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

 
We decided that the Plan does not have to pre-approve PriMatrix per square centimeter (Q4110). 
 
You asked the Plan to pre-approve PriMatrix. You say that PriMatrix is medically necessary. The Plan 
denied your request. The Plan says PriMatrix is not medically necessary and does not meet the Plan's Medical 
Policy coverage criteria. 
 
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 PriMatrix. Our reviewer says that the 
requested PriMatrix is not considered medically reasonable and necessary. Our physician reviewer found that 
the documentation does not show that the enrollee has adequate perfusion of involved limb. Also, there is no 
documentation of a lack of response to conventional therapy such as optimal glycemic management and no 
documentation that the enrollee has no allergy to bovine products. 
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PriMatrix have not been met. Therefore, we decided that the Plan does not 
have to pre-approve PriMatrix per square centimeter (Q4110).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve rhinoplasty services. 
 
You asked the Plan to pre-approve the requested services. You say that you are not able to use the correct 
restroom. The Plan denied your request. The Plan says the services are not medically reasonable or necessary. 
 
 The Plan follows Medicare rules. Medicare rules say that reconstructive surgery is only covered under certain 
medical 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 the requested services. Our physician 
reviewer found that you have gender dysphoria. The record does not document the need for repair of accidental 
injury or for the improvement of the functioning of a malformed body member. The record does not document 
the presence of an enumerated condition for which coverage is available under the coverage criteria. The 
elements of the coverage criteria are not satisfied. Therefore, the requested service is not recommended. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve rhinoplasty services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Palonosetron. 
 
You asked the Plan to pre-approve Palonosetron. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested drug is not medically necessary. 
 
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 Palonosetron. Our reviewer says that 
the documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has a diagnosis of breast cancer who is receiving paclitaxel, pertuzumab and 
trastuzumab. Palonosetron is indicated for prophylaxis of nausea and vomiting related to moderately to highly 
emetogenic chemotherapy. Paclitaxel, pertuzumab and trastuzumab are classified in the Medicare-approved 
major drug compendia (Drugdex/Micromedex) as having minimal to low emetogenic potential. Therefore, the 
enrollee does not meet criteria for the requested drug. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Palonosetron have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Palonosetron.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided February 11, 2022, to March 
8, 2022. 
 
You asked the Plan to pay for the home health services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
 
 
 
 
 
 We find that the documentation does not support the billed home Health services. Specifically, a valid Notice 
of Admission was not submitted. Based on this information, we decided that Medicare rules for coverage of the 
home health services have not been met. Therefore, we decided that the Plan does not have to pay for home 
health services provided February 11, 2022, to March 8, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the medical records provided there is no documentation that the enrollee 
requires the services on an inpatient basis, only in a skilled nursing facility setting. Records do not document 
those services in the long-term care facility on a part time basis are not appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical boot or shoe (L3260). 
 
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this item does not meet Medicare criteria for coverage. 
 
Medicare rules state that supportive devices for the feet (such as a surgical  boot or shoe) are only covered for 
patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
The records in this case show that you do not meet Medicare criteria for coverage of the requested orthopedic 
footwear. Specifically, this orthopedic footwear is only covered when it is an integral part of a covered brace 
and medically necessary for the proper functioning of that brace.  Additionally, this type of orthopedic footwear requested in this case is denied by Medicare as non-covered. 
Therefore, we decided that the Plan does not have to pre-approve a surgical boot or shoe (L3260).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient visit and debridement services provided on 
April 21, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient visit and debridement services. You say that you were unaware 
that a separate contract was involved. You say you have since applied to be credentialed and feel that this visit 
should be paid. The Plan denied your request. The Plan says no prior authorization was 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 did not pre-approve the 
outpatient visit and the debridement services. We found no exception that would require the Plan to pay for the 
outpatient visit and debridement services. The records provided for review do not show that the services at 
issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for the outpatient visit 
and debridement services provided on April 21, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient stay provided from January 5, 
2022, to January 18, 2022. 
 
You asked the Plan to waive the copayment for an inpatient stay. You say that you disagree with this 
copayment amount. The Plan denied your request. The Plan says the copayment that was applied was correct. 
 
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 days 1 to 
8 is a $235 copayment per day for inpatient hospital care ($235 x 8 days= $1880)..  
 
You have been asked to pay a $1880 copayment for an inpatient stay. An inpatient 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 stay provided from January 5, 
2022, to January 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 15, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you could not get a referral from your primary care 
physician. The Plan denied your request. The Plan says the rendering provider is an OON provider and there 
was no referral from an in-network provider or an approved authorization. Also, the service rendered was not 
urgent or emergent. 
 
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 an office visit provided on June 15, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit on March 15, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing you are being charged is correct. 
 
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 $45 
copayment for each Medicare-covered specialist visit. Covered services include consultation, diagnosis, and 
treatment by a specialist. 
 
You have been asked to pay a $45 copayment for office visit. Office visits fall within the Physician/Practitioner 
services, including doctor's office visits 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 office visit on March 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient stay provided from November 
24, 2021, to November 27, 2021. 
 
You asked the Plan to waive the copayment for an inpatient stay. You say that you only had to be hospitalized 
due to a complication from a procedure you had. The Plan denied your request. The Plan says the copayment 
that was applied was correct. 
 
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 $300 
copayment per day for days 1 to 6 for inpatient hospital care.  
 
You have been asked to pay a $900 copayment for three days of an inpatient stay ($300 x 3 = $900). An 
inpatient 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 stay provided from November 24, 2021, to November 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repatha Sureclick. 
 
You asked the Plan to pre-approve Repatha Sureclick. You say that the services are 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 Repatha Sureclick.  
 
Benefits for Repatha Sureclick 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 FreeStyle Libre 2 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve FreeStyle Libre 2 CGM. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested device. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
FreeStyle Libre 2 CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve 
FreeStyle Libre 2 continuous glucose monitor (CGM).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an office visit and x-rays provided on 
April 15, 2022. 
 
You asked the Plan to waive the copayments for an office visit and x-rays. You say that you do not understand 
why you are responsible to pay copayments for follow-up visits, as they are short and not much is done during 
that time. The Plan denied your request. The Plan says the copayments applied are correct. 
 
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 $15 
copayment for each Medicare-covered standard x-ray service and a $30 copayment for services obtained from a 
specialist, or under certain circumstances, treatment by a nurse practitioner or physicians assistant or other 
non-physician health care professionals in a specialists office.  You have been asked to pay $60 for an office visit and two x-rays ($30 copayment for office visit + $15 
copayment per x-ray = $60). An office visit falls within the Physician/Practitioner Services, Including Doctors 
Office Visits, benefit category. X-rays 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 copayments for an office visit and x-rays 
provided on April 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services provided on May 18, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the pathology services. You say that the referring provider sent the specimen to 
your laboratory to process, and you would like the claim paid. The Plan denied your request. The Plan says the 
rendering and referring providers are both OON providers and there was no approved authorization. Also, the 
service rendered was not urgent or emergent. 
 
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 pathology services provided on May 18, 2022, 
by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a duplex scan (ultrasound) of extracranial 
arteries provided on February 10, 2022. 
 
You asked the Plan to reduce the copayment for the ultrasound. You say that your copayment should only be 
$35. 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 $185 
copayment for radiological diagnostic services, such as ultrasounds.  
 
You have been asked to pay a $185 copayment for the ultrasound. The ultrasound 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 reduce 
the copayment for a duplex scan (ultrasound) of extracranial arteries provided on February 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive or reduce the copayment for a back injection performed on 
April 13, 2022. 
 
You asked the Plan to waive or reduce the copayment for the injection. You say that you do not know why you 
are paying a majority of the bill. 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 $255 
copayment for surgical services at an ambulatory surgical center.  
 
You have been asked to pay a $255 copayment for the injection. The injection falls within the Outpatient 
Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 or reduce the copayment for a back injection performed on April 
13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids, digital, binaural, behind the ear (V5261) 
provided April 13, 2022. 
 
You asked the Plan to pay for the hearing aids. You say that you were not aware you needed to purchase 
hearing aids through the Plan's hearing provider. The Plan denied your request. The Plan says the hearing aids 
were purchased from a provider who is not part of the Plans hearing aid vendors network. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased through the Plans hearing aid vendor. 
 
We looked at the file and the Plan's rules. In this case the hearing aids were not purchased through the Plans 
hearing aid vendor. Based on this information, we decided that the Plan's rules for coverage of the hearing aids 
have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids, digital, 
binaural, behind the ear (V5261) provided April 13, 2022.