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

 
We decided that the Plan does not have to pay for the hearing aid services (V5011, V5267, and V5298) 
provided on December 14, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aid services. You say that you feel that you should be reimbursed for 
these services. The Plan denied your request. The Plan says these services were rendered by an OON provider. 
The Plan also says that there is no coverage for hearing aids or related services that are received from an 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 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 hearing aid services (V5011, V5267, and 
V5298) provided on December 14, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the continuation of medically necessary 
acute care services for the enrollee is define below and demonstrates an LTACH medically appropriate 
admission. The Plan denied your request. The Plan says records do not show that the enrollee's doctors expect 
that the enrollee will get better at LTACH, that hospice is not preferred, or that it is medically safe for the 
enrollee to go to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving and more stable and should only require short-
term additional acute care services that can safely be administered at the current facility until more stable and 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current facility. There are no services at the LTACH that the enrollee requires that are not 
already available and covered at the current facility. Transfer to the LTACH is not medically necessary as it 
would not be clinically advantageous at this time. Completion of treatment at the current facility is 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have waive the copayment for outpatient clinic visits provided January 5, 
2022, to January 19, 2022. 
 
You asked the Plan waive the copayment for outpatient clinic visits. You say that you had the same specialty 
services in 2021 and they were all covered. The Plan denied your request. The Plan says the cost share was 
applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $360 
copayment for Medicare-covered observation services. Your contract with the Plan clearly says that you must 
pay a $360 copayment for an outpatient clinic visit. However, you have only been asked to pay $193.80, which 
is less than the $360 copayment amount. 
 
 
 
 You have been asked to pay a $193.80 ($77.28 +$77.28 + 39.24= $193.80) copayment for outpatient clinic 
visits. Outpatient clinic visits fall within the outpatient Hospital Observation 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 waive the copayment for outpatient clinic visits provided January 5, 2022, to January 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that this item is medically necessary. The Plan 
denied your request. The Plan says the criteria for coverage have not been met. 
 
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 a therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
therapeutic continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for oxygen equipment provided May 27, 2021, to June 
27, 2022. 
 
You asked the Plan to waive the coinsurance for oxygen equipment. You say that you should not be responsible 
for this coinsurance. The Plan denied your request. The Plan says that this claim processed correctly. 
 
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. The Plan has not provided an Explanation of Benefits. Without this 
documentation, we are unable to determine if the cost share that was applied is appropriate. It is the burden of 
the Health Plan to substantiate their denial with evidence. In this case, the Plan's denial has not been 
substantiated so we must find in your favor. Therefore, we decided that the Plan has to waive the coinsurance 
for oxygen equipment provided May 27, 2021, to June 27, 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 pay for Vitamin D assay and glucose testing provided on March 17, 
2021. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for this testing is correct, because these tests are not 
covered when done without documentation of a medical indication from the treating provider. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The tests at issue in this appeal, lab tests, were requested for screening purposes. Medicare does not cover these 
tests for screening purposes. Therefore, we decided that the Plan does not have to pay for Vitamin D assay and 
glucose testing provided on March 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve duplex scan of extremity veins including responses to 
compression and other maneuvers, unilateral or limited study (93971) endovenous ablation therapy of 
incompetent vein, extremity, by transcatheter delivery of a chemical adhesive remote from the access site 
(36482).  
You asked the Plan to pre-approve the procedure. You say that you can no longer sleep at night. You cannot eat 
and can no longer handle this pain anymore. 
 The Plan denied your request. The Plan says the records do not show that the enrollee meets the 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 the procedure. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found on two separate office visit notes there is specific documentation that the enrollee denies lower 
extremity pain bilaterally, heaviness, fatigue, weakness, wounds ulcers, paresthesias, or inability to ambulate.  
There is documentation that the enrollees lower extremities have changes consistent with lymphedema. There 
is a plan to refer the enrollee for lymphedema treatment, but the provider is deferring that referral until after his 
vein treatments.  Although compression stockings have been recommended, there does not appear to have been 
a concerted effort to treat conservatively including the provision of Velcro style stockings that can be adjusted 
to the enrollees anatomy.  There appears to be a request for 4 separate ablative procedures on 4 separate days 
without a plan to reassess symptomatic response between procedures (or sides).  Coverage requires that the 
documentation demonstrates symptoms referable to the veins to be treated that are recalcitrant to conservative 
efforts. These coverage criteria have not been met. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve duplex scan of extremity veins including responses to compression and other maneuvers, 
unilateral or limited study (93971) endovenous ablation therapy of incompetent vein, extremity, by 
transcatheter delivery of a chemical adhesive remote from the access site (36482).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are asking for reconsideration for 
coverage based on medical necessity and records are included for review. The Plan denied your request. The 
Plan says according to the information reviewed on appeal, the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted to the acute care hospital with respiratory failure due to 
angioedema requiring intubation. The course was complicated by diabetic ketoacidosis, acute kidney injury, 
urinary tract infection, bacteremia, pressure wounds, and required antibiotics, mechanical ventilation support, 
tube feeds, wound care, steroids and percutaneous endoscopic gastrostomy and trach placement. Recent notes 
describe the enrollee as now undergoing weaning successfully with the expectation of another 2-3 weeks of 
additional recovery and weaning in the acute care hospital.  
 The enrollee appears to be more stable and improving and should only require short-term acute care services 
that can safely be administered at the current facility until more appropriate for transfer to a lower level of care.  
The enrollee does not require services at the LTACH that are not available at the current facility. There are no 
services at the LTACH that the enrollee requires that are not already available and covered at the current 
facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for GeneSight pharmacogenomics testing (81479) provided on 
May 12, 2022. 
 
You asked the Plan to pay for pharmacogenomic testing. You say that these services were necessary and 
ordered by a physician. The Plan denied your request. The Plan says there is insufficient information provided 
to show that the criteria for coverage of this test are met. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether Medicare 
criteria are met. The rules say that tests which are not ordered by a physician who is treating the beneficiary are 
considered not medically reasonable and necessary. The rules also say that for pharmacogenomics (PGx) 
testing to be covered, a patients medical record must clearly reflect that the clinician has made an initial 
personalized decision for the patient based on the patients diagnosis, the patients other medical conditions, 
other medications the patient is taking, past medical history and other factors.  
 
We looked at the file and Medicare rules. Based on the information provided, we decided that there is 
insufficient information to verify that Medicare criteria for PGx testing have been met. Specifically, the only 
records provided include the test requisition form and results. There are no previous records to show that the 
ordering physician is treating the enrollee, and there is no evidence of the clinicians initial personalized choice 
in medications for this enrollee. Without additional information, it cannot be confirmed that coverage criteria 
are met in this case. Therefore, we decided that the Plan does not have to pay for GeneSight 
pharmacogenomics testing (81479) provided on May 12, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 1, 2021. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says original Medicare is 
responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for an office visit provided on November 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman fusion plate procedure. 
 
You asked the Plan to pre-approve the Minuteman fusion plate procedure. You say that this procedure is 
medically reasonable and necessary. The Plan denied your request. The Plan says there is a lack of evidence in 
the peer-reviewed published medical literature to support the long-term clinical benefit of interspinous process 
fixation devices when used in combination with interbody fusion or as a stand-alone procedure. 
 
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 the Minuteman fusion plate procedure. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the Minuteman plate is experimental. More research is needed before 
coverage can be approved. 
 
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 Minuteman fusion plate procedure have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Minuteman fusion plate procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a right sacroiliac (SI) joint injection. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show that you have a 
history of inflammation of the sacroiliac (SI) joints (sacroilitis) and spinal surgery. You have not received 
supervised physical therapy. There is no documentation on physical examination of tenderness of the SI joint 
and no mention of SI provocative testing being completed with positive findings. The clinical value and 
effectiveness of an SI joint injection in the absence of tenderness and negative provocative testing results have 
not been demonstrated in the peer-reviewed literature. The services are therefore not reasonable or medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a right sacroiliac (SI) joint injection.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory testing provided on September 8, 2021. 
 
You asked the Plan to pay for lab test. You say that you are appealing with supporting records. The Plan denied 
your request. The Plan says that the denial of payment for this testing is correct, because this testing was not 
medically necessary. 
 
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. 
 
This testing was ordered by a contracted provider. The file does not show that the plan provided notice that lab 
test would not be covered. Under Medicare rules, this means lab test is considered approved by the plan. 
Therefore, we decided that the Plan has to pay for laboratory testing provided on September 8, 2021.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids (V5261) received on February 27, 2022. 
 
You asked the Plan to pay for hearing aids. You say that you purchased your hearing aids with this provider 
because you were told by friends that they were cheaper. You do not understand why they were denied for out-
of-network. The Plan denied your request. The Plan says in order for hearing aids to be covered you must 
contact the Plan's hearing vendor. 
 
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 you utilize the Plan's hearing vendor.  
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
hearing aids (V5261) received on February 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient visit, and debridement provided on April 25, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient visit and debridement. You say that you are appealing the claim 
payment denial. The Plan denied your request. The Plan says the services were provided out-of-network and 
were not approved in advanced. 
 
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 outpatient visit, and debridement provided on 
April 25, 2022, by an out-of-network (OON) provider.