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

 
We decided that the Plan does not have to waive the copayment for the diagnostic tests provided on January 31, 
2022. 
 
You asked the Plan to waive the copayment for the diagnostic tests. You say that when you scheduled your 
appointment you asked if there would be a fee for the visit and you were told no fee. You say that you asked 
again when you arrived at your appointment and was told again there would be no fee. The Plan denied your 
request. The Plan says you have been charged the correct copayment amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $50 
copayment for Medicare-covered diagnostic procedures/tests: $0 - $50 copayment ($0 copayment for a 
diagnostic bone mass measurement, diagnostic colonscopy and diagnostic mammography test performed on the 
same date of service as the corresponding preventive test. $50 copy for all other services.) 
 You have been asked to pay a $50 copayment for the diagnostic tests. The diagnostic tests 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 the diagnostic tests provided on January 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on November 23, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that your physician only provided 
medically necessary services to the member in good faith, and the rendered services meet professionally 
recognized standards of healthcare. The Plan denied your request. The Plan says this provider is not a network 
provider with the Plan and the services were not referred by a network provider or rendered in an in-network 
facility. The Plan also says that they have also determined that these services are not urgent or emergent, nor 
were they approved in advance. 
 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 domiciliary or rest home visit provided on 
November 23, 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 the domiciliary visit provided on October 13, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the domiciliary visit. You say that the physician depends on the hospital staff to 
obtain proper authorization and the physician should not be penalized. The Plan denied your request. The Plan 
says no prior authorization was obtained. 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the domiciliary visit provided on October 13, 2021, by an out-of-
network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transthoracic echocardiography (TTE) with doppler 
(93306). 
 
You asked the Plan to pre-approve TTE with doppler. You say that this test is necessary as the enrollee has 
known congestive heart failure with lower leg swelling. The Plan denied your request. The Plan says the 
documentation does not show that the enrollee has any of the heart conditions which would make this test 
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 TTE with doppler. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that previous cardiac imaging in 2019 showed no ischemia and normal left 
ventricular function. Documentation does not point to a change in status that would support the medical 
necessity of TTE at this time. Clinical guidelines do not support carrying out TTE with no intervening change 
in clinical status or new signs, symptoms or physical findings. In summary, there is no supportive evidence for 
the medical necessity of repeat TTE in this 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 TTE with doppler have not been met. Therefore, we decided that the Plan does 
not have to pre-approve transthoracic echocardiography (TTE) with doppler (93306).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the office visit and acupuncture service 
provided by a network provider on October 15, 2021. 
 
You asked the Plan to reduce the copayment for the office visit and acupuncture service. You say that there 
should only be a $20 copayment. The Plan denied your request. The Plan says you have been asked to pay the 
correct cost-sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment per specialist visit and a $20 copayment for Medicare-covered and routine services.   
You have been asked to pay a $20 copayment for the office visit, which is less than the standard copayment 
amount, and a $20 copayment for acupuncture service. The office visit falls within the Physician/Practitioner 
services, including doctors office visits benefit category. The acupuncture service falls within Acupuncture 
for chronic low back pain  benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment for the office 
visit and acupuncture service provided by a network provider on October 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory service provided on January 20, 
2022. 
 
You asked the Plan to waive the copayment for laboratory service. You say that you were told if you went to 
the hospital for blood work there would not be a copayment. You say that you were given the wrong 
information by the health plan staff. The Plan denied your request. The Plan says you have been charged the 
correct copayment amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for lab services at an outpatient hospital.  
 
 
 
 
 You have been asked to pay $39.61, which is less than the standard $40 copayment for the laboratory service. 
Laboratory 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 laboratory service provided on January 20, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 31, 2022, by an OON 
provider. 
 
You asked the Plan to pay for the office visit. You say that you went to the provider because the list you 
received from the Plan of in-network providers showed the providers name on it. The Plan denied your request. 
The Plan says the rendering provider is an OON provider and there was no referral from an in-network 
provider or an approved authorization. Also, the service rendered was not urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on January 31, 2022, by an 
OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that this home ventilator 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. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says 
that the requested home ventilator is not medically reasonable and necessary. Our physician reviewer found a 
home ventilator is not medically necessary. This patient has severe COPD with chronic hypoxic and 
hypercarbic respiratory failure, documented on arterial blood gas as an outpatient when the patient was stable. 
This patient may benefit from bilevel positive airway pressure (BiPAP) in the average volume-assured pressure 
support mode during sleep as an outpatient. But Medicare does not cover a home ventilator when used as BiPAP.  There is no documented failure of BiPAP as an outpatient. The requested item is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services provided on January 19, 2022, by an 
OON provider. 
 
You asked the Plan to pay for the imaging services. You say that your primary care physician (PCP) referred 
you to the provider to get services done. The Plan denied your request. The Plan says the rendering provider is 
an OON provider, and it was confirmed with the enrollee's PCP office that there was no referral on file for the 
enrollee to see the OON provider. 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 imaging services provided on January 19, 
2022, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on August 5, 2021. 
 
You asked the Plan to waive the copayment for the office visit. You say that you were billed incorrectly. The 
Plan denied your request. The Plan says the copayment 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 $5 
copayment for PCP office visits or other health care professional visits. 
 
The records show you were treated for medical conditions that are not covered under a routine physical.  
You have been asked to pay $5 for the office visit. An office visit falls within the Physician/Practitioner 
services, including doctors office visits benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for the office visit provided on August 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Osphena. 
 
You asked the Plan to pre-approve Osphena. You say that you are unable to pay over $800 for a 3 month 
supply of this drug. You also say that you are quite uncomfortable due to the fact that you are unable to 
continue with this drug. The Plan denied your request. The Plan says the requested drug is considered self-
administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug 
plan. The Plan also says the requested drug is not covered under Medicare Part B. 
 
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 Osphena.  
 Benefits for Osphena 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Visco-3 (J7321). 
 
You asked the Plan to pre-approve Visco-3. You say that the requested drug is medically necessary. You also 
say that the enrollee did a 3 shot series in his knee in the past which worked really well for him. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, Orthovisc or 
Supartz FX. 
 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 Visco-3. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
that the enrollee has tried and failed the preferred drugs, Orthovisc and Supartz FX. The reviewer also found 
that the documentation does not support that Orthovisc or Supartz FX would likely be less effective, and/or 
would likely have adverse effects for the enrollee in this case. Therefore, the reviewer found that the step 
therapy 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 Visco-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Visco-3 (J7321).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hearing aids. 
 
You asked the Plan to pre-approve hearing aids. You say that the item is medically necessary. The Plan denied 
your request. The Plan says you have exhausted the Plan benefit for this service. 
 
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 up to a $2,000 maximum allowance for hearing aids every three years..  
 
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 pre-approve 
hearing aids.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous passive motion (CPM) device provided on 
September 16, 2021. 
 
You asked the Plan to pay for CPM device. You say that you needed this after your anterior cruciate ligament 
(ACL) reconstruction surgery. The Plan denied your request. The Plan says a continuous passive motion device 
is not covered by Medicare for this purpose. 
 
The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have 
received total knee replacement surgery. 
 
You have not had total knee replacement surgery. Therefore, we decided that the Plan does not have to pay for 
a continuous passive motion (CPM) device provided on September 16, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic manipulative treatment and electrical 
stimulation provided from September 15, 2021, to September 29, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for chiropractic manipulative treatment and electrical stimulation. You say that you 
want to be reimbursed as you paid cash for the bill. The Plan denied your request. The Plan says this was 
denied because this is a type of physical therapy services that required prior authorization prior to receiving the 
care. The Plan also says there was no prior authorization submitted to request coverage of these services and 
the providers have not sent any medical records from these two dates of service to the Plan for review to 
determine if the care would have met the Plan's medical policy criteria for coverage or not. 
 
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 chiropractic manipulative treatment and electrical 
stimulation provided from September 15, 2021, to September 29, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the left shoulder arthroscopy with subacromial balloon 
spacer (InSpace device). 
 
You asked the Plan to pre-approve left shoulder arthroscopy with subacromial balloon spacer (InSpace device). 
You say that this procedure is medically necessary. The Plan denied your request. The Plan says the requested 
procedure is considered experimental/investigational. 
 
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 left shoulder arthroscopy with 
subacromial balloon spacer (InSpace device). Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is a 
72-year-old female being treated for rotator cuff tear or rupture, not traumatic. She presented with significant 
pain with empty can testing. Although the strength of the shoulder is relatively preserved; she does have some 
definitive weakness with attempts at empty can testing. This is consistent with the massive rotator cuff tear 
visualized on magnetic resonance imaging scan. The exam reveals good function and strength. She is quite 
crepitant and rough in the subacromial space. Her range of motion is preserved both actively and passively.  
However, detailed documentation is not evident regarding trial and failure of recent, reasonable, and 
comprehensive less invasive conservative care measures. Regardless, there is limited published, large-scale, 
long-term peer-reviewed literature that shows this request to be an effective and/or safe treatment for the noted 
pathology. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the requested left shoulder arthroscopy with 
subacromial balloon spacer (InSpace device), in this case, is not medically reasonable or 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 left shoulder arthroscopy with subacromial balloon spacer (InSpace device) 
have not been met. Therefore, we decided that the Plan does not have to pre-approve the left shoulder 
arthroscopy with subacromial balloon spacer (InSpace device).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that the item is medically necessary. 
The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0265).