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

 
We decided that the Plan does not have to pay for the refraction services (92015) provided January 31, 2022 
 
 
 You asked the Plan to pay for the vision services. You say that the refraction was for your macular 
degeneration and needs to be done annually. You do not understand why the refraction is not covered and feel 
that the denial should be overturned. The Plan denied your request. The Plan says this service is not covered 
under the Plan benefits. 
 
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 these services when the Plan covers outpatient physician services for the diagnosis 
and treatment of diseases and injuries of the eye, including treatment for age related macular degeneration. 
 
We looked at the file and the Plan's rules. Refraction is not covered under the Plan benefits. Based on this 
information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, 
we decided that the Plan does not have to pay for the refraction services (92015) provided January 31, 2022
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter repair (K0733, K0108, E2388, E2394, 
K0739). 
 
You asked the Plan to pre-approve a power scooter repair. You say that you need this equipment for your day-
to-day life. You also say that you have had the current scooter for three years and it will not be possible to 
obtain a new one covered by the Plan. The Plan denied your request. The Plan says that repairs are not covered 
when the expense for repairs exceeds the estimated expense for replacement of the scooter/wheelchair. 
 
The Plan follows Medicare rules.  Medicare rules say that repairs that are more expensive than replacing the 
durable medical equipment are not covered. 
 
The file shows that the repair cost is greater than the cost to replace the scooter. This means that Medicare rules 
for coverage of a power scooter repair have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a power scooter repair (K0733, K0108, E2388, E2394, K0739).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Lite Test Strips (CPT code A4253). 
 
You asked the Plan to pre-approve the test strips. You say that the strips are necessary. The Plan denied your 
request. The Plan says they do not have a documented medical reason why you cannot use Lifescan testing 
supplies. 
 
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 test strips. Our physician reviewer 
found there is no data provided why you need freestyle brand and cannot use the one touch brand. 
 
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 test strips have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Freestyle Lite Test Strips (CPT code A4253).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Telehealth visit provided on January 20, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Telehealth visit. You say that you would like to appeal the denial of the claim 
and that you would like to have this service covered. The Plan denied your request. The Plan says we need an 
approved referral from the primary care 
physician. 
 
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 Telehealth visit provided on January 20, 2022 by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the next generation sequence testing panel provided on May 
26, 2021. 
 
You asked the Plan to pay for the next generation sequence testing panel. You say that you would like the plan 
to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that panels that include the FANCC gene are non-
covered.  
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. Review of the file shows that the next generation sequence testing 
panel provided included testing for the FANCC gene. This means the entire panel is not covered. Based on this 
information, we decided that Medicare rules for coverage of the next generation sequence testing panel have 
not been met. Therefore, we decided that the Plan does not have to pay for the next generation sequence testing 
panel provided on May 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve an ILR. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
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 an ILR. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documentation provided to suggest a history of unexplained syncope, cryptogenic 
stroke or any other apparent indication for an ILR. In summary, there is insufficient documentation to support 
the medical necessity for insertion of an ILR in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an implantable loop recorder (ILR).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
February 10, 2022. 
 
You asked the Plan to pay for dental services. You say that you believe the Plan should pay for this. The Plan 
denied your request. The Plan says this claim has been processed according to the out-of-network benefits 
listed. 
 
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. 
 
We looked at the file and Medicare rules. The rendering dentist is out-of-network. Based on this information, 
we decided that the Plan's rules for coverage of dental services have been met and processed according to the 
out-of-network benefits rule. Therefore, we decided that the Plan does not have to pay for dental services 
provided by an out-of-network provider on February 10, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Daliresp 500MG oral tablet. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says Daliresp oral tablet is a self-administered drug and does not fall under Part B 
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 Daliresp 500MG oral tablet.  Benefits for the medication 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraspinal chiropractic manipulative treatment (98943) 
provided on April 27, 2021, and May 4, 2021. 
 
You asked the Plan to pay for the extraspinal chiropractic manipulative treatment (98943). You say that the 
claims should be processed to allow payment. The Plan denied your request. The Plan says CPT codes 98941 
and 97012 have been paid. The Plan also says CPT 98943 remains denied as a non-covered service. 
 
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 CPT code 98943 is not manual manipulation of the spine. Therefore, we decided that the 
Plan does not have to pay for the extraspinal chiropractic manipulative treatment (98943) provided on April 27, 
2021, and May 4, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) stay provided from January 
1, 2022, to January 5, 2022. 
 
You asked the Plan to pay for the SNF stay. You say that you were not given an adequate amount of time to 
make a transfer for the enrollee. You also say that in it being a holiday weekend there was not much you could 
do. The Plan denied your request. The Plan says the enrollee did not receive skilled services on the dates of 
service in this case. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the SNF stay have not been met. Specifically, we find that the services at issue in this case are 
considered custodial in nature. Therefore, we decided that the Plan does not have to pay for the skilled nursing 
facility (SNF) stay provided from January 1, 2022, to January 5, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for Nivolumab and related services provided on January 18, 2022. 
 
You asked the Plan to pay for Nivolumab and related services. You say that this drug is on-label for the 
patient's diagnosis, and you had an authorization for this drug. The Plan denied your request. The Plan says that 
this service requires pre-certification and it was not obtained. The Plan also says that some of these services 
were performed in connection with an excluded service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan's denial rationale fails to address any of the issues raised in 
the appeal request.  You provided an authorization number in your appeal, claiming that this drug was 
authorized for the patient.  The Plan has failed to dispute this.  You also provided evidence that this drug is on-
label for the patient's diagnosis.  The Plan has failed to dispute this either. The burden is on the Plan to prove 
that its denial was appropriate.  The Plan's has failed to address any of the arguments you raise in your appeal 
request.  Without documentation from the Plan regarding a response to these issues, we find that the Plan's 
denial cannot be supported. Therefore, we decided that the Plan has to pay for Nivolumab and related services 
provided on January 18, 2022.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for laboratory services provided to the 
enrollee from August 17, 2021 to January 19, 2022. 
 
You asked the Plan to waive the copayments for the services. You say that you have not had to pay this much 
in previous years. The Plan denied your request. The Plan says the claim processed appropriately. 
 
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 $450 deductible which applies to covered medical services, including 
laboratory services.  
 
The item or service you asked the Plan to waive the copayments for falls within the benefit category covered 
medical services, including laboratory services. The Plan has followed Medicare rules by clearly disclosing in 
the contract that there is the $450 deductible which applies to covered medical services, including laboratory 
services. This cost sharing is a contractual obligation that had not been met at the time the services was 
received on August 17, 2021 to January 19, 2022. Therefore, we decided that the Plan does not have to waive 
the copayments for laboratory services provided to the enrollee from August 17, 2021 to January 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary services provided on January 4, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for domiciliary services. You say that that it isn't your responsibility to obtain prior 
authorization. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 domiciliary services provided on January 4, 2022 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 28, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that your services were medically necessary in 
providing a diagnosis for the enrollee's referring provider and you would like the claim charged as in-network 
benefits. 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 laboratory services provided on September 28, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services provided from October 25, 2021, to 
December 20, 2021. 
 
You asked the Plan to pay for the acupuncture services. You say that acupuncture is a covered benefit for your 
condition. The Plan denied your request. The Plan says the provider of service is not supervised by any 
physician, Physician's Assistant (PA), or Nurse Practitioner/Clinical Nurse Specialist (NP/CNS), so they are 
not a valid provider for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that eligible providers are physicians or physician 
assistants, nurse practitioners, clinical nurse specialists, or auxiliary personnel, as long as they meet applicable 
state requirements and have a masters or doctoral degree in acupuncture or Oriental Medicine; and a current, 
full, active, and unrestricted license to practice acupuncture.  Auxiliary personnel furnishing acupuncture must 
be under the appropriate level of supervision of a physician, PA, or NP/CNS. 
 
We looked at the file and Medicare rules. We confirmed via an internet search that the provider is considered 
auxiliary personnel.  The provider does have a masters and doctor degree in acupuncture and Oriental 
Medicine, as well as an active license in the state of Oregon.  However, there is no evidence on the claims 
submitted that this provider is under the appropriate level of supervision by a required provider type in order to bill Medicare.  In order for this providers services to be covered, there would need to be evidence of this 
supervision either in the medical records or on the claims submitted.  This information is not present in either 
of these sets of information. Based on this information, we decided that Medicare rules for coverage of the 
acupuncture services have not been met. Therefore, we decided that the Plan does not have to pay for 
acupuncture services provided from October 25, 2021, to December 20, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia 60 MG/ML Syringe. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says to meet the enrollee's formulary's criteria to qualify for this drug, the enrollee must 
have tried an intravenous  bisphosphonate, which is a medication used to prevent brittle bones, for one (1) year 
and failed it, or have a clinical reason why the enrollee cannot take an intravenous bisphosphonate. 
 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 the medication. Our physician reviewer 
found the enrollee has not tried and failed the required drug(s). There is no documentation provided indicating 
that the plans required drug(s) would likely be less effective and/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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prolia 60 MG/ML Syringe.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on November 9, 
2021. 
 
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 the code cannot be verified. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 services Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found that 
although CTP 25270 is documented in the operative report, this procedure would be inclusive to CPT 22515. 
Modifier -59 would not be supported 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 the services have not been met.  Therefore, we decided that the Plan does not have to pay for surgical services provided to the enrollee on 
November 9, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a transcatheter ablation. 
 
You asked the Plan to pre-approve a transcatheter ablation. You say that the services are necessary. The Plan 
denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 transcatheter ablation. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case.  Our 
physician reviewer found recent randomized clinical studies have supported the role of catheter ablation for the 
treatment of symptomatic atrial fibrillation and atrial flutter as an acceptable first-line alternative to 
medications in the treatment of patients with these arrhythmias. Clinical guidelines have been modified to 
reflect the findings of these new studies. Therefore, electrophysiologic evaluation and catheter ablation would 
be considered medically appropriate and reasonable in this enrollees clinical management. 
 
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 transcatheter ablation have been met. Therefore, we decided that the Plan has 
to pre-approve a transcatheter ablation.  
 
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.