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

 
We decided that the Plan does not have to pay for ambulance response and treatment, no transport provided on 
December 25, 2021. 
 
You asked the Plan to pay for ambulance response and treatment, no transport. The Plan denied your request. 
The Plan says the ambulance benefit is a transport benefit, if no transport of a Medicare beneficiary occurs then 
there is no Medicare covered service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on December 25, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport 
(code A0998) provided on December 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion Interspinous device. 
 
You asked the Plan to pre-approve a Vertiflex Superion Interspinous device. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
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 Vertiflex Superion Interspinous 
device. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the Vertiflex is experimental. More research needed. 
 
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 Vertiflex Superion Interspinous device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Vertiflex Superion Interspinous device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a 180-day supply of Tacrolimus. 
 
You asked the Plan to pre-approve a 180-day supply of Tacrolimus. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says the documentation has provided no special 
circumstance as to why a supply of Tacrolimus in excess of 30 days is medically necessary. Tacrolimus is 
available to the enrollee as a recurring 30-day supply under Medicare Part B. 
 
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. Prescriptions for immunosuppressive drugs generally should be non-
refillable and limited to a 30-day supply. Unless there are special circumstances, contractors will not consider a 
supply of drugs in excess of 30 days to be reasonable and necessary and should deny payment accordingly. The 
file shows that you did not provide any documentation showing there are special circumstances for why the 
enrollee needs a 180-day supply versus a 30-day supply. Therefore, we decided that the Plan does not have to 
pre-approve a 180-day supply of Tacrolimus.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on  
February 7, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the physician provided medically 
necessary services in good faith. The Plan denied your request. The Plan says the member's Plan excludes 
coverage for this out-of-network 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 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 subsequent nursing facility care provided on February 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services (99292) provided August 8, 2021. 
 
You asked the Plan to pay for the critical care services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the documentation does not support the billed services. 
 
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 99292 is critical care services, 30 additional minutes. 
 
We find that CPT code 99292 is not supported in the medical record. Specifically, the record shows 60 minutes 
of critical care time. The additional 30 minutes is not supported in addition to the initial 30-74 minutes. Based 
on this information, we decided that Medicare rules for coverage of the critical care services have not been met. 
Therefore, we decided that the Plan does not have to pay for critical care services (99292) provided August 8, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (70450) provided January 19, 2022. 
 
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
 
 
 
 
 
 
 
 
 We find that CPT code 70450 is not supported in the medical record. Specifically, the claim was submitted 
with an outpatient place of service (22) but the records show the service was provided in the inpatient setting. 
Based on this information, we decided that Medicare rules for coverage of the radiology services have not been 
met. Therefore, we decided that the Plan does not have to pay for radiology services (70450) provided January 
19, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tadalafil. 
 
You asked the Plan to pre-approve Tadalafil. You say that the medication is necessary. The Plan denied your 
request. The Plan says there are in-network providers that are able to provide these services. Therefore, 
coverage criteria have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered 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 Tadalafil.  
 
Benefits for Tadalafil may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve palonosetron HCL (J2469) and aprepitant (J0185). 
 You asked the Plan to pre-approve the anti-emetic drugs. You say that the requested drugs are medically 
necessary for the enrollee's treatment. The Plan denied your request. The Plan says the requested drugs are 
considered routine costs associated with the trial and therefore are not covered. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve the anti-emetic drugs as part of a clinical trial. The Plan does not 
cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have 
to pre-approve palonosetron HCL (J2469) and aprepitant (J0185).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc One. 
 
You asked the Plan to pre-approve Synvisc One. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 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 Synvisc One. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the provided records do not indicate that 
the enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that the 
enrollee has a contraindication to, or would have an adverse effect from the plan's preferred step one 
alternative. The elements of the coverage criteria are not satisfied. The requested service cannot be 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc One have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc One.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital services. 
 
You asked the Plan to pre-approve inpatient hospital services. You say that the requested inpatient hospital 
services are medically necessary. The Plan denied your request. The Plan says the records do not support an 
inpatient level of care. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of inpatient hospital services have been 
met.  Therefore, we decided that the Plan does not have to pre-approve inpatient hospital services.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the computed tomography (CT) scan services (70450) provided on 
February 3, 2022. 
 
You asked the Plan to pay for the CT scan services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says that they are not the primary insurer and 
have yet to receive the explanation of benefits from the primary insurer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
In this case, the Plan has not satisfied its obligation with regards to coordination of benefits. There is no 
evidence that the Plan has sent the bill directly to the primary insurer for payment, directed the provider to send 
the bill to the primary insurer, or paid for the services and submitted a bill for reimbursement to the primary 
insurer. The record only indicate that the Plan called the primary insurer to request an updated explanation of 
benefits. The Plan has failed to coordinate their benefits with the primary insurer. Therefore, we decided that 
the Plan has to pay for the computed tomography (CT) scan services (70450) provided on February 3, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the duplex scan you had on March 9, 2022. 
 
You asked the Plan to waive the copayment for the duplex scan. You say that you do not think the Plan paid its 
fair share for this service since you were left with the entire bill. The Plan denied your request. The Plan says 
you were charged this copayment correctly.  Because the allowed amount for this service is less than your 
copayment obligation, you are responsible for the full allowed amount. 
 
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 $160 
copayment for Medicare-covered radiologic diagnostic services (excluding x-rays).  
 
You have been asked to pay a $160 copayment for the duplex scan. the duplex scan falls within the Medicare-
covered radiologic diagnostic services (excluding x-rays) 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 duplex scan you had on March 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. This enrollee has severe chronic obstructive pulmonary disease (COPD)/asthma and obesity-
hypoventilation syndrome, with chronic carbon dioxide (CO2) retention documented on an arterial blood gas 
(ABG) done while stable. The enrollee may benefit from bilevel positive airway pressure (BiPAP) with 
average volume-assured pressure support (AVAPS) during sleep. Medicare does not cover a home ventilator when used as bipap. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on January 7, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the physician provided medically 
necessary services in good faith. The Plan denied your request. The Plan says services from non-participating 
providers are not covered unless preauthorized. 
 
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 subsequent nursing facility care provided on January 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair and a raised toilet seat. 
 
You asked the Plan to pre-approve a shower chair and a raised toilet seat. You say that you would like the Plan 
to reconsider their denial. The Plan denied your request. The Plan says your over-the-counter supplemental 
benefit does not require authorization or approval. The Plan says you can order the shower chair and raised 
toilet seat on-line or by calling the toll-free number in your benefit guide. The Plan says you have been 
instructed on how to place an order using your over-the-counter benefit for these items. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair and raised toilet seat may be appropriate in this case, these items are not covered under 
Medicare. However, your Plan does offer an over-the-counter supplemental benefit that these items are covered 
under. You do not need authorization or approval to use your over-the-counter supplemental benefit for these 
items. Therefore, we decided that the Plan does not have to pre-approve a shower chair and a raised toilet seat.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
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 pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the documentation, therefore, did not suggest that the enrollee would require hospital services that would likely cross 2 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an MRI provided on February 28, 2022. 
 
You asked the Plan to waive the copayment for an MRI. You say that you should not need to pay this 
copayment. The Plan denied your request. The Plan says the copayment applied was 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 $145 
copayment for Medicare-covered radiological diagnostic services.  
 
You have been asked to pay the allowed amount of $125.41 which is less than the $145 copayment for an MRI. 
An MRI falls within the Medicare-covered radiological diagnostic 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 a magnetic resonance imaging (MRI) provided on February 28, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids provided on January 28, 2022. 
 
You asked the Plan to pay for hearing aids. The Plan denied your request. The Plan says hearing aids ordered 
through providers other than the Plan hearing provider are not covered. 
 
We looked at the file and the Plan's rules. The file shows that the hearing aids were not ordered through the 
Plans hearing provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids 
have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on 
January 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for repairs to a power wheelchair provided December 30, 2021. 
 
You asked the Plan to pay for the repairs to a power wheelchair. You say that this service was medically 
necessary. The Plan denied your request. The Plan says the documentation does not support the billed services. 
 
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 a valid physician order. The physician order provided is for a different patient. 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 repairs to a power wheelchair provided December 
30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99213) provided on March 29, 2022. 
 
You asked the Plan to pay for the office visit. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this service was not emergent or pre-approved. 
 
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 services 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 these services. Therefore, we decided 
that the Plan does not have to pay for an office visit (99213) provided on March 29, 2022.