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

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on February 21, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you did 
not want to be transported to a hospital emergency room. The Plan denied your request. The Plan says 
ambulance transportation is covered only when you are actually transported by ambulance. The Plan also says 
since you were not transported by this ambulance, the service is not covered under your plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on February 21, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on February 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5298) provided on March 9, 2022. 
 
You asked the Plan to pay for the hearing aids. You say that you paid the bill thinking the Plan would pay a 
portion of it. The Plan denied your request. The Plan says the treating provider is not part of the Plan's vendor 
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 you use the Plan's hearing aid vendor to use your hearing aid benefits. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
the hearing aids (V5298) provided on March 9, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 26, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 26, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that you would like the Plan to reconsider their denial. The 
Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for the requested CGM. 
 
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 and does not require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa injections. 
 
You asked the Plan to pre-approve the requested injections. The Plan denied your request. The Plan says the 
enrollee has not tried and failed conservative treatment. The Plan follows Medicare rules. Medicare rules say that hyaluronan acid therapies are only covered under 
certain medical indications.  
 
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 requested injections. Our physician 
reviewer found that there is no documentation that the coverage criteria for the Euflexxa injections have been 
met. The magnetic resonance scan of the right knee shows intact medial and lateral articular cartilage and a 
lateral meniscus tear. There is no radiologic imaging which reports joint space narrowing, subchondral 
sclerosis, osteophytes or sub-chondral cysts as required by Medicare rules. 
 
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 requested injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Euflexxa injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you must remain at home due to this 
happening often and your quality of life is gone. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided January 27, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment. You say that you took the advice of the 
911 team and decided not to go to the hospital. The Plan denied your request. The Plan says this service is not 
covered when there is no transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.   
The ambulance company did not provide transport services on January 27, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The trip report in this case shows that the enrollee refused transport to the hospital and thus the wavier criteria 
is not met. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, 
no transport (A0998) provided January 27, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the basic vestibular evaluation provided on February 22, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the basic vestibular evaluation. You say that this claim should be paid because it 
is for an office visit and the enrollee has policy and home address in the same state. 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 
basic vestibular evaluation. We found no exception that would require the Plan to pay for the basic vestibular 
evaluation. The records provided for review do not show that the basic vestibular evaluation was urgent or 
emergent. Therefore, we decided that the Plan does not have to pay for the basic vestibular evaluation provided 
on February 22, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia 
 
You asked the Plan to pre-approve Prolia. You say that the options have side effects related to kidney disease. 
The Plan denied your request. The Plan says the coverage criteria 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 looked at the file, and Medicare rules. The Plan requires a trial of an intravenous bisphosphonate therapy, 
such as zoledronic acid, before they will approve the requested drug. The limited documentation provided does 
not show that you have tried and failed the required drug. There is no documentation that shows the Plans 
required drug is likely be less effective or likely have adverse effects. The file does show that the Plan made 
multiple attempts to obtain additional information with no success. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary visit provided on March 25, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the domiciliary visit. You say that the nursing facility failed to obtain the prior 
authorization which should have covered the medical treatments. You say the treatment was medically 
necessary. 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 
domiciliary visit. We found no exception that would require the Plan to pay for the domiciliary visit. The 
records provided for review do not show that the domiciliary visit was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the domiciliary visit provided on March 25, 2022, by an out-of-
network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology services provided on March 28, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the surgical pathology services. You say that you work with several doctor 
groups who are participating providers and use your laboratory exclusively. You say the enrollee does not go to 
the laboratory, so they are not using their out-of-network benefits. 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 
surgical pathology services. We found no exception that would require the Plan to pay for the surgical 
pathology services. The records provided for review do not show that the surgical pathology services at issue 
were urgent or emergent. Therefore, we decided that the Plan does not have to pay for the surgical pathology 
services provided on March 28, 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 the chiropractic manipulative treatment (98941), the 
mechanical traction therapy (97012), and the massage therapy (97124) rendered by the out-of-network (OON) 
provider on February 4, 2022 and  March 7, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out-of-
network provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the chiropractic manipulative treatment (98941), the mechanical traction therapy 
(97012), and the massage therapy (97124) rendered by the out-of-network (OON) provider on February 4, 2022 
and  March 7, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided March 12, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment. You say that you were feeling better, so 
you declined transport to the emergency room. The Plan denied your request. The Plan says this service is not 
covered when there is no transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.   
The ambulance company did not provide transport services on March 12, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport (A0998) provided March 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6530 that 
were issued on April 4, 2022. 
 
You asked the Plan to pay for the compression stockings. You say that you are requesting a reconsideration of 
the Plan's denial for payment. The Plan denied your request. The Plan says these items are not a covered benefit 
under your contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code A6530 that were issued on April 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual health club membership purchased on January 20, 
2022. 
 
You asked the Plan to pay for the annual health club membership. You say that the Plan has not adequately 
explained why this claim was denied. The Plan denied your request. The Plan says the maximum Wellness 
Allowance amount has been paid. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan offers a Wellness 
Allowance which reimburses gym benefits up to $150 per calendar year. 
 
 
 
 The Plans rules for coverage of gym benefits have not been met because the record shows your Wellness 
Allowance for the 2022 calendar year has been exhausted. The Plan says your reimbursement check of $150 
was mailed out to you on April 15, 2022. Therefore, we decided that the Plan does not have to pay for the 
annual health club membership purchased on January 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you have a history of falls. The Plan denied 
your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ozempic injections. 
 
You asked the Plan to pre-approve Ozempic injections. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says Ozempic injections 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 Ozempic injections.  
 
Benefits for Ozempic injections may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the nutrition course taken on January 1, 2021. 
 
You asked the Plan to reimburse you for the nutrition course. You say that your friend was advised by a plan 
representative that this course would be covered. The Plan denied your request. The Plan says this is not a 
covered benefit. 
 
Medicare generally does not cover nutrition services. However, the Plan offers a supplemental benefit that 
exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a supplemental benefit in excess of Medicare coverage, the nutrition course is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for 
the nutrition course taken on January 1, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from February 13, 2022 to February 17, 2022 and February 21, 2022 to March 14, 2022. 
 You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says there was no daily skilled need. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found based 
on the medical records provided there is no documentation that the patient required skilled nursing services, 
i.e., the specialized skill, knowledge and judgment of a skilled professional nurse or qualified therapist were 
not required to safely and effectively provide medically necessary and reasonable treatment from 02/13/2022 
through 02/17/2022 and from 02/21/2022 through 03/14/2022. The records did not document the need for 
intravenous medications, new tube feeding or ostomy care or daily complex wound care or respiratory care. 
The patient was walking household distances with a rolling walker with stand-by assistance and was stand-by 
assist for transfers. Services in the nursing facility appear custodial in this case. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) services provided to the enrollee from February 13, 2022 to 
February 17, 2022 and February 21, 2022 to March 14, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Methotrexate. 
 
You asked the Plan to pre-approve Methotrexate. You say that this is necessary for the enrollee's diagnosis. The 
Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's 
prescription drug plan. 
 
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 Methotrexate.  
 
Benefits for Methotrexate 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 treatment with Novolog Flexpen. 
 
You asked the Plan to pre-approve Novolog Flexpen. You say that the requested drug is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have 
not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Novolog 
Flexpen.  
 Benefits for Novolog Flexpen may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.