Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits (99204, 99214, 99244) with an oncologist 
to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve office visits. You say that you were denied a clinical trial for treatment for 
advanced prostate cancer that has metastasized. You had prostate cancer in 2019 and you 
have a rare mutation in your blood that is preventing treatment from working. The clinical trials are to attempt 
to find a treatment that will work for you. The Plan denied your request. The Plan says 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 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 
office visits (99204, 99214, 99244) with an oncologist to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zilretta. 
 
You asked the Plan to pre-approve Zilretta. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Zilretta. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has a diagnosis of unilateral primary osteoarthritis of right knee. The enrollee 
received a Zilretta 32mg injection in the right knee on August 4, 2022. Based on the medical records provided 
and the Medicare-approved major drug compendia there is no documentation that the Zilretta at issue in this 
case meets all Medicare criteria for medically reasonable and necessary for the patient. As stated in the 
prescribing information from the drug manufacturer: "The efficacy and safety of repeat administration of 
Zilretta have not been demonstrated". 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 Zilretta have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Zilretta.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a debridement procedure at an assisted living facility 
provided on January 7, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a debridement procedure at an assisted living facility. You say that the enrollee is 
in a facility and the facility should have obtained the prior authorization. This was also medically necessary. 
The Plan denied your request. The Plan says there was no preauthorization by a primary care provider (this is 
different than a referral) for an out-of-network (OON) provider or facility, and this was not an emergency. 
Therefore, the decision 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 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 a debridement procedure at an assisted living 
facility provided on January 7, 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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would benefit from inpatient rehabilitation 
services due to your medical complexity. The Plan denied your request. The Plan says your needs can be met at 
a lower level of care such as skilled nursing facility (SNF), home health or 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 there are no complex nursing or rehabilitation needs. While you have a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
  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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for single vision sphere lenses (V2100) and deluxe frames 
(V2025) provided on August 26, 2022. 
 You asked the Plan to pay for single vision sphere lenses (V2100) and deluxe frames (V2025). You say that 
you did not get frames with the eye-doctor because it was well over $600 for frames. You also say you only 
wanted basic frames you can afford. The Plan denied your request. The Plan says you do not have out-of-
network benefits per your plan. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when an in-network $200 maximum amount for routine eye wear 
every year. Out-of-network providers are excluded from this benefit. 
 
We looked at the file and the Plan's rules. The Plan rules say that there is an in-network $200 maximum plan 
coverage amount for routine eye wear every year. Out-of-network providers are excluded from this benefit. The 
record shows that the frames and lenses were purchased out-of-network. Based on this information, we decided 
that the Plan's rules for coverage of single vision sphere lenses (V2100) and deluxe frames (V2025) have not 
been met. Therefore, we decided that the Plan does not have to pay for single vision sphere lenses (V2100) and 
deluxe frames (V2025) provided on August 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from long-
term acute care due to medical complexity. The Plan denied your request. The Plan says the enrollee's care can 
be provided in the current inpatient hospital. The enrollee may be ready to move to another setting in the future. 
 
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 enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for pharmacy visit and injection provided on 
May 4, 2022. 
 
You asked the Plan to waive the cost share for pharmacy visit and injection. You say that you are disputing the 
share cost. The Plan denied your request. The Plan says this cost sharing was charged 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 10% 
coinsurance for outpatient hospital services and 10% coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay 10% coinsurance for each pharmacy visit and each injection. These items/services 
fall within the outpatient hospital services and Medicare Part B prescription drugs benefit categories. 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 cost share for pharmacy visit and injection provided on May 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 29, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 June 29, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqvio Solution (J1306). 
 
You asked the Plan to pre-approve a prescription drug. You say that the enrollee has significant dyslipidemia 
and CAD with statin intolerance related recurrent myalgias on repeated statin challenges. The enrollee needs to 
continue this solution every 6 months. The Plan denied your request. The Plan says the requested medication is 
not being supplied by the physician and is not being administered by the physician. The enrollee does not have 
a pharmacy benefit with the plan. 
 
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 Leqvio Solution (J1306).
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the emergency room services provided on July 1, 2022. 
 
You asked the Plan to pay for the billed services. You say that the charges were appropriate for the level of 
services provided. The Plan denied your request. The Plan says that the provider did not bill as required. 
 
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. 
 
We looked at the file and the rules. Emergency room services were billed using procedure code 99283. The 
services were provided at an independent emergency room. The place of service was billed correctly. The code 
was not billed with a 26 or TC modifier. We find that the evaluation and management services were billed 
correctly. Physician service and emergency room service are not mutually exclusive. The Plan has not indicated 
to the provider how to correct their claim. The Plan has not made reasonable and diligent efforts to gather and 
forward to us information regarding their decision to deny your request.  Therefore, we decided that the Plan 
has to pay for the emergency room services provided on July 1, 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient therapy services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve outpatient therapy services. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the requested services can be provided by a 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 
outpatient therapy services 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 waive the cost share for cane provided on June 1st, 2022. 
 
You asked the Plan to waive the cost share for cane. You say that you are disputing the share cost. The Plan 
denied your request. The Plan says this cost sharing was charged 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 $17.60 
deductible for durable medical equipment and related supplies. You have not met $250 deductible.  
 
You have been asked to pay $17.60 deductible for cane. This item/service falls within the durable medical 
equipment and related supplies benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost share for 
cane provided on June 1st, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (PCD) coded E0652. 
 
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 medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that an E0652 PCD is covered when specific criteria 
are met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records do not document that the 
enrollee has lymphedema extending into the chest, trunk, and/or abdomen. There is no documentation of a trial 
and failure of at least four weeks of regular, daily, multiple-hour home usage of a standard pump after careful, 
in-person fitting. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a pneumatic compression device (PCD) coded E0652.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pneumatic compression device (E0652) and 
segmental pneumatic appliance (E0667) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the pneumatic compression device and appliance. You say that the enrollee's 
uncontrolled lymphedema requires swift intervention, and this pump is needed to prevent the enrollee's 
condition from growing even worse. The Plan denied your request. The Plan says enrollees must receive their 
medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered. 
 
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 the pneumatic compression device (E0652) and segmental pneumatic appliance (E0667) to be provided by an 
out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) 
provided on June 25, 2022. 
 
You asked the Plan to pay for ambulance response and treatment, no transport. You say that you did not refuse 
transport. The Plan denied your request. The Plan says medical records show that you refused transport and 
signed the refusal. The Medicare ambulance benefit is a transportation benefit. If no transport occurs, there is 
no 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 June 25, 2022. 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 
(A0998) provided on June 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal bone growth stimulator. 
 
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 medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a spinal bone growth stimulator is covered when 
specific criteria are met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee had a multiple-level spinal 
fusion. There is no sufficient documentation of her condition to substantiate that the spinal bone growth 
stimulator is reasonable and medically necessary. There is no documentation of the duration of her condition, 
clinical course, prognosis, nature and extent of functional limitations, other therapeutic interventions and 
results, or past experience with related items. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a spinal bone growth stimulator.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that admission to a SNF is medically necessary. The 
Plan denied your request. The Plan says SNF care is 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 SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not require daily skilled nursing and/or skilled therapy services. You are 
medically stable and can receive further rehabilitation services at a lower level of 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.