Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on September 3, 2021. 
 
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 as billed. 
 
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 September 3, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214), an x-ray exam of the knee (73562), 
an x-ray exam of the shoulder (73030) and an x-ray exam of the collar bone (73000) provided on September 
23, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit and x-rays. You say that the enrollee was a surgical patient from 
2019. She was experiencing pain and required immediate treatment which was provided to maintain continuity 
of care. You also say that the enrollee did not notify the office of her transition to this new Plan and presented a 
Medicare card for payment. The Plan denied your request. The Plan says the requested services were not 
authorized by network/primary care providers.  
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. The records provided for review do not show that the services at issue were urgent or 
emergent. 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 (99214), an x-ray exam of the knee (73562), an x-
ray exam of the shoulder (73030) and an x-ray exam of the collar bone (73000) provided on September 23, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network 
(OON) provider on January 24, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service was rendered by an out of network 
provider, without prior authorization or a referral. 
 
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 had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99213) rendered by the out-of-network (OON) provider on January 24, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that you would like the plan to reconsider their 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 Prolia. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has osteoporosis. The enrollee had a fracture while on Fosamax; the enrollee's creatinine 
clearance is reported to be either 51 mL/minute or 60 mL/minute (race not defined). While the documentation 
does show that the enrollee has tried and failed an oral bisphosphonate, the documentation does not support 
that the enrollee has tried and failed zoledronic acid. Based on the medical records provided and the Medicare-
approved major drug compendia there is no indication that zoledronic acid would likely be less effective and/or 
likely have adverse effects for the enrollee. Therefore, the enrollee does not meet criteria for the requested 
drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the anesthesia (01922). 
 
You asked the Plan to pay for the anesthesia. You say that the service was medically necessary. The Plan 
denied your request. The Plan says that the service was not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that services that are medically necessary are 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 pay for the anesthesia. Our reviewer says that the 
service was medically necessary. Our physician reviewer found the patient had a significant past medical history to warrant monitored anesthesia care for this procedure. 
 
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 anesthesia have been met. Therefore, we decided that the Plan has to pay for 
the anesthesia (01922).  
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio. 
 
You asked the Plan to pre-approve Entyvio. You say that Entyvio is the most appropriate medication for this 
enrollee. The Plan denied your request. The Plan says the enrollee has not tried and failed Stelara. 
 
 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 Entyvio. Our physician reviewer found 
that Entyvio was requested to treat Crohn's disease. The Plan requires a trial of Stelara before they will approve 
the requested drug. In this case, the enrollee has not tried and failed the required drug. There is no 
documentation provided indicating that the plans required drug would likely be less effective 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 Entyvio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Entyvio.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Electrical stimulator supplies (A4595), provided on January 
20, 2022. 
 
You asked the Plan to pay for Electrical stimulator supplies. You say that the item are medically necessary. The 
Plan denied your request. The Plan says the item are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that items 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 pay for Electrical stimulator supplies. Our reviewer 
says that the items are not medically necessary. Our physician reviewer found the provided documentation did 
not clearly show that the TENS provided measurable functional gains and pain reduction to justify ongoing 
regular use which would require replacement leads. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Electrical stimulator supplies have not been met. Therefore, we decided that the 
Plan does not have to pay for Electrical stimulator supplies (A4595), provided on January 20, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound provided on March 21, 
2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you should not have to pay for the 
ultrasound because it was not done properly. The Plan denied your request. The Plan says the copayment was 
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 $30 
copay for all other in-network Medicare-covered diagnostic tests and procedures.  
 
  You have been asked to pay $30 for the ultrasound as the $50 copayment is for x-rays only. The ultrasound 
falls within the Outpatient diagnostic tests and therapeutic services and supplies 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 the ultrasound provided on March 21, 2022
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard (21089). 
 
You asked the Plan to pre-approve the occlusal guard. You say that the occlusal guard is medically necessary. 
The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that Oral appliances, devices, splints, and occlusal 
guards- of any kind - are non-covered for the treatment of temporomandibular joint (TMJ) disorders. 
 
We looked at the file and Medicare rules. The requested guard is for treatment of a temporomandibular joint 
disorder. This is not a covered item. Based on this information, we decided that Medicare rules for coverage of 
the occlusal guard have not been met. Therefore, we decided that the Plan does not have to pre-approve an 
occlusal guard (21089).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300) for a power 
wheelchair. 
 
You asked the Plan to pre-approve the power seat elevation system. You say that the requested feature is 
medically necessary. The Plan denied your request. The Plan says this item is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and 
power standing feature (E2301) are non-covered because they are not primarily medical in nature. 
 
We looked at the file and Medicare rules. The power seat elevation feature is not covered under Medicare rules. 
Based on this information, we decided that Medicare rules for coverage of the power seat elevation system 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation 
system (E2300) for a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) for a power 
wheelchair. 
 
You asked the Plan to pre-approve the power seat elevation feature. You say that this feature is medically 
necessary. The Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and 
power standing feature (E2301) are non-covered because they are not primarily medical in nature. 
 
We looked at the file and Medicare rules. The requested power seat elevation feature is not covered under 
Medicare rules. Based on this information, we decided that Medicare rules for coverage of the power seat 
elevation feature have not been met. Therefore, we decided that the Plan does not have to pre-approve a power 
seat elevation feature (E2300) for a power wheelchair.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a tubal ligation procedure (58700). 
 
You asked the Plan to pay for the tubal ligation procedure. You say that the service is medically necessary. The 
Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that services for the purposes of preventing conception 
(contraception) are not considered medically reasonable and necessary.  
 
Records show that the requested service is primarily for the purpose of contraception. The documentation does 
not show that this service is being requested to treat a specific illness/injury. As such, the Medicare rules for 
coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for a tubal 
ligation procedure (58700).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ear, nose, and throat visit (99203, 99213) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the out-of-network ear, nose, and throat visit. You say that the service is 
medically necessary. The Plan denied your request. The Plan says there are network providers available that 
can provide this service. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an ear, 
nose, and throat visit (99203, 99213) 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 pre-approve durable medical equipment to be provided by Amazon. 
 
You asked the Plan to pre-approve durable medical equipment provided by Amazon. You say that you would 
like the Plan to reconsider their denial. The Plan denied your request. The Plan says the services are not 
covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pre-approve durable medical equipment to be 
provided by Amazon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve resin-based posteriors for teeth #4, #5, and #12 (D2393) 
to be provided by a network provider. 
 
You asked the Plan to pre-approve the resin-based posteriors for teeth #4, #5, and #12 (D2393). You say that 
you are appealing the denials of the services. The Plan denied your request. The Plan says the restorations are a 
benefit only when the x-ray and/or photo show evidence of decay or tooth fracture. The Plan says this does not 
meet criteria. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the resin-
based posteriors for teeth #4, #5, and #12 (D2393) when the services are medically necessary and reasonable.  
 
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 resin-based posteriors for teeth #4, 
#5, and #12 (D2393). Our reviewer says that the services are not medically necessary. Our physician reviewer 
found that the photos do show a darkening of the dentin on all three teeth on the buccal surfaces which would be small areas of decay. The record does appear to show that there is a need for the requested restorations on 
only the facial surface of #4 and #5, and not the mesial and distal surfaces. The planned restoration of tooth #12 
does not appear to address the cavities on two surfaces. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the resin-based posteriors for teeth #4, #5, and #12 (D2393) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve resin-based posteriors for teeth #4, #5, and 
#12 (D2393) to be provided by a network provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on February 
23, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that ambulance transport was 
totally unnecessary. The Plan denied your request. The Plan says the copayment was 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 $250 for 
each one-way Medicare-covered ambulance transport.  
 
You have been asked to pay the allowed amount of $233.65 for the ambulance services rather than the standard 
$250 copayment. The ambulance services fall within the Ambulance Services benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for ambulance services provided on February 23, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Mental Health services provided on November 
10, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Outpatient Mental Health 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 it 
was determined these services were not urgent or emergent. 
 
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 Outpatient Mental Health services provided on 
November 10, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99215) rendered by the out-of-network 
(OON) provider on January 13, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99215) rendered by the out-of-network (OON) provider on January 13, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an octreotide injection (J2353) provided 
on January 18, 2022. 
 
You asked the Plan to waive the coinsurance for the octreotide injection. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
 
  You have been asked to pay a 20% coinsurance for octreotide injections (allowed is $4,234.52 x 20% = 
$846.91). Octreotide injections fall within the Medicare Part B prescription drugs 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 coinsurance for an octreotide injection (J2353) provided on January 18, 2022.