the allowance. Based on this 
information, we decided that the Plan's rules for coverage of the optometry services have not been met. 
Therefore, we decided that the Plan does not have to pay for optometry services provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on April 23, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you know you should have called to see who 
was approved but you were sick and needed to be seen. You say that you now have established with a doctor. 
The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 physician services provided on April 23, 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 endodontic therapy and core buildup for tooth 12. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
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 pre-approve 
endodontic therapy and core buildup for tooth 12.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services rendered on May 13, 
2020, and June 30, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that nothing was done during the 
services. 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 $40 
copayment for visits to specialists.  
 
Review of the file shows that you received specialist services on May 13, 2020, and June 30, 2020. You have 
been asked to pay a $40 copayment per date of service for these services, for a total of $80. These services fall 
within the visits to specialists 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 
specialist services rendered on May 13, 2020, and June 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the physician 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 provided were neither emergent 
nor urgent and prior authorization was not obtained to provide out-of-network care. 
 
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 the physician services provided by an out of 
network (OON) provider.