Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group three power wheelchair with accessories. 
 
You asked the Plan to pre-approve a group three power wheelchair with accessories. You say that you would 
like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for the requested item. 
 The Plan must follow Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The 
rules also say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility 
limitation that is due to: 
1. A neurological condition; 
2. Myopathy; or 
3. Congenital skeletal deformity. 
 
In addition, to the group three wheelchair requirements, the enrollee must meet the regular power wheelchair 
and group two power wheelchair criteria. 
 
The file does not support that the enrollee can safely operate the power wheelchair being requested. The 
requested group three power wheelchair exceeds the enrollees needs. This means that Medicare rules for 
coverage of a group three power wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group three power wheelchair with accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an injection on January 31, 2022. 
 
You asked the Plan to waive the copayment for an injection. You say that you would like to appeal the cost 
share. The Plan denied your request. The Plan says the cost share 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 20% 
coinsurance for an injection. The total allowed amount of the injections is $3,339, resulting in a coinsurance 
amount of $667.80. 
 
You have been asked to pay a 20% coinsurance for an injection. An injection falls 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 copayment for an injection on 
January 31, 2022.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance basic life support (BLS) services (A0429) provided on 
January 4, 2022. 
 
You asked the Plan to pay for BLS ambulance services. You say that these services were billed appropriately 
and should be paid at the BLS rate. You say that payment should be provided at the BLS emergency transport 
(A0429) rate with the QL modifier. The Plan denied your request. The Plan says that the code submitted for 
this claim is inappropriate for the services provided. 
 
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. Based on the medical records provided, the enrollee was experiencing shortness 
of breath and trouble breathing following a coughing fit, which resulted in family members calling emergency 
medical services (EMS). EMS arrived on the scene, where the enrollee was pronounced dead. Based on the 
medical records, it appears that the enrollee was pronounced dead after EMS was dispatched but before he was 
loaded onboard the ambulance. This means that the provider/supplier may bill the Basic Life Support (BLS) 
base rate with no mileage or rural adjustment. Modifier QL must be appended to the claim. 
 
The Plan did not provide a clear copy of the original claim submitted for payment. The single image submitted 
to us for review has poor resolution, and while we can verify that the code billed does appear to be A0429, 
which is emergency ambulance services at the BLS rate, we cannot clearly see if a modifier, specifically QL, 
was billed with this claim. It is the Plans responsibility to send clear supporting documentation, and the provider does mention the modifier and appears to be aware that modifier QL is appropriate in this case. The 
Plans argument is not substantiated in this case. Therefore, we decided that the Plan has to pay for ambulance 
basic life support (BLS) services (A0429) provided on January 4, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prolotherapy. 
 
You asked the Plan to pre-approve prolotherapy. The Plan denied your request. The Plan says this is not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that intraarticular and extraarticular facet joint 
prolotherapy are not covered. 
 
We looked at the file and Medicare rules. Per LCD L38801, the requested prolotherapy is not medically 
reasonable and necessary, and therefore, is non-covered. Based on this information, we decided that Medicare 
rules for coverage of prolotherapy have not been met. Therefore, we decided that the Plan does not have to pre-
approve prolotherapy.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
February 8, 2022. 
 
You asked the Plan to waive the copayment for the ER visit. 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 $120 
copayment for Emergency care.  
 
 
  You have been asked to pay a $30 copayment for the ER visit, which is less than the standard $120. 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 emergency room (ER) visit provided on February 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pneumatic compression device (E0652, E0656, E0667). 
 
You asked the Plan to pre-approve pneumatic compression devices. You say that the requested items are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for the 
requested items have not been met. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve pneumatic compression device 
(E0652, E0656, E0667).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an Emergency Room visit provided on 
January 8, 2022, to January 10, 2022. 
 
You asked the Plan to waive the copayment for an Emergency Room visit. You say that you went to the ER 
and that you were kept in the room there for an extended period of time, therefore you should not have to pay a 
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 $90 
copayment for Emergency Care.  
 
You have been asked to pay a $90 copayment for an Emergency Room visit. An Emergency Room visit falls 
within the In-Network Emergency 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 an Emergency Room visit provided on January 8, 2022, to January 10, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio for the enrollee. 
 
You asked the Plan to pre-approve Entyvio. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is no indication their preferred drugs would likely be less effective, and/or 
cause adverse effects for the enrollee. 
 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 reviewer says that 
Entyvio is not medically reasonable and necessary. There is no indication that the patient has tried and failed 
Stelara. There is no indication that the Plan's required drug would likely be less effective and/or likely have 
adverse effects for the patient. Our physician reviewer found that the enrollee's condition does not meet step 
therapy criteria for Entyvio. 
 
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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgery provided on March 25, 2022 by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for surgery. You say that you would like to appeal the denial of the claim. The Plan 
denied your request. The Plan says the provider is out-of-network, and it was determined these services can be 
received in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for surgery provided on March 25, 2022 by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on January 5, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the rendering provider is a 
hospitalist physician with the group and depends upon the hospital staff to verify eligibility and to obtain the 
proper authorization from the patient's insurance company. The Plan denied your request. The Plan says 
services from non-participating providers are not covered under open access 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 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 subsequent nursing facility care provided on 
January 5, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee can safely receive the services the enrollee needs in other 
settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for pancreatitis. The 
enrollees medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does 
not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that this patient will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Privigen for the enrollee. 
 You asked the Plan to pre-approve Privigen. You say that this is medically necessary for the treatment of the 
patient's cancer. The Plan denied your request. The Plan says that the requested drug would be deemed a 
routine cost of the clinical trial. 
 
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 Privigen 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 Privigen for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
February 9, 2022. 
 
You asked the Plan to waive the copayment for the office visit. You say that you were not seen that day. You 
say that you were told to return on March 4th. 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 $45 
copayment for each specialist visit.  
 
The record shows that you were seen and evaluated on February 9, 2022. Therefore, you have been asked to 
pay a $45 copayment for the office visit. The office visit falls within the Physician/Practitioner Services, 
Including Doctor's 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 a 
specialist office visit provided on February 9, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3. 
 
You asked the Plan to pre-approve Gelsyn-3. You say that this is medically necessary. The Plan denied your 
request. The Plan says that you do not have any stated contraindications to the preferred products. 
 
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 Gelsyn-3. Our reviewer says that 
Gelsyn-3 is not medically reasonable and necessary. There is no indication that the patient has tried and failed 
Orthovisc, Synvisc or Synvisc-One. There is no indication that the Plan's required drugs would likely be less 
effective and/or likely have adverse effects for the patient. Our physician reviewer found that your condition 
does not meet step therapy criteria for Gelsyn-3. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gelsyn-3.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Personal Emergency Response System provided on 
February 1, 2022. 
 
You asked the Plan to pay for Personal Emergency Response System. The Plan denied your request. The Plan 
says the prior authorization was exhausted, no more units left. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
We looked at the file, the Plans rules and the Medicare rules. The file shows that you have exhausted the 
approved units. Therefore, we decided that the Plan does not have to pay for Personal Emergency Response 
System provided on February 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 7, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on February 7, 2022 by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the genetic testing provided to the enrollee on March 2, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says that prior approval was 
not obtained. 
 
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 provided the testing by a contract provider. The file does not show that the plan provided 
notice that the testing would not be covered. Under Medicare rules, this means the testing is considered 
approved by the plan. Therefore, we decided that the Plan has to pay for the genetic testing provided to the 
enrollee on March 2, 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.