Persius/hicric huggingface dataset:
Appeal type: Other
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for a neurostimulator provided on August 20, 2021. 
 
You asked the Plan to waive the coinsurance for the neurostimulator. You say that you did not know the 
neurostimulator was a prosthetic. The Plan denied your request. The Plan says that you have been charged the 
correct cost sharing amount. 
 
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 enrollees must pay 0% coinsurance for durable medical equipment.  
 
The neurostimulator is not a prosthetic device. It is categorized as durable medical equipment medical/surgical 
supplies. The Plan says you must pay 20% coinsurance for the neurostimulator. Based on the Plan contract, 
however, you cannot be asked to pay more than 0% coinsurance for the neurostimulator. Therefore, we decided 
that the Plan has to waive the coinsurance for a neurostimulator provided on August 20, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal surgery for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says the plan has no contractual obligation to cover services that are not covered by 
Medicare. 
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found percutaneous laminectomy or laminotomy surgery is experimental. More research is needed. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve spinal surgery for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist new patient office visit 
provided on October 25, 2021. 
 
You asked the Plan to waive the copayment for the specialist new patient office visit. You say that there should 
not be a copayment for a hearing exam. The Plan denied your request. The Plan says there is a zero copayment 
for a hearing test, but there is a $35 copayment for the specialist 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 $35 
copayment for Hearing Services, Specialist Office.  
 
You have been asked to pay a $35 copayment for the specialist new patient office visit. The specialist new 
patient office visit falls within the Hearing Services, Specialist Office 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 a specialist new patient office visit provided on October 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal surgery for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says the medical record must include a description of the necessary alterations and/or 
modifications planned for fitting at delivery. 
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no documentation of knee instability or fracture. The brace is not medically needed. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve spinal surgery for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya. 
 
You asked the Plan to pre-approve Ilumya. You say that this is medically necessary. The Plan denied your 
request. The Plan says that you do not have any stated contraindications to the preferred products. 
 
 
 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 Ilumya. Our reviewer says that Ilumya 
is not medically reasonable and necessary. The Plan requires a trial of Humira, Enbrel or Skyrizi before they 
will approve the requested drug. In this case, you have not tried and failed the required drugs. There is no 
documentation provided indicating that the Plan's required drugs would likely be less effective and/or likely 
have adverse effects for you. Our physician reviewer found that your condition does not meet step therapy 
criteria for Ilumya. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Ilumya.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for hearing aids provided on July 27, 2021. 
 
You asked the Plan to reimburse you for hearing aids. The Plan denied your request. The Plan says members 
must receive services from a network provider. Services provided by out-of-network providers are not covered. 
 
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 provided by the Plans hearing vendor. 
 
We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by the Plans 
hearing vendor. 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 reimburse you for hearing aids provided on 
July 27, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a pneumatic compression device (E0651) and segmental 
pneumatic appliance (E0667x2). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that you request an 
approval of the basic pump so that the enrollee may be able to control his swelling and prevent worsening of 
his wounds. The Plan denied your request. The Plan says that the records do not support that the requested 
device is medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 a pneumatic compression device and 
appliance. Our reviewer says that the requested items/services are considered medically reasonable and 
necessary in this case.  Our physician reviewer found in this case, the record indicates that the enrollee has chronic venous 
insufficiency with weeping wounds, hyperkeratosis and hyperpigmentation. The Independent Review Entity 
has received additional documentation that the enrollee underwent a trial of other treatment that was 
unsuccessful. The elements of the coverage criteria are satisfied, and the requested service is recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a pneumatic compression device and appliance have been met. Therefore, we 
decided that the Plan has to pre-approve a pneumatic compression device (E0651) and segmental pneumatic 
appliance (E0667x2).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a transthoracic echocardiography (93306) provided on 
November 10, 2020, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a transthoracic echocardiography. You say that the patient was seen urgently for 
recurrent fatigue, chest pain and shortness of breath. You also say that the enrollee has a history of angina, 
bradycardia and hypertension and the medical records establishes medical necessity. The Plan denied your 
request. The Plan says this was denied for no 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 at issue in this case is not a network provider with the Plan. 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 a transthoracic echocardiography. Our reviewer says that this does not meet 
criteria. Our physician reviewer found at issue is the medical necessity of a repeat a transthoracic 
echocardiogram (TTE), in the absence of any apparent significant change in the patients clinical condition. 
Clinical guidelines do not support repeating a TTE with no intervening change in clinical status or physical 
findings. In summary, there is no supportive evidence for the medical necessity of repeat TTE in this this 
patients 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 a transthoracic echocardiography have not been met.  
 
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 pay for a transthoracic echocardiography. Therefore, we decided 
that the Plan does not have to pay for a transthoracic echocardiography (93306) provided on November 10, 
2020, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on October 18, 
2021. 
 
You asked the Plan to waive the copayment for an office visit. You say that you should not owe a copayment 
for your annual physical. The Plan denied your request. The Plan says the claims were processed correctly and 
you are being charged the correct 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 $10 
copayment for primary care provider visits.  
 
The medical records show that you received services beyond an annual wellness exam on October 18, 2021. 
Therefore, you are responsible to pay the $10 copayment.  You have been asked to pay a $10 copayment for an 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 an office visit provided on October 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6545. 
 You asked the Plan to pre-approve the compression stockings. You say that the compression stockings are 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6545 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code 
A6545.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgery to place a Vertiflex Superion device for the 
enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to 
insufficient evidence of efficacy. 
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this device is experimental. More research is needed. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve surgery to place a Vertiflex Superion device for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says daily skilled services are no longer required. 
 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 pre-approve the services. Our reviewer says that the 
requested continuation of services is not medically reasonable or necessary. Our physician reviewer found no 
required skilled nursing services are identified. The documentation does not support that it is medically 
reasonable and necessary to provide skilled therapy services on a "daily basis" on an inpatient basis, in a skilled 
nursing facility setting. The enrollee does not require the necessary services on an inpatient basis, in a skilled 
nursing facility setting. 
 
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 pre-approve continued skilled nursing facility (SNF) services.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 the enrollee continues to have a need for skilled therapy with ongoing safety 
concerns and a potential for functional improvement however, the documentation doesnt support that she 
would meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication that the 
enrollee would require skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under 
the supervision of a physician with at least 3 visits weekly to regain or maintain her functional status. The 
enrollee is ambulating up to 130 feet with minimal assistance. She is near her prior level of function and can 
receive services at a lower level of care. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a LifeVest (K0606) provided on April 22, 2021, to May 22, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a LifeVest. You say that because of the Plan's processes, you could not 
reasonably have known a prior authorization was required or secured a prior authorization. The Plan denied 
your request. The Plan says this service was rendered by a non-part provider. The Plan also says that they also 
determined that these services were 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 LifeVest (K0606) provided on April 22, 2021, to 
May 22, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic behavioral services provided on July 3, 2021, to 
September 30, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the therapeutic behavioral services. You say that services were provided to the 
enrollee so the claim should be paid. The Plan denied your request. The Plan says the services provided was not 
referred by an in-network provider. The rendering provider is also an out-of-network provider and the services 
provided 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 therapeutic behavioral services provided on July 3, 
2021, to September 30, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a lumbar-sacral orthosis (back brace) 
provided on September 21, 2021. 
 
You asked the Plan to waive the coinsurance for the back brace. You say that the provider informed you that 
the brace would be free of charge. The Plan denied your request. The Plan says the correct coinsurance was 
applied. 
 
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 20% 
coinsurance for each durable medical equipment (DME) item, including braces.  
 
You have been asked to pay $124.68, which is 20% of the allowed amount for the back brace ($623.38 allowed 
amount x 20% coinsurance = $124.68).  The back brace falls within the Durable Medical Equipment (DME) and Related 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 coinsurance for a lumbar-sacral orthosis (back brace) provided on 
September 21, 2021.