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

 
We decided that the Plan does not have to pre-approve specialist visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve specialist visit. You say that you would like to see an out-of-network Neuro-
Ophthalmologist for a second opinion. 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 
specialist visit to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Vyvgart. 
 
You asked the Plan to pre-approve Vyvgart. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Vyvgart. Our reviewer says that the 
services are medically necessary. Our physician reviewer found the clinical documentation in the case file 
supports that Vyvgart is medically reasonable and necessary for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vyvgart have been met. Therefore, we decided that the Plan has to pre-approve 
Vyvgart.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve orthopedic shoes (L3221) and foot orthotics (L3030). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says these items are not covered under your contractual policy 
or by Medicare for your condition. 
 
Medicare rules state that supportive devices for the feet (such as orthopedic footwear) are only covered for 
patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthopedic footwear may be appropriate for you, neither Medicare nor the Plan provides coverage of these 
items for your condition. Additionally, the rules say that with the exception of the situations described, 
orthopedic footwear billed using codes L3030 and L3221 will be denied as noncovered. Therefore, we decided 
that the Plan does not have to pre-approve orthopedic shoes (L3221) and foot orthotics (L3030).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic laboratory services provided on March 22, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for diagnostic laboratory services. You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the provider is out-of-network and 
authorization is required prior to an out-of-network visit. 
 
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 diagnostic laboratory services provided on March 
22, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic care. 
 
You asked the Plan to pre-approve chiropractic care. You say that you need chiropractic care for neck pain.  
The Plan denied your request. The Plan says the member has not been evaluated in clinic for neck pain. Based 
on medical records and expert review, the member has no diagnosis to justify referral for chiropractic care. 
 
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 chiropractic care. Our reviewer says 
that chiropractic care is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the record indicates that you were last evaluated for neck pain over one year ago. The 
record provided does not indicate that you have subluxation. The record does not include a current evaluation 
for neck pain due to subluxation or any other diagnosis. The record provided does not establish the medical 
necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the 
coverage criteria are not satisfied.   
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of chiropractic care have not been met. Therefore, we decided that the Plan does 
not have to pre-approve chiropractic care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 7, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. 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 an office visit provided on June 7, 2022, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the eye exam provided on June 27, 2022. 
 
You asked the Plan to waive the copayment for the eye exam. You say that you do not feel that this should be 
considered diagnosis or treatment of a disease or condition of the eye. You state that you presented to the 
provider for a routine eye exam and mentioned one vision issue which was noted to be not of concern with no 
follow-up recommended. The Plan denied your request. The Plan says that this copayment was correctly 
applied for a Medicare-covered eye exam. 
 
The Plan must follow Medicare rules. Medicare rules say that health plans must clearly and accurately describe 
all conditions for coverage under the Plan. 
 
In this case, the determining factor of whether a copayment is assessed is whether the eye exam is to diagnose 
and treat conditions of the eye or to determine the level of refractive error for the purposes of prescribing 
eyeglasses. We find that the contract does not clearly indicate the distinction for situations in which an enrollee 
presents for the purpose of having eyeglasses prescribed but incidentally mentions a related vision problem that 
is discussed briefly. The provider in this case was confirmed per the company website to be in-network with 
the routine vision care vendor, as well as a network provider with the Plan. This was assessed a copayment 
because the claim was submitted directly to the Plan and not to the routine vision vendor. It does not appear 
from the record that any conditions were diagnosed or treated that would not be generally considered part of a 
full history given during a routine eye exam. The progress note indicates that you were directed to consult your 
primary care provider for the symptoms you related during the vision exam. Based on the entirety of the 
evidence and the lack of clarity from the contract, we find that the assessment of the copayment for this visit is 
not supported. Therefore, we decided that the Plan has to waive the copayment for the eye exam provided on 
June 27, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dupixent. 
 
You asked the Plan to pre-approve Dupixent. You say that you would like the Plan to reconsider their denial. 
The Plan denied your request. The Plan says Dupixent is not covered under the enrollee's Medicare Part B 
benefit. 
 
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 Dupixent.  
 
Benefits for Dupixent 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 waive the copayment for office visit on June 07, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing you are being charged is 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 $5 
copayment for office visits.  
 
You have been asked to pay a $5 copayment for office visit. Office visit falls within the Doctor office visits 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for office visit on June 07, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from June 
22, 2021, to July 21, 2021.  
You asked the Plan to pay for home health 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. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the claim 
was billed with discharge status code of 06, which indicates this is a partial period. However, a full period of 
care was billed. This means these services are not payable as billed. Therefore, we decided that the Plan does 
not have to pay for the home health services provided to the enrollee from June 22, 2021, to July 21, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight (8) massage therapy visits to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve massage therapy. You say that there is only one in-network provider in 
close proximity to the enrollees home. You also say this provider has limited access. The Plan denied your 
request. The Plan says the requested services are available within the Plans network. The only time out-of-
network care is authorized is when the services are not available within the network. The Plan provided a list of 
several massage therapists located near the enrollee. 
 
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 eight (8) massage therapy visits to be provided by an out-of-network 
(OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you have been to the local skilled nursing facility 
and you always end back up in the hospital. You also say that you need more physical therapy to become 
stronger before you are discharged home. The Plan denied your request. The Plan says There is no indication 
that a lower level of care such as a skilled nursing facility would not be able to provide the appropriate therapy 
services you require. You do not meet criteria for IRF admission based on your need for, or ability to 
participate in a higher intensity of therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you were admitted for lower extremity weakness. Medical problems are stable. There 
are no complex nursing or rehabilitation needs. While you have a need for physical or occupational therapy, 
there is no documentation of a need for an intensive rehabilitation program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code billed for date of service April 21, 2022. 
 
You asked the Plan to pay for procedure code . You say that this service was medically necessary and billed 
correctly. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 15777 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
billed for date of service April 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an Injection provided on May 30, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an Injection. You say that you would like to request reconsideration for payment. 
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 an Injection provided on May 30, 2022, by an out-
of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve Injectafer. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee is not on oral iron supplements. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare covers sodium ferric gluconate 
complex in sucrose injections or iron sucrose injections as a first line treatment of iron deficiency anemia when 
furnished intravenously to patients undergoing chronic hemodialysis who are receiving supplemental 
erythropoeitin therapy. 
 
We looked at the file and Medicare rules. The records do not show that the enrollee is undergoing chronic 
hemodialysis or receiving supplemental erythropoeitin therapy. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from December 30, 
2020, through December 31, 2020. 
 
You asked the Plan to pay for the acute inpatient hospital care. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the inpatient 
hospital care provided was not medically necessary. 
 
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 the 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 was sent to the Emergency Department (ED) on  
December 30, 2020 from an outside hospital with elevated troponin. He was then admitted. The enrollee 
remained in a sinus rhythm. A stress test was not fully completed due to patient anxiety. The enrollee was felt 
to be stable and was discharged home on December 31, 2020 with outpatient follow-up. The review has 
determined that the record did not show that at the time of the inpatient admission the admitting physician 
reasonably expected that the enrollees necessary hospital care (including earlier ED and/or observation care) 
would span two midnights. 
 
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 acute inpatient hospital care have not been met. Therefore, we decided that 
the Plan does not have to pay for the acute inpatient hospital care provided from December 30, 2020, through 
December 31, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance on April 02, 2022. 
 
You asked the Plan to waive the copayment for ambulance. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing you are being charged is 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 $250 
copayment for each one-way Medicare-covered ground trip. Covered ambulance services include fixed wing, 
rotary wing, and ground ambulance services, to the nearest appropriate facility that can provide care only if 
they are furnished to a member whose medical condition is such that other means of transportation could 
endanger the persons health or if authorized by the plan.  
 
You have been asked to pay a $250 copayment for ambulance. Ambulance 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 on April 02, 2022.