Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Injectafer. 
 
You asked the Plan to pre-approve Injectafer. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step-therapy rules for the requested drug have not been 
met. 
 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 Injectafer. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of drugs Infed and Venofer before they will approve the requested drug. In this case, the 
enrollee has not tried and failed the required drugs. There is no documentation provided indicating that the 
Plans required drugs 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 Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Injectafer.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on 
November 07, 2021. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you recently received the 
bill as they had the wrong mailing address. 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 $250 
copayment for ambulance services. 
 
You have been asked to pay a $250 copayment for the ambulance services. This item/service falls within the 
ambulance 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 ambulance 
services provided on November 07, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility care provided on May 12, 2022, to 
July 31, 2022. 
 
You asked the Plan to pay for skilled nursing facility care. You say that you are requesting reconsideration. 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 skilled nursing facility 
care provided on May 12, 2022, to July 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and debridement procedure provided on 
September 12, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit and debridement procedure. You say that the records attached 
support the services provided. The Plan denied your request. The Plan says there is no referral or prior 
authorization on file for the services rendered. 
 
 
 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 and debridement procedure 
provided on September 12, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the x-rays provided on October 19, 2022. 
 
You asked the Plan to waive the copayment for the x-rays. You say that the x-rays were done in an office 
setting. 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 $90 
copayment for basic radiological services at an outpatient hospital. 
 
You have been asked to pay a $90 copayment for the x-rays. This item/service falls within the basic 
radiological services at an outpatient hospital 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 x-rays provided on October 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on August 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. 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 January 06, 2020. 
Therefore, we decided that the Plan does not have to pay for the dental services on August 9, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a skilled nursing facility (SNF) visit provided on June 13, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a SNF visit. You say that the records attached support the services rendered. The 
Plan denied your request. The Plan says the services were provided by an out-of-network (OON) provider. 
 
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 a skilled nursing facility (SNF) visit provided on 
June 13, 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 an office visit provided on September 9, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the records attached support these services provided. 
The Plan denied your request. The Plan says the services were provided by an out-of-network (OON) provider, 
and there is no referral or prior authorization on file for the services rendered. 
 
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 September 9, 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 an office visit provided on September 20, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
The Plan denied your request. The Plan says there is no referral or prior authorization on file for the services 
rendered. 
 
 
 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 September 20, 2022, by 
an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on November 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 the dental 
services on November 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for office visits, injections, DME, CT scans, 
ambulance transport, inpatient hospital stay, physical therapy visits and an ER visit provided from January 13, 
2022, to September 22, 2022. 
 
You asked the Plan to waive the cost share for office visits, injections, DME, CT scans, ambulance transport, 
inpatient hospital stay, physical therapy visits and an ER visit. You say that you reached your out-of-pocket 
maximum early in the year so this should be covered. The Plan denied your request. At the time these claims 
had been received your out-of-pocket maximum had not yet been reached. 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 $290 
copayment for ambulance services, 20% coinsurance for DME, $90 copayment for a ER visit, $275 copayment 
per day for days 1 through 6 per inpatient stay, 20% coinsurance for injections, $180 copayment for advanced 
imaging services, $20 copayment per physical therapy visits and $25 copayment per specialist office visit. 
 
You have been asked to pay a total of $5,835.21 copayment for office visits, injections, DME, CT scans, 
ambulance transport, inpatient hospital stay, physical therapy visits and an ER visit. 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 cost share for office visits, injections, DME, CT scans, ambulance transport, inpatient hospital 
stay, physical therapy visits and an ER visit provided from January 13, 2022, to September 22, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on August 19, 2022. 
 
You asked the Plan to pay for psychotherapy. You say that you are requesting reconsideration. 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 psychotherapy provided 
on August 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upper and lower partial dentures (D5211, D5212). 
 
You asked the Plan to pre-approve the upper and lower partial dentures (D5211, D5212). You say that you are 
appealing this denial. The Plan denied your request. The Plan says the services are not covered 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 upper and lower partial dentures 
(D5211, D5212) are not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pre-approve the upper and lower partial dentures (D5211, D5212).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the debridement services provided on January 25, 2022. 
 
You asked the Plan to pay for the debridement services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says that they were unable to make a 
determination within the allotted time frame. 
 
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. In this case, we find that the Plan has not provided enough evidence to support 
the denial of payment for the services provided on January 25, 2022. Therefore, we decided that the Plan has to 
pay for the debridement services provided on January 25, 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: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve an unattended (home) sleep study. 
 
You asked the Plan to pre-approve a home sleep study. You say that the enrollee has known obstructive sleep 
apnea (OSA), but is intolerant of continuous positive airway pressure (CPAP), and not benefiting from this. 
You also say the enrollee is interested in the alternate therapy, and in order to proceed, they need a sleep study 
showing that they still have OSA. The Plan denied your request. The Plan says that this request cannot be 
approved because the enrollee does not meet the criteria for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that the evidence is sufficient to determine that the results 
of the sleep tests identified in the Medicare rules section of this letter can be used by a beneficiarys treating 
physician to diagnose OSA, and are 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 a home sleep study. Our reviewer says 
that a home diagnostic polysomnography is reasonable and medically necessary. Our physician reviewer found 
this enrollee has a diagnosis of OSA based on a sleep study in 2021, is intolerant of CPAP, and is being 
evaluated for the Inspire device. Our reviewer found that the previous sleep study included only 1.1 hours of 
sleep, so the apnea-hypopnea index (AHI) may be inaccurate. Our physician reviewer also found that an 
accurate AHI is necessary to determine if the enrollee qualifies for the Inspire device. 
 
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 home sleep study have been met. Therefore, we decided that the Plan has to 
pre-approve an unattended (home) sleep study.   
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transcutaneous electrical nerve stimulator (TENS) unit 
supplies provided on August 3, 2022. 
 
You asked the Plan to pay for TENS supplies. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says there is no evidence to support the ordering provider ordered these 
supplies. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage of DMEPOS items requires proof of 
delivery.  
 
We looked at the file and Medicare rules. The documentation submitted does not include valid proof of 
delivery for the specific item billed on this claim. Specifically, the delivery form does not show evidence of 
delivery to the enrollees specific address. Based on this information, we decided that Medicare rules for 
coverage of TENS supplies have not been met. Therefore, we decided that the Plan does not have to pay for 
transcutaneous electrical nerve stimulator (TENS) unit supplies provided on August 3, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for code 99291 billed for date of service January 26, 2022. 
 
You asked the Plan to pay for code 99291. You say that you have billed this service correctly for separate 
payment. The Plan denied your request. The Plan says that you did not bill code 99291 correctly to allow for 
separate payment. 
 
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 sole rationale for denial is that you didn't bill code 99291 
with an appropriate modifier to allow for separate payment.  However, it appears as though you submitted a 
claim to the Plan correctly appending modifier 25 to the E/M service in dispute (99291).  The Plan has made no 
effort at all to discuss this modifier's application in this case.  It isn't even clear in the minimal case file that the 
Plan submitted to us that it even reviewed this modifier.  The Plan has not made any assertion that the 25 
modifier was appended inappropriately.  The burden is on the Plan to show why its denial is correct, and it has 
failed to do so in this case. Therefore, we decided that the Plan has to pay for code 99291 billed for date of 
service January 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the brain 
(78608). 
 
You asked the Plan to pre-approve a PET scan of the brain. You say that the service is medically necessary. 
The Plan denied your request. The Plan says you do not meet the diagnostic criteria of both Alzheimer's disease 
and frontotemporal dementia. There is no indication that the examination is being requested in the context of a 
clinical trial. 
 
The Plan follows Medicare rules. Medicare rules say that an FDG PET scan is only covered when there is a 
need to separate a differential diagnosis of frontotemporal dementia and Alzheimers disease. 
 
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 PET scan of the brain. Our reviewer 
says that you do not meet Medicare criteria for coverage of the service. Our physician reviewer found based on 
the records provided you are not noted to have either AD or FTD, nor do you meet diagnostic criteria for both 
conditions. 
 
   
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 PET scan of the brain have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a positron emission tomography (PET) scan of the brain (78608).