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

 
We decided that the Plan has to pay for the lipid panel testing provided on October 26, 2022. 
 
You asked the Plan to pay for the testing services. You say that the test was done and paid in 2020, and 2021. 
The Plan denied your request. The Plan says that the test is covered once every five years. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the testing services by a contract provider. The file does not show that the Plan provided 
notice that the testing services would not be covered. Under Medicare rules, this means the testing services are 
considered approved by the Plan. Therefore, we decided that the Plan has to pay for the lipid panel testing 
provided on October 26, 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Avsola. 
 
You asked the Plan to pre-approve Avsola. You say that the enrollee did well on Remicade therapy. The Plan 
denied your request. The Plan says the enrollee has not tried the preferred drug. 
 
 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 Avsola. Our physician reviewer found 
that the enrollee has ulcerative colitis. The Plan requires a trial of Stelara before they will approve the requested 
drug. In this case, the enrollee has not tried and failed the required drug. There is no documentation provided 
indicating that the Plans 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 Avsola have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Avsola.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for CT scan provided on June 01, 2021. 
 
You asked the Plan to waive the copayment for CT scan. You say that you should not have to pay this claim 
because the doctor only read the results. The Plan denied your request. The Plan says this cost sharing was 
charged 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 $50 
copayment for Outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $50 copayment for CT scan. This item/service 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 
copayment for CT scan provided on June 01, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the over-the-counter drug allowance carry-over. 
 
You asked the Plan to pre-approve OTC allowance carry-over. You say that you were not sent a catalog before 
the end of the year, and you do not have access to a computer to order online. You say you want your unused 
$100 allowance to carry over to use in 2023. The Plan denied your request. The Plan says the service is not a 
covered benefit. 
 
Medicare generally does not cover OTC services. However, the Plan offers an OTC benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers an OTC benefit in excess of Medicare coverage, the OTC drug allowance is not among 
those covered under this benefit. Specifically, quarterly allowances cannot be carried over to another quarter. 
Therefore, we decided that the Plan does not have to pre-approve the OTC drug allowance carry-over.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar 
spine. 
 
You asked the Plan to pre-approve the MRI. You say that it is medically necessary for the enrollee to have the 
test completed. The Plan denied your request. The Plan says the enrollee has not tried conservative treatment 
for their back pain. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 the MRI. Our reviewer says that the 
MRI of the lumbar spine is not medically necessary. Our physician reviewer found that the enrollee was being 
treated for low back pain. The enrollee presented with an exacerbation of knee pain for more than 4 weeks. The 
exam reveals the left knee has a slight varus deformity. There is tenderness to palpation to medial joint line. 
There is patellofemoral crepitus. The enrollee was provided with a left knee steroid injection. 
 
  However, detailed documentation is not evident regarding a trial and failure of recent, reasonable, 
comprehensive less invasive conservative care measures for the lumbar spine. Moreover, there are no lumbar 
spine findings noted on the examinations provided for review. There is no clear documentation of a previous 
lumbar spine x-ray having been performed and results being non-diagnostic. There are limited large-scale, 
long-term references showing the medical necessity of the requested imaging study in this clinical setting. 
There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you will be discharged home and will not be able to 
receive wound care or perform activities of daily living resulting in declining health. The Plan denied your 
request. The Plan says based on Medicare guidelines, the IRF services you are requesting do not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 
 Our physician reviewer found the clinical documentation does not specify any complex functional impairments 
or active medical issues The complexity of your documented nursing, medical and rehabilitation needs would 
not be expected to require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 
care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the neurology office visit and the Botox 
injection provided on October 5, 2022. 
 
You asked the Plan to waive the copayment for the office visit and the injection. You say that you thought 
these services were covered. The Plan denied your request. The Plan says this cost sharing was charged 
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 $35 
copayment for each Medicare-covered specialist visit, and a 20% coinsurance for chemotherapy drugs and 
other Medicare-covered Part B drugs. 
 
 
 You have been asked to pay a $35 copayment for the office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits benefit category. You have also been asked to 
pay a cost-share of $498.32 for the injection ($2491.60 allowed amount x .20 = $498.32). This item/service 
falls within the Medicare Part B prescription drugs benefit category. You have been asked to pay a total cost-
share of $533.32 for the office visit and the injection. 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 neurology office visit and the Botox injection provided on October 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit - 30-39 minutes (99233) provided on February 
19, 2022. 
 
You asked the Plan to pay for an office visit - 30-39 minutes (99233). You say that the hospital inpatient 
department visit was reasonable and necessary for the treatment of this condition, and the code accurately 
reflects the treatment and documentation provided. The Plan denied your request. The Plan says the documents 
do not support the services billed. 
 
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 an office visit - 30-39 minutes (99233). Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the provided documentation did not sufficiently describe the patient with a 
complex high risk clinical scenario to justify the code, 99233. Our physician reviewer also found that a level 2 
hospital subsequent care (follow up) note (99232) would be more appropriate based on the provided 
documentation. 
 
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 office visit - 30-39 minutes (99233) have not been met. Therefore, we 
decided that the Plan does not have to pay for an office visit - 30-39 minutes (99233) provided on February 19, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropratic care visit provided on September 09, 2022, to 
September 16, 2022. 
 
You asked the Plan to pay for chiropratic care visit. You say that the records attached support the services 
provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for chiropratic care visit 
provided on September 09, 2022, to September 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient hospital clinic visit, and the 
joint injection provided on August 23, 2022. 
 
You asked the Plan to waive the copayment for the outpatient hospital clinic visit and the joint injection. You 
say that you would like the cost sharing to be lower. The Plan denied your request. The Plan says this cost 
sharing was charged 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 $450 
copayment per visit to an outpatient hospital facility. 
 
You have been asked to pay a $450 copayment for the outpatient hospital clinic visit and the joint injection. 
These items/services fall within the outpatient hospital services benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for the outpatient hospital clinic visit, and the joint injection provided on August 23, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5211). 
 
You asked the Plan to pre-approve the dental service. You say that you are appealing the denied dental service. 
The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the 
upper partial denture is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
partial upper denture (D5211).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology testing procedure provided on September 14, 
2022. 
 
You asked the Plan to pay for pathology testing procedure. You say that these services were medically 
necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for pathology testing 
procedure provided on September 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam CT scan (D0364) provided on October 26, 
2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, 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 a cone 
beam CT scan (D0364) provided on October 26, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided from June 13, 2022, to June 
14, 2022. 
 
You asked the Plan to pay for self-administered drugs. You say that you were admitted to the hospital, 
therefore, you believe you should be covered. The Plan denied your request. The Plan says self-administered 
medication 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 pay for self-administered drugs provided 
from June 13, 2022, to June 14, 2022.  
 Benefits for self-administered drugs 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for complete denture - maxillary (D5110), and complete denture 
- mandibular (D5120) provided on September 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you lost your previous dentures. You also say 
that the Plan did not tell you dentures were covered only once every five years. The Plan denied your request. 
The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service August 12, 2021. Therefore, we decided that the Plan does not have to pay for complete denture - maxillary (D5110), and 
complete denture - mandibular (D5120) provided on September 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hearing aids to be rendered by the out-of-network 
provider. 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says there are in-network providers available to render the 
requested items. 
 
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 from the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plan provides coverage for hearing aids only when 
purchased from the Plans select hearing aid provider. Your request in this case is for hearing aids to be 
purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve 
hearing aids to be rendered by the out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for x-ray services provided on October 25, 
2022. 
 
You asked the Plan to waive the copayment for x-ray services. You say that you disagree with the copaymet. 
The Plan denied your request. The Plan says this cost sharing was charged 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 outpatient diagnostic tests/Medicare-covered x-ray and  ultrasound. 
 
You have been asked to pay a $40 copayment for x-ray services. This item/service falls within the outpatient 
diagnostic tests/Medicare-covered x-ray and  ultrasound 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 x-ray services provided on October 25, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient hospital stay provided on July 20, 2022, to July 
26, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an inpatient hospital stay. You say that you do not remember being told you 
needed to transfer. The Plan denied your request. The Plan says services could have been provided in-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 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 inpatient hospital stay provided on July 20, 
2022, to July 26, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Cosentyx Pen. 
 
You asked the Plan to pre-approve the Cosentyx Pen. You say that this drug is medically necessary. The Plan 
denied your request. The Plan says Cosentyx Pen is self-administered. 
 
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 the Cosentyx Pen.  
 Benefits for the Cosentyx Pen may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.