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

We decided that the Plan has to pay for the over the counter glasses provided on December 17, 2020.
You asked the Plan to pay for the over the counter glasses. You say that you did not go to the eye doctor because of COVID so you purchased the necessary reading glasses. The Plan denied your request. The Plan says that the service is not covered by Medicare.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Evidence of Coverage clearly states that in addition to Medicare-covered services, the Plan also covers non-Medicare covered eyewear. We looked at the file and the Plan's rules. The Evidence of Coverage does not clearly indicate that over the counter eyeglasses are not a covered benefit. Based on this information, we decided that the Plan's rules for coverage of the over the counter glasses have been met. Therefore, we decided that the Plan has to pay for the over the counter glasses provided  on December 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) and arthrocentesis, aspiration and/or 
injection of a major joint or bursa (20610) rendered by the out-of-network (OON) provider on April 1, 2021. 
 
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 office visit (99213) and arthrocentesis, aspiration and/or injection of a major 
joint or bursa (20610) rendered by the out-of-network (OON) provider on April 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair (K0861) and associated billed codes.
You asked the Plan to pre-approve the power wheelchair. You say that the claim should be paid. The Plan denied your request. The Plan says the enrollee has previously received the same supplies within the 5-year RUL.
The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of durable medical equipment is no less than five years. Replacement equipment may be granted when irreparable wear or irreparable damage is demonstrated or there has been a change in the enrollee's medical condition. A replacement was requested, due to the fact that the specific chair has been discontinued and the parts cannot be received. The manufacturer's website indicates that the Sunrise Quickie Pulse is still being sold. We looked at the file and Medicare rules. In this instance, the submitted documentation indicates that the enrollee has received the same durable medical equipment in 2017. This means the power wheelchair is still within the 5-year RUL. There is insufficient documentation to show a replacement is warranted. Based on this information, we decided that Medicare rules for coverage of the power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair (K0861) and associated billed codes.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had with Dr. on October 13, 2020.
You asked the Plan to waive the copayment for the office visit. You say that this doctor is your primary care doctor, so you shouldn't be charged the specialist copayment. The Plan denied your request. The Plan says you were charged the specialist copayment correctly. The Plan says that the doctor who provided this service is not your assigned primary care provider. This doctor did not become your primary care doctor until November 20, 2020, more than a month after this office visit.
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 $50 copayment for visits with a specialist. You have been asked to pay a $50 copayment for the office visit. Because the provider of this service was not your primary care provider on the date of service in question, the office visit falls within the specialist 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 you had on October 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit on March 9, 2021.
You asked the Plan to waive the deductible for the office visit. You say that office visits are exempt from the deductible, so you should only have a $5 copayment. The Plan denied your request. The Plan says the deductible does apply to physician services, so you were charged this amount correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $225 deductible that applies to physician visits. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $225 deductible that applies to physician visits. This cost sharing is a contractual obligation that had not been met at the time the office visit was received on March 9, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the office visit on March 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an alignable system (L5910) for the enrollee. 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says the physician office visit notes do not corroborate the vendor's notes showing the need to 
replace L5910. 
 
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 system. Our reviewer says that the 
requested system is not considered medically reasonable and necessary in this case. Our physician reviewer 
found based on the medical records provided, there is no documentation that the alignable system (L5910) at 
issue in this case meets Medicare criteria for medically reasonable and necessary. The records from the 
enrollee's treating physician do not state why the enrollee's present alignable system (L5910) is damaged 
beyond repair or cannot be used with the new prosthesis/socket.  
 
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 system have not been met. Therefore, we decided that the Plan does not have to pre-approve an alignable system (L5910) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp (J0881). 
 
You asked the Plan to pre-approve Aranesp. The Plan denied your request. The Plan says the information 
submitted does not meet the Plan's medical necessity guidelines for coverage. 
 
 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 Aranesp. Our reviewer says that 
Aranesp (J0881) is not medically reasonable and necessary for the enrollee. Our physician reviewer found the 
enrollee has not tried and failed the required drug, Retacrit. Our reviewer also found that there is no indication 
that the Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp (J0881).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Procrit (J0885). 
 
You asked the Plan to pre-approve Procrit. You say that the requested drug is medically necessary. You also 
say that Retacrit is not available in vials with the necessary dosage. The Plan denied your request. The Plan 
says the enrollee has not tried and failed the required drug, Retacrit. 
 
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 Procrit. Our reviewer says that Procrit 
is not medically necessary. Our physician reviewer found the provided documentation does not indicate that the 
enrollee has tried and failed the required drug, Retacrit. The reviewer also found that there is no indication that 
the plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. 
Therefore, the reviewer found that the step therapy criteria has 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 Procrit have not been met. Specifically, the file shows that the enrollee has not 
tried and failed the required drug. Therefore, we decided that the Plan does not have to pre-approve Procrit 
(J0885).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for drug testing (G0483) provided on May 22, 2021. 
 
You asked the Plan to pay for drug testing. You say that you are appealing with supporting records to prove the 
necessity of this testing. The Plan denied your request. The Plan says that the denial of payment for this testing 
is correct, because the records do not support that 22 or more drug classes were tested. 
 
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, the CPT Code Manual definition of 
code G0483 is drug tests, definitive; qualitative or quantitative, all sources, includes specimen validity testing, 
per day; 22 or more drug classes, including metabolite(s) if performed. 
 
We find that CPT code G0483 is supported in the medical record. Specifically, the record shows that definitive 
testing was performed on more than 22 drug classes. Based on this information, we decided that Medicare rules 
for coverage of drug testing have been met. Therefore, we decided that the Plan has to pay for drug testing 
(G0483) provided on May 22, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient mental health services provided from May 6, 
2021, to May 12, 2021. 
 
You asked the Plan to pay for the inpatient mental health services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the enrollee did not pose imminent danger to themself 
or others. You also say that the enrollee did not require medications throughout their stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient mental health services. Our 
reviewer says that the inpatient mental health services were not medically necessary. Our physician reviewer 
found that the records provided indicate that it was not expected this enrollee would improve in a reasonable 
period of time as she did not have dangerousness to self or others and was not showing any auditory/visual 
hallucinations or any aggressive behaviors. The reviewer found it did not appear medically necessary and 
reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care 
as she did not have dangerousness to self or others. The reviewer found the enrollee did not appear to require 
inpatient mental health treatment as she was not a danger to herself or others and was cooperative with care 
without any aggressive behaviors. Therefore, the reviewer found that the inpatient mental health services were 
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 the inpatient mental health services have not been met. Specifically, the file 
shows that the enrollee was not a danger to themself or others. Therefore, we decided that the Plan does not 
have to pay for the inpatient mental health services provided from May 6, 2021, to May 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from May 8, 2021, 
to May 9, 2021. 
 You asked the Plan to pay for the acute inpatient hospital care. You say that you believe the admission was 
appropriate, as the services rendered could not have been provided in an outpatient setting. The Plan denied 
your request. The Plan says the care delivered is consistent with an observation stay. The Plan also says that 
there is no medical necessity for formal hospitalization. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found the record did not show that at the time of inpatient admission the 
admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier 
emergency department and/or observation care) would span two midnights. 
 
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 acute inpatient hospital care have not been met. Therefore, we decided that 
the Plan does not have to pay for the acute inpatient hospital care provided from May 8, 2021, to May 9, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a neurostimulator trial for the enrollee. 
 
You asked the Plan to pre-approve the trial. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if they are medically 
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 the trial. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee had a psychological evaluation which cleared him for another trial. The enrollee 
had a generator placed by another pain physician but the generator does not seem to function consistently and 
needs to be replaced. Change of a failed generator is medically reasonable and 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 the trial have been met. Therefore, we decided that the Plan has to pre-approve 
a neurostimulator trial for the enrollee.  
 
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Evenity for the enrollee.
You asked the Plan to pre-approve Evenity. You say that this drug is medically necessary. The Plan denied
your request. The Plan says the enrollee has not met the Plans step therapy criteria. The QIC overturned the
Plans denial stating the case file lacked the Plans step therapy criteria. The Plan requested a reopen and
provided the required information.
The Plan is correct in this case. 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 preapprove
Evenity. Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer found
the Plan requires a trial of Prolia or IV Zoledronic Acid before they will approve the requested drug. In this
case, the enrollee has not tried and failed one of the required drugs. There is no documentation provided
indicating that the Plan's required drug(s) would likely be less effective and/or likely have adverse effects for
the enrollee. Therefore, the required step therapy criteria are not 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 Evenity have not been met. Therefore, we decided that the Plan does not have to
pre-approve Evenity for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), bitewing x-
rays (D0274), the initial periapical x-ray (D0220), and the additional periapical x-ray (D0230) provided on 
June 24, 2021. 
 
You asked the Plan to pay for the dental services. You say that there are 3 dentists at this office. You say that 2 
of the are in network. You say that your regular dentist was out that day. You also say that the services should 
be covered since most of the work was provided by your regular dentist's hygienist. The Plan denied your 
request. The Plan says the provider in this case is out of network. The Plan also says that dental services 
received out of network are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case.  
Though the Plan offers a dental benefit in excess of Medicare coverage and the services are listed as covered, 
dental services received out of network are not among those covered under this benefit. Therefore, we decided 
that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), bitewing x-rays (D0274), 
the initial periapical x-ray (D0220), and the additional periapical x-ray (D0230) provided on June 24, 2021.
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is 
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 you continue to receive acute care services, and these have not been denied. The 
medical records do not indicate that you require services that you are not currently receiving but that would be 
available at the LTACH 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 long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services (D0150, D7140, D7953) received March 16, 2021 from the out-of-network provider.
You asked the Plan to pay for the dental services. You say that you feel deceived by the dental provider office for having the non-network provider perform the services. The Plan denied your request. The Plan says if you receive services from a Medicare Advantage Dentist or a dentist that does not participate with the Dental plan, you will be responsible for the full cost of those services and no payment will be made.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit when performed by an out-of-network provider. Therefore, we decided that the Plan does not have to pay for the dental services (D0150, D7140, D7953) received March 16, 2021 from the out-of-network provider.