Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6531. 
 You asked the Plan to pre-approve the compression stockings. You say that these are necessary for your 
condition. The Plan denied your request. The Plan says the criteria for coverage for the requested compression 
stockings have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6531 
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 
A6531.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services (00864) provided on January 3, 2022. 
 
You asked the Plan to pay for the anesthesia services (00864). You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not supported 
as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 338 units of CPT code 00864 are not supported in the medical record. The medical record only 
supports 317 units of CPT code 00864. Therefore, we decided that the Plan does not have to pay for the 
additional units of the anesthesia services (00864) provided on January 3, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on January 18, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the laboratory services by a contract provider. The file does not show that the 
plan provided notice that the laboratory services would not be covered. Under Medicare rules, this means the 
laboratory services are considered approved by the plan. Therefore, we decided that the Plan has to pay for the 
laboratory services provided on January 18, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vision services provided on April 21, 2022, by an OON 
provider. 
 
You asked the Plan to pay for vision services. You say that you were not advised the provider was out-of-
network. You say that you respectfully request support from the Plan to cover this obligation. The Plan denied 
your request. The Plan says the out-of-network services were not authorized. 
 
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 vision services provided on April 21, 2022, by an 
OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the two removals of cataracts with 
insertion of prosthetic lenses (66984 x2) provided on April 8, 2022, and April 18, 2022. 
 
You asked the Plan to waive the copayments for the removals of cataracts with insertion of prosthetic lenses. 
You say that you are being overcharged for these services, and should not have a copay. The Plan denied your 
request. The Plan says the copayment amounts you are being charged are correct. 
 
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 $295 
copayment for each Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities 
and Ambulatory Surgical Centers.  
 
 You have been asked to pay a $295 copayment for each the removals of cataracts with insertion of prosthetic 
lenses. The removals of cataracts with insertion of prosthetic lenses fall within the Outpatient Surgery and 
Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 copayments for the two removals of cataracts with insertion of 
prosthetic lenses (66984 x2) provided on April 8, 2022, and April 18, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Methylprednisolone. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
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 Methylprednisolone.  
 
Benefits for this drug 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the treatment of a thigh fracture provided on March 1, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the treatment of a thigh fracture. You say that the patient was brought into the 
emergency room, where you were called in for a consult on this patient's case. You also say the patient was 
then brought to the operating room on the same day, which prevented you from being able to obtain a 
referral/prior authorization from the primary care physician. The Plan denied your request. The Plan says this 
provider is not a network provider with the Plan, and the services were not referred by a network provider. The 
Plan also says that these services were not 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 the treatment of a thigh fracture provided on 
March 1, 2022, by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia service provided on February 4, 2020. 
 
You asked the Plan to pay for the anesthesia service. You say that the claim was filed timely per your billing 
software. The Plan denied your request. The Plan says the enrollees claim would be covered under Original 
Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of 
the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the 
enrollees coverage before rendering services and to know proper billing procedures for a Medicare Advantage 
member on hospice. 
 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 the anesthesia service provided on February 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 
You asked the Plan to pre-approve Evenity. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 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 Evenity. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has age related osteoporosis without osteoporotic fracture. The documentation does not 
support that the enrollee has tried and failed Forteo. The documentation does not support that Forteo 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 Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on April 22, 2022. 
 
You asked the Plan to pay for the services provided. You say that this was the first visit under this specialty. 
The Plan denied your request. The Plan says the rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99204 is office or other outpatient visit for the evaluation 
and management of a new patient. We find that CPT code 99204 was billed within the last 3 years by the same 
group practice from providers with the same specialty.  Based on this information, we decided that Medicare rules for coverage of the services provided have not been 
met. Therefore, we decided that the Plan does not have to pay for the office visit provided on April 22, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the pneumococcal vaccine provided by an in-network provider on June 
7, 2022. 
 
You asked the Plan to pay for the pneumococcal vaccine. You say that you would like the Plan to reconsider 
their denial of payment as the pneumococcal vaccine is covered under Medicare Part B. The Plan denied your 
request. The Plan says that the pneumococcal vaccine is covered under Medicare Part D. 
 
The Plan follows Medicare rules. Medicare rules state that most immunizations are not covered unless they are 
directly related to the treatment of an injury or direct exposure to a disease or condition. However, the 
pneumococcal vaccine is an exception to this rule and is covered by Medicare Part B. Your contract with the 
Plan states that the Plan covers the pneumococcal vaccine twice per lifetime. 
 
The pneumococcal vaccine you received is covered by Medicare Part B. This vaccine was obtained from an in-
network provider. The Plan has not provided any documentation showing you have exceeded the limit for this 
vaccine. The Plan has not provided any other justification for their decision to deny payment for this claim. 
Therefore, we decided that the Plan has to pay for the pneumococcal vaccine provided by an in-network 
provider on June 7, 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 pre-approve additional non-emergency transportation. 
 
You asked the Plan to pre-approve additional transportation. You say that you have not been to your 
appointments because you do not have transportation. The Plan denied your request. The Plan says you have 
used 16 one-way trips this year. The Plan also says additional trips in excess of the 16 one-way trips allowed by 
the Plan are not covered. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 16 one-way trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Supartz FX injections (J7321 x 10) to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve Supartz FX. You say that you will provide the requested services in good 
faith and for good. The Plan denied your request. The Plan says the requested services can be provided 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 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 confirmed there are 
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 Supartz FX injections (J7321 x 10) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen equipment provided on February 14, 2022, to 
February 17, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the oxygen equipment. You say that you would like reimbursement for the 
oxygen equipment. The Plan denied your request. The Plan says the provider is out-of-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 oxygen equipment. The Plan did not pre-approve the oxygen equipment. 
We found no exception that would require the Plan to pay for the oxygen equipment. Therefore, we decided 
that the Plan does not have to pay for the oxygen equipment provided on February 14, 2022, to February 17, 
2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oxygen concentrator, single delivery port provided from 
January 6, 2022, to April 6, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for oxygen concentrator, single delivery port. You say that you had prior approval 
for oxygen equipment with your old insurance plan and you were expecting the approval to transfer to your 
new plan. The Plan denied your request. The Plan says the services were provided out-of-network and were not 
approved in advanced. 
 
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 oxygen concentrator, single delivery port provided 
from January 6, 2022, to April 6, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the office visit (99214) provided on April 
29, 2022, by a specialist. 
 
You asked the Plan to waive the deductible for the evaluation and management service. You say that you had 
already paid a $10 copayment for this date of service. You say that you received a bill for an additional $91.51. 
You say that you have never paid such a large amount for a doctor visit. You also say that you should not have 
to pay this additional amount. The Plan denied your request. The Plan says the $500 deductible had not been 
met on the date of service in this case. The Plan also says the deductible applied correctly to the Specialist 
office visit. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $500 deductible which applies to Physician/Practitioner Services, 
Including Doctor's Office Visits.  
 
The item or service you asked the Plan to pay falls within the benefit category Physician/Practitioner Services, 
Including Doctor's Office Visits. The Plan has followed Medicare rules by clearly disclosing in the contract that 
there is a $500 deductible which applies to Physician/Practitioner Services, Including Doctor's Office Visits. 
This cost sharing is a contractual obligation that had not been met at the time the evaluation and management 
service was received on April 29, 2022. The record shows that prior to the date of service in this case, you had only paid $9.71 of the $500 deductible. Therefore, we decided that the Plan does not have to waive the 
deductible for the office visit (99214) provided on April 29, 2022, by a specialist.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve luspatercept-aamt. 
 
You asked the Plan to pre-approve luspatercept-aamt. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 luspatercept-aamt. Our reviewer says 
that the documentation does not support that the requested drug is medically reasonable or necessary. Our 
physician reviewer found the enrollee has a diagnosis of macrocytic anemia related to myelodysplastic 
syndrome ring sideroblasts. The record does not indicate that the enrollee has erythropoiesis stimulating agent 
failure and required transfusion. The Food and Drug Administration has not stated that the requested drug is 
indicated for the enrollee's condition. The Medicare approved drug compendia do not contain a supportive 
citation for the use of the requested drug in the enrollee's clinical situation. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of luspatercept-aamt have not been met. Therefore, we decided that the Plan does 
not have to pre-approve luspatercept-aamt.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on March 25, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the wound care supplies provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network 
care. 
 
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 wound care supplies provided on March 25, 
2022, by an out-of-network (OON) provider.