Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the member clearly exceeds the Centers 
for Medicare and Medicaid Services (CMS) established, defining criteria for an appropriate LTACH admission. 
The physician also says that the LTACH patient should have multiple co-morbidities and require an average 
length of stay greater than 25 days. The physician also says that the member was admitted with shortness of 
breath and now requires LTACH level of care in order to fully recover. The Plan denied your request. The Plan 
says the member is receiving appropriate in-patient acute care and is currently unstable for transfer to an 
LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. Our physician reviewer also found that the 
Plan has approved ongoing care in the current acute care setting.  
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hearing aids (V5261) and hearing aid or assistive 
listening device/supplies/accessories (V5267). 
 
You asked the Plan to pre-approve the hearing aids and hearing aid or assistive listening 
device/supplies/accessories. You say that your audiologist specifically prescribed a non-plan approved hearing 
aid brand because the Plan's approved brand does not work for your hearing loss. The Plan denied your request. 
The Plan says these hearing aids are not covered by Medicare. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when the hearing aids are the Plan's approved hearing aid brand. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids and hearing aid or assistive listening device/supplies/accessories have not been 
met. Therefore, we decided that the Plan does not have to pre-approve hearing aids (V5261) and hearing aid or 
assistive listening device/supplies/accessories (V5267).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqvio. 
 
You asked the Plan to pre-approve Leqvio. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Leqvio. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a diagnosis of hyperlipidemia with a strong family history of cardiovascular disease and 
intolerance or therapeutic failure with statin medications and other cholesterol medications. The documentation 
does not support that the enrollee has tried and failed Repatha. The documentation does not support that 
Repatha 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 Leqvio have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Leqvio.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation. 
 
You asked the Plan to pre-approve additional transportation. The Plan denied your request. The Plan says you 
have already received the Plan benefit of 36 one-way transportation trips. The Plan also says that your plan 
benefit for this service is exhausted. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 36 one-way non-emergency ground transportation trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional transportation.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zofran tablets. 
 
You asked the Plan to pre-approve Zofran tablets. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says Zofran tablets are 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 Zofran tablets.  
 
Benefits for Zofran tablets 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete lower denture and upper partial denture. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
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 one complete 
upper denture every five years and one lower partial denture every five years.  
 
We looked at the file and the Plans rules. The file shows that the enrollee previously received complete 
dentures on January 21, 2019. Based on this information, we decided that the Plan's rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pre-approve a complete lower 
denture and upper partial denture.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional transportation. You say that you are requesting a total of 60 rides 
to be provided to the enrollee continue to receive the services provided at the adult care facility. The Plan 
denied your request. The Plan says this request exceeds the maximum count allowed per period. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 60 one-way trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex superion interspinous device. 
 
You asked the Plan to pre-approve Vertiflex superion interspinous device. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
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 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 enrollee was being treated for spinal stenosis of the lumbar region 
with neurogenic claudication. Food and Drug Administration (FDA) contraindications include spinal 
instability, scoliosis, obesity, and osteoporosis, and which have not been adequately addressed in the medical 
records. There is imaging evidence of 3mm of degenerative anterolisthesis of L3 on L4, with no discussion of 
spinal instability on flexion/extension films. There is no discussion of scoliosis of the lumbar spine, with no 
documentation of the Cobb angle. There is no discussion indicating that a DEXA scan has demonstrated the 
lack of significant osteoporosis in this enrollee. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the enrollee 
does not meet criteria for the requested services.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex superion interspinous device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Vertiflex superion interspinous device.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy visits. 
 
You asked the Plan to pre-approve massage therapy visits. You say that you feel your need is more of a priority 
than what was suggested. You also say that you see this as a way for the insurance to not have to pay so much. 
The Plan denied your request. The Plan says Medicare does not cover massage therapy. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve massage therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit and follow up visits to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a specialist office visit and follow up visits. You say that you have been 
going to this provider for 15 years. The Plan denied your request. The Plan says this request can be safely given 
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 
a specialist office visit and follow up visits 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 Headgear used with positive airway pressure device 
(A7035) to be covered every 4 months. 
 
You asked the Plan to pre-approve the headgear. You say that the headgear stretches out when you sleep and 
over time does not fit correctly, which causes the mask to fall off. In the past it was covered every 3 months. 
You need it at least every 4 months for the machine to work properly and help your health issues. The Plan 
denied your request. The Plan says this request exceeds the Plan's benefit allowed. 
 
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. Per the Plan's policy for Respiratory Assist Devices, the allowed 
quantity for A7035 is 1 per 6 months or 1 every 170 floating days. The policy says that billing for quantities of 
supplies greater than those described in the policy as the usual maximum amounts will deny as not medically 
necessary. Based on this information, we decided that Medicare rules for coverage of the headgear have not 
been met. Therefore, we decided that the Plan does not have to pre-approve Headgear used with positive 
airway pressure device (A7035) to be covered every 4 months.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
May 18, 2022, to May 21, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that because the urinary 
infection which was never cured during the first inpatient hospitalization a second was required. The Plan 
denied your request. The Plan says you have been charged the correct cost sharing 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 $295 
copayment per day for days 1 to 6 and $0 copayment per day for days 7 to 90 for inpatient hospital care.  
 
You have been asked to pay a $590 copayment for the inpatient hospital stay. The inpatient hospital stay falls 
within the Inpatient Hospital Care 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 inpatient hospital stay provided from May 18, 2022, to May 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on April 12, 2022. 
 
You asked the Plan to waive the copayment for the office visit. You say that you are appealing this cost-
sharing. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $40 
copayment for a specialist visit.  
 
You have been asked to pay a $40 copayment for the office visit. The office visit falls within the 
Physician/Practitioner Services, Including Doctors 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 the office visit provided on April 12, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that this large copayment will 
cause a financial hardship. The Plan denied your request. The Plan says you were charged this cost sharing 
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 $350 
copayment for each ambulance trip. You had 2 ambulance trip(s). The Plan charged you $557.76 for these 
services. The first trip was $262.88, the second trip was $293.88, totaling $557.76. 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 ambulance services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service January 14, 
2022. 
 
You asked the Plan to pay for procedure code 99053. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code 99053 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service January 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an arthrocentesis provided on April 8, 
2022. 
 
You asked the Plan to waive the copayment for an arthrocentesis. You say that you believe this claim was 
billed incorrectly. You say the service was a procedure and not an operation. The Plan denied your request. The 
Plan says the copayment applied 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 $310 
copayment for each Medicare-covered outpatient surgery at an outpatient hospital facility.  
 
 
  You have been asked to pay a $310 copayment for an arthrocentesis. An arthrocentesis falls within the 
Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers, benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for an arthrocentesis provided 
on April 8, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says you have used 40 out of the 50 allotted 
one-way trips for the 2022 benefit year and additional trips will not be approved. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 50 one-way transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have used 40 out of the 50 allotted one-way trips for the 2022 benefit year and additional trips will not 
be approved. Therefore, we decided that the Plan does not have to pre-approve additional routine 
transportation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for targeted genomic sequence analysis testing provided on 
April 26, 2022. 
 
You asked the Plan to pay for genetic testing. You say that this testing has been determined by Medicare to be 
reasonable and necessary for the management of the enrollee's condition. The Plan denied your request. The 
Plan says this testing was not billed in accordance with Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic tests must be billed with 
certain coding elements, including the DEX Z-Code for the test.  
 
We looked at the file and Medicare rules. This testing was not billed with the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field, as required by Medicare rules. Based on this 
information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we 
decided that the Plan does not have to pay for targeted genomic sequence analysis testing provided on April 26, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the patient is stable and will require 
extended acute care. You also say that the requested facility is the appropriate level of care to manage this 
member's ongoing intensive care unit (ICU) needs. You also say that the present facility is not a LTACH 
facility. The Plan denied your request. The Plan says the member is receiving appropriate in-patient acute care 
and is currently unstable for transfer 
to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the patient does not require services at the LTACH that are not already available at 
the current facility. Our physician reviewer also says that completion of treatment at the current facility is 
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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.