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

 
We decided that the Plan does not have to pre-approve a battery backup. 
 
You asked the Plan to pre-approve a battery backup. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says a battery backup is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a battery backup.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a genvisc joint injection with fluoroscopic 
guidance performed by an out-of-network (OON) provider on August 23, 2021. 
 
You asked the Plan to waive the coinsurance for the OON injection with fluoroscopic guidance. You say that 
you were informed that all costs would be covered. The Plan denied your request. The Plan says the correct 
coinsurance was applied. 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 50% 
coinsurance for surgery or services at an out-of-network (OON) outpatient hospital or ambulatory surgical 
center. 
 
Your contract with the Plan also clearly says that you must pay a 50% coinsurance for diagnostic procedures 
and tests at an out-of-network (OON) facility. 
 
Your contract with the Plan also clearly says that you must pay a 50% coinsurance for Part B drugs received at 
an out-of-network (OON) facility. 
 
Service/Drug Allowed Amount 50% Coinsurance (OON) 
Injection Procedure $59.68 $29.84 
Fluoroscopic Guidance $107.47 $53.73 
Genvisc Drug $411.00 $205.50 
Total:  $289.07 
 
You have been asked to pay $289.07, which is 50% of the allowed amount for the OON injection with 
fluoroscopic guidance. The injection procedure falls within the Outpatient Surgery, Including Service Provided 
at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. The fluoroscopic guidance 
falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. The 
genvisc drug 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 coinsurance for a genvisc joint injection with fluoroscopic guidance performed by an out-of-
network (OON) provider on August 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a genvisc joint injection performed by an 
out-of-network (OON) provider on September 23, 2021. 
 
You asked the Plan to waive the coinsurance for the OON injection. You say that you were informed that all 
costs would be covered. The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 50% 
coinsurance for surgery or services at an out-of-network (OON) outpatient hospital or ambulatory surgical 
center. 
 Your contract with the Plan also clearly says that you must pay a 50% coinsurance for Part B drugs received at 
an out-of-network (OON) facility. 
 
Service/Drug Allowed Amount 50% Coinsurance (OON) 
Injection Procedure $59.68 29.84 
Genvisc Drug $411.00 $205.50 
Total:  $235.34 
 
You have been asked to pay $235.34, which is 50% of the allowed amount for the OON injection. The 
injection procedure falls within the Outpatient Surgery, Including Service Provided at Hospital Outpatient 
Facilities and Ambulatory Surgical Centers benefit category. The genvisc drug 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 coinsurance for a genvisc joint 
injection performed by an out-of-network (OON) provider on September 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair (K0861) and accessories 
(E1007, E2377, E2311, E1028, K0040, E2313, E2361, E1012, E2609, E2617, E2343, E1020). 
 
You asked the Plan to pre-approve a group 3 power wheelchair and accessories. You say that these items are 
medically necessary. The Plan denied your request. The Plan says this is not covered for the enrollee's 
condition. 
 
The Plan must follow Medicare rules. The rules 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. 
 
The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, 
myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a 
group 3 power wheelchair (K0861) and accessories (E1007, E2377, E2311, E1028, K0040, E2313, E2361, 
E1012, E2609, E2617, E2343, E1020).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services can be safely received in other settings, for example: a skilled nursing 
facility, home with home health services or home with outpatient therapy. 
 
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. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for a stroke. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do 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 you will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 39 fractions of proton beam radiation therapy (PBRT). 
 
You asked the Plan to pre-approve 39 fractions of proton beam radiation therapy (PBRT). You say that the 
requested 39 fractions of proton beam radiation therapy (PBRT) are medically necessary. The Plan denied your 
request. The Plan says the requested 39 fractions of proton beam radiation therapy (PBRT) is 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 39 fractions of proton beam radiation 
therapy (PBRT). Our reviewer says that the requested 39 fractions of proton beam radiation therapy (PBRT) is 
not medically necessary. Our physician reviewer found proton therapy for prostate cancer is not experimental, 
and in fact is an accepted treatment approach.  While I do not think that proton therapy is an experimental 
therapy, any potential benefit or detriment of proton therapy over standard Intensity-modulated radiation 
therapy (IMRT) is an investigational question. Other treatment approaches (IMRT +/- IGRT) are also highly 
effective and well tolerated.  Thus, whether proton therapy affords a benefit over other standard approaches 
(IMRT/IGRT) for prostate cancer is an area of investigation and remains controversial. To date, there are no compelling data to suggest that proton therapy is superior to or more beneficial than IMRT/IGRT. The 
generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, 
and to not routinely offer it to patients. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 39 fractions of proton beam radiation therapy (PBRT) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve 39 fractions of proton beam radiation therapy 
(PBRT).
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 January 
7, 2022. 
 
You asked the Plan to waive the copayment for the office visit. You say that this was your yearly visit with this 
provider. 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 each 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 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 January 7, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a genvisc joint injection performed by an 
out-of-network (OON) provider on September 21, 2021. 
 
You asked the Plan to waive the coinsurance for the OON injection. You say that you were informed that all 
costs would be covered. The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 50% 
coinsurance for surgery or services at an out-of-network (OON) outpatient hospital or ambulatory surgical 
center. 
 Your contract with the Plan also clearly says that you must pay a 50% coinsurance for Part B drugs received at 
an out-of-network (OON) facility. 
 
Service/Drug Allowed Amount 50% Coinsurance (OON) 
Injection Procedure $59.78 29.89 
Genvisc Drug $411.00 $205.50 
Total:  $235.39 
 
You have been asked to pay $235.39, which is 50% of the allowed amount for the OON injection. The 
injection procedure falls within the Outpatient Surgery, Including Service Provided at Hospital Outpatient 
Facilities and Ambulatory Surgical Centers benefit category. The genvisc drug 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 coinsurance for a genvisc joint 
injection performed by an out-of-network (OON) provider on September 21, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a group 3 wheelchair and accessories and upgraded electronics. 
 
You asked the Plan to pre-approve the ser4vices. You say that this is medically necessary. The Plan denied 
your request. The Plan says that this is medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will be covered if the patient has a mobility 
deficit that impairs their participation in MRADLs, the patients condition cannot be ameliorated by a walker, 
cane or manual wheelchair, and the patient is capable of safely operating the requested PMD.  
 
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 ser4vices. Our reviewer says that 
the requested wheelchair is medically reasonable and necessary. Our physician reviewer found you have a 
neurological condition and other comorbidities which meets the coverage criteria for a group 3 power 
wheelchair. The wheelchair evaluation included specifications for you require elevating leg rests, power tilt, 
and recline; thus, three power functions which would qualify for upgraded electronics through the joystick. 
Accessories such as a battery would also then by medically necessary. 
 
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 ser4vices have been met. Therefore, we decided that the Plan has to pre-approve a group 3 wheelchair and 
accessories and upgraded electronics.  
 
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 physician's services to be provided by the requested  
out-of-network provider. 
 
You asked the Plan to pre-approve physician's services to be provided by the requested provider. You say that 
this podiatrist is the only provider that will do home visits and you have been a patient with this provider for 
five years. The Plan denied your request. The Plan says with limited exceptions, while you are a member of our 
Plan you must use network providers to get your medical care and services. 
 
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 
physician's services to be provided by the requested out-of-network provider.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says that transfer to a SNF for inpatient skilled rehab services is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested admission is not medically reasonable or necessary. Our physician reviewer found that you qualify 
for SNF coverage. You do have documented skilled nursing needs. You are to receive IV antibiotics through 
7/15/22. The health plan argues that you do not have skilled therapy needs based on your 6/26/2022 
functionality, but has not provided records to support that argument. Daily skilled services are required to 
establish a maintenance program or to prevent deterioration of your condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET/MRI to be provided by the requested out-of-
network provider. 
 
You asked the Plan to pre-approve a PET/MRI to be provided by the requested provider. You say that due to 
pain, you are unable to drive to Madison for this specialized imaging. The Plan denied your request. The Plan 
says the Radiation Oncology notes state that you are doing well overall with no pain except rare shooting pains 
occurring roughly once per month. Because PET/MRI imaging capability exists in network, the initial denial is 
upheld. 
 
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 a 
PET/MRI to be provided by the requested out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a genvisc joint injection with fluoroscopic 
guidance performed by an out-of-network (OON) provider on August 26, 2021. 
 
You asked the Plan to waive the coinsurance for the OON injection with fluoroscopic guidance. You say that 
you were informed that all costs would be covered. The Plan denied your request. The Plan says the correct 
coinsurance was applied. 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 50% 
coinsurance for surgery or services at an out-of-network (OON) outpatient hospital or ambulatory surgical 
center. 
 
Your contract with the Plan also clearly says that you must pay a 50% coinsurance for diagnostic procedures 
and tests at an out-of-network (OON) facility. 
 
Your contract with the Plan also clearly says that you must pay a 50% coinsurance for Part B drugs received at 
an out-of-network (OON) facility. 
 
Service/Drug Allowed Amount 50% Coinsurance (OON) 
Injection Procedure $59.68 $29.84 
Fluoroscopic Guidance $107.47 $53.73 
Genvisc Drug $411.00 $205.50 
Total:  $289.07 
 
You have been asked to pay $289.07, which is 50% of the allowed amount for the OON injection with 
fluoroscopic guidance. The injection procedure falls within the Outpatient Surgery, Including Service Provided 
at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. The fluoroscopic guidance 
falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. The 
genvisc drug 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 coinsurance for a genvisc joint injection with fluoroscopic guidance performed by an out-of-
network (OON) provider on August 26, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $100 copayment for ambulance services provided on 
November 21, 2020. 
 
You asked the Plan to waive the $100 copayment for an ambulance ride provided on November 21, 2020. You 
say that you were told the enrollee did not have to pay a copayment. The Plan denied your request. The Plan 
says the enrollee must pay a $100 copayment for each Medicare-covered (one-way) ambulance trip. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay $100 copayment for Ambulance Services.  
 
The enrollee has been asked to pay a $100 copayment for an ambulance ride provided on November 21, 2020. 
An ambulance ride falls within the Ambulance Services benefit category. This means that the enrollee has been 
asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the $100 copayment for ambulance services provided on November 21, 2020.