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

 
We decided that the Plan has to waive the copayment for a telehealth visit provided on November 30, 2021. 
 
You asked the Plan to waive the copayment for a telehealth visit. You say that you did not go to the office, and 
this was a telehealth visit. You also say that for the last two year all visits have been done via telehealth and 
have never had a copayment until now. The Plan denied your request. The Plan says that you have been 
charged the correct cost sharing amount. The Plan also says that the telehealth cost sharing waiver expired 
November 15, 2021. 
 
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 did not provide documentation of their COVID-19 telehealth cost 
sharing waiver program policy. Without that documentation we are unable to confirm when the waiver expired 
and determine if cost sharing applies. Therefore, we decided that the Plan has to waive the copayment for a 
telehealth visit provided on November 30, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a RT300 Functional Electrical Stimulation (FES) Arm 
and Leg System with 12 channels. 
 
You asked the Plan to pre-approve a RT300 FES Arm and Leg System with 12 channels. You say that the 
services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 
coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that NMES is covered when specific criteria are met. 
 
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 RT300 FES Arm and Leg System 
with 12 channels. Our reviewer says that the services are not medically necessary. Our physician reviewer 
found the RT300 is not medically necessary per NCD 160.12. The NCD states that NMES is used to treat 
muscle atrophy and limited to the treatment of disuse atrophy where nerve supply to the muscle is intact, including brain, spinal cord and peripheral nerves, and other non-neurological reasons for disuse atrophy. A 
September 28, 2021, letter of medical necessity states your diagnosis is primary progressive multiple sclerosis 
and you have weak muscles due to your chronic condition. The documentation does not reveal that you have a 
non-neurologic cause of disuse atrophy. 
 
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 RT300 FES Arm and Leg System with 12 channels have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a RT300 Functional Electrical Stimulation 
(FES) Arm and Leg System with 12 channels.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids provided on November 3, 2021. 
 
You asked the Plan to pay for hearing aids. The Plan denied your request. The Plan says there is no coverage if 
hearing aids or related services are received from a provider not part of the Plan's hearing aid vendor's network. 
 
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 a Plan hearing network provider. 
 
We looked at the file and the Plan's rules. The file shows that the hearing aids were not purchased from a Plan 
hearing network provider. 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 provided on 
November 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ophthalmological services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve ophthalmological services. You say that you cannot read, and you have been 
seeing this ophthalmologist for 7-8 years. The Plan denied your request. The Plan says the requested provider is 
not a network provider, and they will approve the office visit and eye testing with a network 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
ophthalmological services to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tier exception for Novolog. 
 
You asked the Plan to pre-approve a tier exception. The Plan denied your request. The Plan says tier exceptions 
are not available for drugs covered by Part B. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a 20% coinsurance for Medicare Part B prescription drugs.  
 
The enrollee has requested a tier exception. Novolog falls within the Medicare Part B prescription drugs benefit 
category. This means that the cost share is the correct amount based on the contract with the Plan. This cost 
sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided 
that the Plan does not have to pre-approve a tier exception for Novolog.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the specialist office visit. You say that you requested the enrollee to see an 
out-of-network provider. The Plan denied your request. The Plan says a list of in-network providers that 
provide the same quality of service, that are located near the enrollee's residence, and are accepting new 
patients was given. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a specialist office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Mohs surgery to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the Mohs surgery. You say that you are requesting to provide the service to 
the enrollee. The Plan denied your request. The Plan says a list of in-network providers that provide the same 
quality of service, are close to the enrollee's residence, and are accepting new patients was given. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
Mohs surgery to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve specialist visit. You say that you would like to request a certain procedure. 
The Plan denied your request. The Plan says there are in-network providers that can care for you. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. There are 
providers in-network that can provide cortisone injections or knee replacement surgery. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a specialist visit to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient physical therapy visits to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve outpatient physical therapy visits. You say that you are requesting 
transitional services because you do not want to repeat services already provided. The Plan denied your 
request. The Plan says the requested treatment is available 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
outpatient physical therapy visits to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the specialist office visit. You say that you received urgent care and would 
like to see the out-of-network provider. The Plan denied your request. The Plan says a list of in-network 
providers was given to the enrollee that are accepting new patients and provide the same quality of service. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a specialist office visit to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis. 
 
You asked the Plan to pre-approve Eliquis. You say that the enrollee has suffered from deep vein thrombosis in 
his lower extremities. The Plan denied your request. The Plan says this drug is not eligible for coverage under 
the Part B benefit. 
 
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 Eliquis.  
 
 Benefits for Eliquis 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 Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 Keytruda. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the review has determined that the 
documentation does not support that the Keytruda is medically reasonable and necessary for the enrollee. The 
documentation does not support that the Keytruda is safe and effective 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement tube using imaging guidance to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the replacement tube using imaging guidance. You say that the enrollee was 
admitted to an inpatient hospital and the follow up care should be done at an outpatient clinic while the enrollee 
is visiting out of state. The Plan denied your request. The Plan says the attending physician stated there was no 
reason the enrollee could not have the procedure performed by an in-network provider. Also, there are in-
network providers that can perform the requested procedure. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a replacement tube using imaging guidance to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Diabetic shoes to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve Diabetic shoes. You say that your request is medically necessary. The Plan 
denied your request. The Plan says the provider is out-of-network and it was determined these services can be 
received 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
Diabetic shoes to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the full upper respiratory infection panel coded as 87541, 
87581, 87640, 87651, 87798, 87496, 87498, 87502 and 87532 provided October 26, 2021. 
 
You asked the Plan to pay for the full upper respiratory infection panel. You say that you ask for 
reconsideration of the denial and request payment in full for the testing. The Plan denied your request. The Plan 
says the service does not meet the Medicare criteria as the tests requested has more than 5 pathogens.  
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Multiplex PCR respiratory viral panels of 6 or more pathogens are 
non-covered. Based on this information, we decided that Medicare rules for coverage of the full upper 
respiratory infection panel have not been met. Therefore, we decided that the Plan does not have to pay for the 
full upper respiratory infection panel coded as 87541, 87581, 87640, 87651, 87798, 87496, 87498, 87502 and 
87532 provided October 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services were medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
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 there is not a reasonable expectation that this patient will be able to fully participate 
in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a facet joint injection. 
 
You asked the Plan to pre-approve a facet joint injection. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that thermal radiofrequency destruction of cervical, 
thoracic, or lumbar paravertebral facet joint (median branch) nerves are considered medically reasonable and 
necessary when specific criteria are met. 
 
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 facet joint injection. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found in this case; the enrollee has 
had 3 therapeutic facet injections in the last 9 months. There is documentation of why the enrollee is not a 
candidate for radiofrequency ablation. The review has determined that the enrollee does not meet the coverage 
criteria detailed in the LCD. 
 
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 facet joint injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a facet joint injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyewear provided on December 29, 2021. 
 
You asked the Plan to pay for the eyewear. The Plan denied your request. The Plan says the maximum allowed 
under the member's benefit was exceeded. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan 
covers these services every year. 
 
 
 We looked at the file and the Plan's rules. The file shows that you received they eyewear benefit on  
April 19, 2021. Therefore, we decided that the Plan does not have to pay for eyewear provided on  
December 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Erleada tablets. 
 
You asked the Plan to pre-approve Erleada tablets. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says Erleada tablets are not covered under the enrollee's 
Medicare Part B benefit. 
 
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 Erleada tablets.  
 Benefits for Erleada tablets may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.