Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xolair. 
 
You asked the Plan to pre-approve Xolair. You say that the medication is 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. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Xolair.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an office visit and Part B medication 
injection provided on June 24, 2022. 
 
You asked the Plan to waive the cost share for an office visit and Part B medication injection. You say that you 
are disputing the share cost. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $30 
copayment for Physician/Practitioner services, including doctors office visits and 20% coinsurance for 
Medicare Part B prescription drugs.  
 
You have been asked to pay $30 copayment for an office visit and 20% coinsurance for Part B medication injection. These items/services fall within the Physician/Practitioner services, including doctors office visits 
and Medicare Part B prescription drugs benefit categories. 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 cost share 
for an office visit and Part B medication injection provided on June 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray exam of the thoracic spine (72070) and the x-ray 
exam of the lumbar spine (72100) provided on October 11, 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 these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the x-ray exam of the thoracic spine (72070) and the x-ray exam of the 
lumbar spine (72100) provided on October 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair (PWC) with multiple power 
options (K0861), expandable controller (E2377), harness (E2313), electronic connection (E2311), battery 
(E2361), joystick mounting brackets (E1028), power seat (E1007), back cushion (E2620), headrest (E0955), 
removable headrest hardware (E1028), power foot platform (E1012), and skin protection cushion (E2603). 
 
You asked the Plan to pre-approve a group 3 PWC with multiple power options and related features and 
accessories. You say that these items are medically necessary. The Plan denied your request. The Plan says 
these items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that if a Group 3 Multiple Power Options PWC is 
provided and if the criteria listed in the Medicare Rules section is not met, it will be denied as not reasonable 
and necessary. If the PWC base is not covered, then related accessories will be denied. 
 
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 group 3 PWC with multiple power 
options and related features and accessories. Our reviewer says that these items are not medically necessary. 
Our physician reviewer found the provided records do not support that the patient is high risk for skin 
breakdown, has a history of pressure ulcer(s) or has had skin flap surgery despite being wheelchair-bound 
presently. Records do not document the patient performs bladder self-catheterization or that she has increased 
muscle tone or spasticity. The enrollee does not use a ventilator which is mounted on the wheelchair. The 
enrollee has 4/5 right upper extremity strength and is independent with feeding thus indicating she has adequate 
upper extremity strength and function to operate the wheelchair's power options with their own switches. As 
the wheelchair base is not medically necessary, none of the accessories are covered. 
 
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 group 3 PWC with multiple power options and related features and 
accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 
power wheelchair (PWC) with multiple power options (K0861), expandable controller (E2377), harness 
(E2313), electronic connection (E2311), battery (E2361), joystick mounting brackets (E1028), power seat 
(E1007), back cushion (E2620), headrest (E0955), removable headrest hardware (E1028), power foot platform 
(E1012), and skin protection cushion (E2603).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continued acute inpatient psychiatric hospital care 
provided from July 10, 2022, through July 14, 2022. 
 You asked the Plan to pay for these services. You say that the acute inpatient psychiatric hospital care provided 
was medically necessary for the enrollee. The Plan denied your request. The Plan says that the acute inpatient 
psychiatric hospital care provided was not medically necessary. 
 
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 these services. Our reviewer says that the 
acute inpatient psychiatric hospital care provided was not medically necessary. Our physician reviewer found 
that the enrollee was originally admitted to the acute inpatient psychiatric hospital on June 18, 2022 with Major 
Depressive Disorder, Recurrent, Severe without Psychotic Features and Opioid Dependence. Based upon the 
review of the records provided, it was not expected that this enrollee would improve in a reasonable period of 
time for the dates in question as she did not have suicidal or homicidal ideation, or auditory and visual 
hallucinations. The enrollee was compliant with treatment while not showing any acute threats to safety. 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 and was compliant 
with her treatment. The health plans denial of continued inpatient psychiatric services is appropriate. This 
enrollee did not appear to require inpatient mental health treatment as she was not a danger to herself or others 
and did not have auditory or visual hallucinations. It did not appear that active treatment was taking place. It 
did not appear that the services were reasonably expected to improve the enrollees condition or were for the 
purpose of a diagnosis. She was treated under an individualized treatment plan found in the record. It did 
appear that the records were supervised and evaluated by a physician. Based upon the review of the records 
provided, the enrollee did not meet criteria for coverage of the services provided.   
 
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 the continued acute inpatient psychiatric hospital care provided from July 10, 2022, through 
July 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for therapeutic radiology services provided on 
May 12, 2022, to May 31, 2022. 
 
You asked the Plan to waive the coinsurance for therapeutic radiology services. You say that you disagree with 
the coinsurance. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for outpatient diagnostic tests/therapeutic radiology services.  
 
You have been asked to pay a 20% coinsurance for therapeutic radiology services. The total allowed amount 
for the radiology services is $8,546.45. You are being asked to pay $1,709.29 ($8,546.45 x 20% =$1,709.29).  
This item/service falls within the outpatient diagnostic tests/therapeutic radiology services 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 therapeutic radiology services provided on May 12, 2022, 
to May 31, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency transportation (T2003). 
 
You asked the Plan to pre-approve the non-emergency transportation. The Plan denied your request. The Plan 
says the information provided shows that you are being treated for congestive heart failure. The Plan also say 
that although you are being treated for pre-diabetes, you are not being treated for diabetes as required to 
participate in this program. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the non-emergency transportation have not been met. Specifically, we have confirmed that you do 
not have one of the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan 
does not have to pre-approve non-emergency transportation (T2003).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B prescription drugs 
provided on February 15, 2022, to August 16, 2022. 
 
You asked the Plan to waive the coinsurance for Medicare Part B prescription drugs. You say that you disagree 
with the copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance for Medicare Part B prescription drugs. The total allowed 
amount for the prescription drugs is $97.88. You are being asked to pay $48.94 ($97.88 x 20% = $48.94). This 
item/service falls within the Medicare Part B prescription drugs 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 Medicare Part B prescription drugs provided on February 15, 2022, to August 16, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a surgical placement of implant body: endosteal implant 
(D6010) provided on November 3, 2022. 
 
You asked the Plan to pay for the surgical placement of implant body: endosteal implant (D6010). You say that 
you have researched to find the proper medical code for the procedures. You also say that you are filing a claim 
for a reimbursement as you have paid the provider for the services. The Plan denied your request. The Plan 
says this service is not covered under the benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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. Therefore, we decided that the Plan does not have to pay for a surgical 
placement of implant body: endosteal implant (D6010) provided on November 3, 2022.
Appeal type: DME/ Orthotics
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 the CGM. You say that the enrollee is under your care and was evaluated 
within the past 6 months. The Plan denied your request. The Plan says the Medicare criteria was not met. 
 
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. Based on this information, we decided that Medicare rules for coverage of 
the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on January 17, 2022. 
 
You asked the Plan to pay for the home visit. The Plan denied your request. The Plan says the enrollee was 
enrolled in hospice services on this date of service. Therefore, traditional Medicare is the primary payer this  
service. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for a home visit provided on January 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on October 
4, 2021, to October 11, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 
copayment per day for days 1-7 for inpatient hospital care.  
 
You have been asked to pay a $100 copayment per day for days 1-7 for inpatient hospital care. The total 
amount you are being asked to pay is $700 ($100 x 7 days = $700). This item/service falls within the inpatient 
hospital care 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 inpatient hospital care 
provided on October 4, 2021, to October 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pain management visit. 
 
You asked the Plan to pre-approve pain management visit. You say that due to health issues, you need to see a 
pain management provider. You say you would like to see the out-of-network provider listed in the 
documentation. The Plan denied your request. The Plan says the service can be provided by an in-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 
pain management visit.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit, injection services, and methylprednisolone 
acetate injection provided on August 12, 2022. 
 
You asked the Plan to pay for office visit, injection services, and methylprednisolone acetate injection. You say 
that you are appealing the claim payment denial. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit, injection 
services, and methylprednisolone acetate injection provided on August 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services billed under codes 87481 and 87798 
provided on September 23, 2022. 
 
You asked the Plan to pay for laboratory services billed under codes 87481 and 87798. You say that you are 
appealing the claim payment denial. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
billed under codes 87481 and 87798 provided on September 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 10, 2022. 
 
You asked the Plan to pay for an office visit. You say that we have been trying to get ourselves in-network for 
all plans while keeping the cost down for our patients. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on August 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient services provided from May 10, 2022, to June 
24, 2022. 
 
You asked the Plan to pay for the inpatient services. The Plan denied your request. The Plan says this request is 
not approved because no records to substantiate medical necessity of the billed amount were received, despite 
multiple attempts by the Plan to obtain. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the inpatient services have been met. 
Medical records were not provided for this case. The record shows that the Plan attempted to obtain this 
information, but it was not provided. Without medical records we cannot determine if the services provided 
were medically reasonable, necessary, and meet the coverage criteria for approval. Therefore, we decided that 
the Plan does not have to pay for the inpatient services provided from May 10, 2022, to June 24, 2022.