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

 
We decided that the Plan has to pay $80 for the bifocal lenses. We decided that the Plan does not have to pay in 
full for the bifocal lenses.  
 
You asked the Plan to pay for the bifocal lenses (V2200) purchased on May 18, 2022. You say that you did not 
receive any services on May 18, 2022. You also say that you had an eye exam in December of 2021, and the 
glasses were purchased on July 16, 2022. The Plan says that you have met the $200 maximum yearly vision 
allowance. The Plan also says that this allowance was exhausted on the frames. 
 
  We decided that the Plan has to pay $80 for the bifocal lenses.  
 
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 Plan covers up to $200 for supplemental eyewear every year. 
 
We looked at the file and the Plan's rules. Specifically, the Plan says that your $200 eyewear allowance has 
been exhausted on the frames. However, the record shows that the Plan allowed an amount of $200 for the 
frames that were also purchased on May 18, 2022, but only paid $120 for them. This means that your $200 
vision allowance has not been exhausted. Based on this information, we decided that the Plan's rules for 
coverage of the bifocal lenses have been met. Therefore, we decided that the Plan has to pay $80 for the bifocal 
lenses.  
 
We also decided that the Plan does not have to pay in full for the bifocal lenses. 
 
The Plan is only obligated to pay $200 every year for supplemental eyewear. We have told the Plan that they 
must pay $80 for these lenses, which will exhaust your benefit.  Based on this information, we decided that the 
Plan's rules for full coverage of the bifocal lenses have not been met. Therefore, we decided that the Plan does 
not have to pay in full for the bifocal lenses. 
 
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 acute inpatient hospital services provided to the enrollee 
from September 1, 2021, to September 26, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The 
Plan denied your request. The Plan says the request is not medically necessary because the enrollee's show that 
they quickly responded to treatment during the observation period and did not have severe findings needing 
additional treatment or that this could alleviated with a change in the medication she was taking. 
 
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 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 that the enrollee presented to the emergency department with hyponatremia, history 
of hallucinations (chronic), and signs of urinary tract infection. There was report of improving hallucinations 
over the prior few days before presentation. Computed tomography (CT) of the head was negative. There was 
no reported confusion or hallucinations during the workup. She was treated with fluids, antibiotics. The rest of 
the workup was unremarkable, and sodium improved the next day to 133 with initial treatment and finally to 
136 on the day of discharge. It appears the main admissible diagnosis was hyponatremia which would not have 
expected to cross 2 midnights of hospitalization due to the low severity and low complexity of the 
presentation.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for acute inpatient hospital services provided to the enrollee from September 1, 2021, 
to September 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services rendered on December 20, 2021. 
 
You asked the Plan to pay for these services. You say that you were given incorrect benefit information. The 
Plan denied your request. The Plan says the provider type is not covered. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the file shows that the services were performed by 
auxiliary personnel and not under the supervision of a physician, physician assistant, or nurse 
practitioner/clinical nurse specialist. Therefore, we decided that the Plan does not have to pay for the 
acupuncture services rendered on December 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient services provided from November 6, 2020, to 
December 3, 2020. 
 
You asked the Plan to pay for the inpatient services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the claim was not submitted timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the inpatient services was not filed until February 1, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the inpatient services provided from November 6, 2020, to 
December 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the remote monitoring provided on March 5, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. 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 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 the remote monitoring provided on March 5, 2022, 
by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Zolpidem tablet. 
 
You asked the Plan to pre-approve Zolpidem. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Zolpidem 
tablet.  
 Benefits for Zolpidem may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Enbrel. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says Medicare says Part B only covers some prescription drugs. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Enbrel.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia and ultrasonic guide needle biopsy services 
provided on May 27, 2022. 
 
You asked the Plan to pay for the anesthesia and ultrasonic guide needle biopsy services. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the services are not payable as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 64448 and 76942 is not supported in the medical record. Specifically, these services 
were billed with a place of service 21 (inpatient). However, the associated facility claim was billed as 
outpatient/observation. This means this claim is not payable as billed. Based on this information, we decided 
that Medicare rules for coverage of the anesthesia and ultrasonic guide needle biopsy services have not been 
met. Therefore, we decided that the Plan does not have to pay for the anesthesia and ultrasonic guide needle 
biopsy services provided on May 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 1, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
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 laboratory services provided on August 1, 2022, 
by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Barostim NEO device. 
 
You asked the Plan to pre-approve the Barostim NEO device. You say that the clinical information provided 
supports the need for the requested device. The Plan denied your request. The Plan says there is no published 
data showing either efficacy or safety of the Barostim NEO device in patients with left ventricular assist device 
(LVAD.) The Plan says that this is of particular concern in patients with prior intravascular infections as this 
patient has had. 
 
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 Barostim NEO device. Our 
reviewer says that the Barostim NEO device is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee has symptoms thought to be due to chronic systolic heart failure 
(CHF) despite medical management, in the setting of severely reduced left ventricular function. There remains 
an absence of randomized, blinded clinical studies examining long-term clinical outcomes establishing the 
value of Barostim Neo in patient management. As a result, at this time the Barostim Neo system would not be 
considered medically reasonable and necessary in this enrollees 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 the Barostim NEO device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Barostim NEO device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression device provided on February 28, 2022. 
 
You asked the Plan to pay for the services provided. You say that the products were delivered based on medical 
necessity. The Plan denied your request. The Plan says the service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The device is a preventive service and excluded from coverage. 
Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the compression device provided on February 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for mammography services provided on July 
29, 2022. 
 
You asked the Plan to waive the coinsurance for mammography services. You say that you believed this 
provider was in-network. 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 50% 
coinsurance for out-of-network screening mammograms, basic rediological services, and diagnostic 
mammograms in an outpatient hospital.  
 
You have been asked to pay a $108.45 coinsurance for mamography services ($216.92 allowed amount x 50% 
coinsurance = $108.46; however, you have been asked to pay less). The record shows that these services were 
provided in an out-of-network outpatient hospital. 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 
mammography services provided on July 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Selective Internal Radiation Therapy (SIRT) (77263, 
77290, 77300, 77778, C2616). 
 
You asked the Plan to pre-approve SIRT. You say that additional medical records were submitted to support 
medical necessity. The Plan denied your request. The Plan says guidelines do not support the routine use of the 
requested type of treatment (therapy) for the enrollee's cancer type. 
 
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 SIRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the technique of radioembolization for liver metastases is not investigational in and of itself. 
The issue is whether or not it is investigational and/or necessary for this enrollee's condition. the case records 
and prior letter of appeal mention that she just started a new systemic agent  perbolizumab (started 10/11/22 
and to be delivered Q6 weeks). There is also legitimate concern of potentially severe toxicity risks in treating 
patients on immunotherapy treated with radioembolization. While severe toxicity from radioembolization is 
rare, I do not know of any data to suggest that such treatment is safe. Our doctor also found that 
radioembolization would not be appropriate and furnished in accordance with accepted standards of medical 
practice in a patient who started a new systemic agent for which response has not been assessed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SIRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Selective Internal Radiation Therapy (SIRT) (77263, 77290, 77300, 77778, C2616).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered on February 28, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the Type of Bill (TOB) code 032x is required for home 
health services under a plan of treatment.  
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the required 032x 
TOB code. Based on this information, we decided that Medicare rules for coverage of these services have not 
been met. Therefore, we decided that the Plan does not have to pay for the home health services rendered on 
February 28, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for air ambulance services provided to the enrollee on April 6, 
2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the point of pickup was not inaccessible by ground vehicle, and the nearest hospital with 
appropriate facilities was in Morelia, Mexico, with at least five acute care hospitals with intensive care units 
(ICUs). 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
services at issue in this case were not medically reasonable or necesasry. Our physician reviewer found that in 
this case, the record indicates that the enrollee had acute respiratory distress and was at an airport in an 
ambulance when the air transportation arrived.  The record provided does not indicate that the enrollees 
medical condition needed immediate and rapid ambulance transport that could not have been provided by 
ground ambulance to a local facility or that the area in which the enrollee was inaccessible to ground vehicles. 
 
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 air ambulance services provided to the enrollee on April 6, 2022.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the services provided on June 20, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the enrollee was in 
hospice on this date of service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not provided documentation showing that the enrollee was enrolled 
in hospice on the date of service in question. Without supporting documentation, the Plan's denial cannot be 
substantiated. Therefore, we decided that the Plan has to pay for the services provided on June 20, 2022.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on May 15, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you have 
been billed twice for this event. You also say it should have all been handled when the first crew arrived, and 
not when the ambulance had to turn around and come back. The Plan denied your request. The Plan says your 
coverage does not provide for this ambulance service, and no payment can be made. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 15, 2022. The record shows that you stated 
several times that you did not want to be transported to the hospital because you were feeling better. The 
ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays 
for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response 
and treatment with no transport (A0998) provided on May 15, 2022.