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

 
We decided that the Plan does not have to pay for the annual wellness visit provided on May 17, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the annual wellness visit. You say that you believed the provider was in-network. 
The Plan denied your request. The Plan says 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 in this case is not a network provider with the Plan. 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 the annual wellness visit provided on May 17, 2022, by an out-
of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says 
according to the information reviewed the requested service is not 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 the enrollee is receiving appropriate care at the present setting. The enrollee does not 
require services at the LTACH that are not available at the current acute care setting where they are currently 
receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inclusion of a left ventricular (LV) lead with an 
approved automatic implanted cardioverter-defibrillator (AICD). 
 
You asked the Plan to pre-approve the requested LV lead. You say that it is felt that the requested LV lead is 
medically indicated. The Plan denied your request. The Plan says there is no documentation of a condition for 
which the LV lead is required in this case. 
 
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 requested LV lead. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has cardiomyopathy and atrial fibrillation, with no evidence of left 
bundle branch block (LBBB). Review of clinical documents does not show that the patient meets implant 
criteria for a biventricular defibrillator insertion according to current guidelines. In the absence of such 
documentation, placement of an LV lead at time of automatic defibrillator implant would not be considered 
medically necessary in the management of this patient. 
 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 LV lead have not been met. Therefore, we decided that the Plan 
does not have to pre-approve inclusion of a left ventricular (LV) lead with an approved automatic implanted 
cardioverter-defibrillator (AICD).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve TriVisc knee injections. 
 
You asked the Plan to pre-approve the TriVisc injections. You say that this is necessary due to worsening pain. 
The Plan denied your request. The Plan says a trial of the preferred agent is required prior to approving this 
medication. 
 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 the TriVisc injections. Our reviewer 
says that the requested drug is not considered reasonable and necessary based on step therapy criteria. Our 
physician reviewer found the Plan requires a trial of drug Synvisc before they will approve the requested drug. 
In this case, the patient has not tried and failed the required drug(s). There is no documentation provided 
indicating that the plans required drug(s) 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 the TriVisc injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve TriVisc knee injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for at-home COVID-19 tests you purchased from January 10, 
2022, to February 11, 2022. 
 
You asked the Plan to pay for the at-home COVID-19 tests. You say that because you are immuno-
compromised, you had to take these tests.  You would like to be reimbursed for them. The Plan denied your 
request. The Plan says you purchased these tests before the date of Medicare coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that as of April 4, 2022, Medicare will cover up to 8 
at-home COVID-19 tests per month.  You purchased the tests in question prior to this April 4, 2022, date. No 
coverage was available for these tests prior to April 4, 2022. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the at-home COVID-19 tests have not been met. Therefore, we decided that the Plan does not have 
to pay for at-home COVID-19 tests you purchased from January 10, 2022, to February 11, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service May 21, 
2022, to June 17, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service May 21, 2022, to June 17, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services you received on May 
25, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that the care manager at the 
nursing home set up a ride with an ambulance without letting you know and now you are being charged and 
you cannot afford to pay for it. 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 $290 
copayment for ambulance services.  
 
You have been asked to pay a $290 copayment for the ambulance services. This item/service falls within the 
ambulance 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 copayment for ambulance services 
you received on May 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve the requested ventilator. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee's needs can be met with a BiPAP device. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer 
says that the requested ventilator is not medically necessary in this case. Our physician reviewer found based 
on the medical records provided, there is documentation that this enrollee has chronic respiratory failure 
consequent to chronic obstructive pulmonary disease. Provided records document that the home ventilator is 
being requested for use in intelligent volume assured pressure support (IVAPS) mode with auto-titration which 
could be provided by a bilevel positive airway pressure (BiPAP) device. Medicare does not cover a ventilator when a BiPAP could meet the enrollee's needs. 
 
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 ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a home ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 5, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the lab services. You did not provide a specific argument with your appeal 
request. The Plan denied your request. The Plan says unauthorized, out-of-network services are 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 in this case is not a network provider with the Plan. 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 lab services provided on April 5, 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 wound care supplies provided on May 18, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the wound care supplies. You say that these items were medically necessary and 
you have an exclusivity agreement with the facility where the patient was located. The Plan denied your 
request. The Plan says unauthorized, out-of-network items and services are 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 in this case is not a network provider with the Plan. 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 wound care supplies provided on May 18, 2022, by an out-of-
network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous transcatheter closure of congenital 
interatrial communication with implant. 
 
You asked the Plan to pre-approve percutaneous transcatheter closure of congenital interatrial communication 
with implant. You say that the enrollee has a history of a cerebrovascular accident (CVA.) You say that the 
enrollee has coronary artery disease (CAD) with total occlusions and is not a surgical candidate. You say that 
the enrollee has patent foramen ovale (PFO) and needs closure. The Plan denied your request. The Plan says 
the records do not show that the enrollee has cardiac chambers dilation, evidence of cryptogenic stroke with 
paradoxical embolism and high RoPE score and PASCAL class, platypnea orthodeoxia, exertional hypoxemia, 
or significant left to right shunt. The Plan says that the requested service is not medically necessary. 
 
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 percutaneous transcatheter closure of 
congenital interatrial communication with implant. Our reviewer says that the requested services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has 
coronary artery disease, atrial fibrillation and echocardiographic evidence of a patent foramen ovale (PFO). A 
request was made by the enrollee's practitioner to implant a PFO closure device. The enrollee had a stroke in 
the past, but there is no evidence that the PFO was causative. There is also no high RoPE score or PASCAL 
class. There is no echocardiographic evidence of cardiac chamber dilatation, evidence of cryptogenic stroke 
with paradoxical embolism, exertional hypoxemia or significant left to right shunt.  As such, guidelines would 
not support the need for a PFO closure device. There is insufficient documentation to support the medical 
necessity for the requested PFO closure in 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 percutaneous transcatheter closure of congenital interatrial communication with 
implant have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous 
transcatheter closure of congenital interatrial communication with implant.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93010 and 93010-76 billed for date of 
service March 15, 2022. 
 You asked the Plan to pay for procedure codes 93010 and 93010-76. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says payment for codes 93010 and 
93010-76 are bundled into payment for code 92960. 
 
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 codes 
93010 and 93010-76 are column II codes to column I code 92960. 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 codes 93010 and 93010-76 billed 
for date of service March 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory tract infection panel for more than 6 
pathogens provided on October 19, 2021. 
 
You asked the Plan to pay for the respiratory tract infection panel for more than 6 pathogens. You say that this 
is medically necessary testing. The Plan denied your request. The Plan says Medicare does not cover panels 
testing for more than 5 pathogens. 
 
The Plan must follow Medicare rules. Medicare rules say that respiratory panels testing for 6 or more 
pathogens are noncovered. Therefore, we decided that the Plan does not have to pay for the respiratory tract 
infection panel for more than 6 pathogens provided on October 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid you purchased on June 2, 2022, from a 
provider outside of the Plan's designated hearing vendor network. 
 
You asked the Plan to pay for the out-of-network hearing aid. You say that you believe that this provider is in-
network, that is why you chose him. The Plan denied your request. The Plan says this provider is not a network 
provider with the Plan's designated hearing 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 purchased from a provider in the Plan's designated hearing network.  The provider you 
used is not in the Plan's designated hearing network. Therefore, we decided that the Plan does not have to pay 
for the hearing aid you purchased on June 2, 2022, from a provider outside of the Plan's designated hearing 
vendor network.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
pneumatic appliance for use with pneumatic compressor (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and a segmental pneumatic appliance. You 
say that the enrollee's lymphedema has not improved despite over months of conservative therapies and 
physical therapy visits. She still has swelling, impaired mobility, elephantiasis, infection, weeping, and 
wounds. Given the severity of her symptoms, Flexitouch compression pump was prescribed. The Plan denied 
your request. The Plan says the requested device does not meet the requirements for approval. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and segmental pneumatic appliance for use with pneumatic compressor (E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve the requested injections. You say that the enrollee should be approved for 
these injections to treat her pain. The Plan denied your request. The Plan says there has not been a trial of 
conservative management, and the pain has not persisted for at least three months. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint injections may be covered for persistent 
pain lasting at least three months where there are no non-facet pathologies which could be causing the pain. 
 
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 reviewer 
says that the requested injections are not shown to be medically necessary based on the LCD rules. Our physician reviewer found this enrollee has new onset (3 weeks) of radicular pain, radiating to the legs with a 
vertebral body fracture. These other pain generators have not been treated. Therefore, facet joint injections are 
not reasonable and necessary at this time. 
 
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 facet joint injections.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram (EKG) and laboratory 
services provided on January 19, 2022. 
 
You asked the Plan to waive the copayment for the EKG and lab services. You say that you feel the services 
should not be denied. 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 $50 
copayment for diagnostic procedures or tests at a network doctor's office and a $15 copayment for lab services 
performed in a physician's office.  You have been asked to pay $14.42 for the EKG, which is less than the $50 copayment per the EOC. This 
item/service falls within the diagnostic procedures or tests at a network doctor's office benefit category. You 
have also been asked to pay a $15 copayment for the lab services. This item/service falls within the lab services 
performed in a physician's office benefit category. The total for all services is $29.42. 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 electrocardiogram (EKG) and laboratory services provided on January 19, 2022.