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

 
We decided that the Plan does not have to pre-approve mobile cardiac outpatient telemetry (MCOT) 
monitoring. 
 
You asked the Plan to pre-approve the MCOT monitoring. You say that it is felt that this service is needed to 
evaluate the enrollee's condition. The Plan denied your request. The Plan says the enrollee does not meet 
coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that services such as MCOT monitoring are used for the 
indications listed in the Medicare rules section of this decision when documentation of medical necessity is 
provided.  
 
 
 
 
 
 
 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 MCOT monitoring. Our reviewer 
says that the requested services are not shown to be medically reasonable and necessary. Our physician 
reviewer found the enrollee has documented atrial fibrillation and what is felt to reflect sick sinus syndrome. 
However, he has been asymptomatic. As such, guidelines would not support a need for MCOT monitoring in 
this setting. In summary, there is insufficient documentation to support the medical necessity for an MCOT 
monitor 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 the MCOT monitoring have not been met. Therefore, we decided that the Plan 
does not have to pre-approve mobile cardiac outpatient telemetry (MCOT) monitoring.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 16, 2021. 
 
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 testing is not covered.  
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on April 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS HF System. 
 
You asked the Plan to pre-approve a CardioMEMS HF System. You say that the requested device is medically 
necessary. The Plan denied your request. The Plan says the requested device has been determined to be of 
uncertain value in the most recent 2022 ACC/AHA guidelines and carries a risk of significant complications 
including death and severe pulmonary artery injury. The device at this point should only be approved for 
patients enrolled in a clinical trial. 
 
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 a CardioMEMS HF System. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there remains a dearth of randomized, blinded clinical studies examining 
long-term clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this 
time the CardioMEMS system would not be considered medically appropriate and necessary in the 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 a CardioMEMS HF System have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a CardioMEMS HF System.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair (E0240) and a vehicle modification (a 
ramp) (T2039). 
 
You asked the Plan to pre-approve a shower chair and a ramp. You say that you need the requested items due 
to osteoarthritis. You also say you need to see an orthopedic surgeon and schedule a surgery. You will not be 
able to schedule surgery until the requested items are available to you. The Plan denied your request. The Plan 
says the requested items are not covered by Medicare or your Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs and a vehicle modification are not 
covered because they are not primarily medical in nature.  
 
While a shower chair and a vehicle modification may be appropriate in this case, neither the Plan nor Medicare 
offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair 
(E0240) and a vehicle modification (a ramp) (T2039).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lanreotide injection (J1930) provided on February 1, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the injection. You say that authorization was obtained for the service in this case. 
You also say that the service is medically necessary. The Plan denied your request. The Plan says prior 
authorization was not obtained. 
 
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 lanreotide injection (J1930) provided on February 1, 2022, by 
an out-of-network (OON) provider.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for skilled nursing facility (SNF) services provided from December 3, 
2021, to December 10, 2021. 
 
You asked the Plan to pay for SNF care. You say that these services were pre-approved. The Plan denied your 
request. The Plan says that this claim cannot be paid because the provider's tax identification number (TIN) 
submitted on this claim is inconsistent with the TIN on the authorization. 
 
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. Specifically, the Plan has not provided a clear explanation as to why a 
mismatched TIN means this claim cannot be paid, as it appears that the provider who received the authorization 
is the one who provided services. The Plan also has not provided any citation or rules to support their claim that 
this discrepancy means this claim cannot be paid by Medicare rules. Therefore, we decided that the Plan has to 
pay for skilled nursing facility (SNF) services provided from December 3, 2021, to December 10, 2021.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 13, 2022, by an 
OON provider. 
 
You asked the Plan to pay for laboratory services. You say that you are requesting a reconsideration for the 
laboratory services. 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 laboratory services provided on January 13, 2022, 
by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Oncology (urothelial), mRNA, gene expression profiling by 
real - time quantitative PCR of five genes (0013M) provided December 20, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that you request prompt review of this information 
and authorization of coverage for the Cxbladder Monitor test for this enrollee. The Plan denied your request. 
The Plan says this service is not covered by Medicare. 
 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 Plan confirmed with the doctor's office that the ordering 
provider indicated did not order these services. Based on this information, we decided that Medicare rules for 
coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
Oncology (urothelial), mRNA, gene expression profiling by real - time quantitative PCR of five genes (0013M) 
provided December 20, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for an echocardiogram provided on January 26, 2022. 
 
You asked the Plan to pay for an echocardiogram. You say that you have had multiple follow-up services and 
the Plan has covered them without any prior authorization. The Plan denied your request. The Plan says that the 
rendering provider is an out-of-network provider and there was no authorization. 
 
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 says there was no authorization for out-of-network services. The 
Evidence of Coverage clearly states that prior authorization is not required for out-of-network services. This 
means that the Plan has not provided a valid reason for denying payment of the echocardiography. It is the 
burden of the Health Plan to substantiate their denial with evidence. In this case, the denial has not been 
substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for an 
echocardiogram provided on January 26, 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: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for the PT visit provided on October 21, 2021. 
 
You asked the Plan to pay for the PT visit. You say that you faxed the referral from the PCP. The Plan denied 
your request. The Plan says that there is not a referral on file for the date of service and will not be covered. 
 
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.  Specifically, the Plan denied for no referral but a referral was submitted in the 
case file. The Plan has not provided any other valid reason for denying coverage of the physical therapy 
services. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the denial 
has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for the 
physical therapy visit provided on October 21, 2021.  
 
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 pay for the lumbar-sacral orthosis (L0650) provided on February 28, 
2022. 
 
You asked the Plan to pay for the lumbar-sacral orthosis. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says this claim is missing documentation 
required for payment. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. In this case, the documentation does not support the ordering provider discussed the need for the 
medical equipment with the enrollee. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the 
lumbar-sacral orthosis (L0650) provided on February 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on July 18, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that you provided the medical records and 
would like the claim reprocessed for payment. The Plan denied your request. The Plan says the rendering 
provider is an OON provider and there was no referral from an in-network provider or an approved 
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 nursing facility care provided on July 18, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the photochemotherapy rendered from 
November 19, 2021, to March 21, 2022. 
 
You asked the Plan to waive the copayments for these services. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the copayments were applied 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 each Medicare-covered specialist office visit for Flex Plan 3 members.  
 
Review of the file shows that you received photochemotheraphy from November 19, 2022, to March 21, 2022. 
You have been asked to pay a $50 copayment per date of service for these services. These services fall within 
the Medicare-covered specialist office visit for Flex Plan 3 members 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 photochemotherapy rendered from November 19, 2021, to 
March 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the squash club membership provided in 2021. 
 
You asked the Plan to pay for a squash club membership. You say that this facility has exercise equipment. The 
Plan denied your request. The Plan says this facility is not considered a qualified health club or fitness facility. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plans benefit does not 
cover membership fees paid to non-qualified health clubs or fitness facilities, including but not limited to 
country clubs, sports clubs and social clubs, or sports activities such as golf and tennis. 
 
The Plans rules for coverage of gym benefits have not been met because a squash club membership does not 
count as a qualified health club or fitness facility. Therefore, we decided that the Plan does not have to pay for 
the squash club membership provided in 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Assessment of and care planning for a patient with cognitive 
impairment provided on February 21, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Assessment of and care planning for a patient with cognitive impairment. 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 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 Assessment of and care planning for a patient with 
cognitive impairment provided on February 21, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 27, 2020. 
 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 testing is not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on October 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided on February 28, 2022. 
 
You asked the Plan to pay for the inpatient hospital care. The Plan denied your request. The Plan says the Plan 
requires prior approval for services that will be given by a non-contracted provider or an out of area service 
(this excludes urgently needed care or emergency 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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for inpatient hospital care provided on February 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses purchased on February 16, 2022, from an out-
of-network provider. 
 You asked the Plan to pay for the eyeglasses. You say that you were not aware that you had a benefit to cover 
eyewear until after you made this purchase. The Plan denied your request. The Plan says eyewear is only 
covered when it is purchased through the Plan's specified vendor network. 
 
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 these services up to $200 when they are received from a provider within the 
specified vendor network. 
 
We looked at the file and the Plan's rules. The eyeglasses in this case were purchased outside of the specified 
network. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not 
been met. Therefore, we decided that the Plan does not have to pay for the eyeglasses purchased on February 
16, 2022, from an out-of-network provider.