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

 
We decided that the Plan does not have to pay for the shingles vaccine (90750) and administration (90471) 
provided on September 23, 2022. 
 
You asked the Plan to pay for the vaccine services. You say that you are being told this is not covered. The 
Plan denied your request. The Plan says the services are not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine services. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccine 
services. Therefore, we decided that the Plan does not have to pay for the shingles vaccine (90750) and 
administration (90471) provided on September 23, 2022.  
 
Benefits for the vaccine services 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental 
pneumatic appliances (E0673) provided September 1, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and appliances. You say that the equipment was 
prescribed by the doctor and was issued to the enrollee for use during their surgery. The Plan denied your 
request. The Plan says the pneumatic compression devices, E0673 and E0675, were billed for use outside of the 
home and is not separately payable. pneumatic compression device is not covered by Medicare to prevent deep 
vein thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  
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, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) and segmental pneumatic appliances (E0673) provided 
September 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory pathogen panel provided on July 4, 2022. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that respiratory pathogen panels testing more than 5 
respiratory pathogens are considered not medically necessary.  
 
We looked at the file and Medicare rules. Per LCD L38916, the requested panel of more than 5 pathogens is 
not medically necessary. Based on this information, we decided that Medicare rules for coverage of the panel 
have not been met. Therefore, we decided that the Plan does not have to pay for the respiratory pathogen panel 
provided on July 4, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for a bi-level positive airway pressure (BiPAP) device (E0471) billed for 
date of service August 17, 2022. 
 
You asked the Plan to pay for a BiPAP device. You say that the item at issue has been billed correctly. The 
Plan denied your request. The Plan says that rules for payment have not been met. 
 
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. Specifically, the case record does not contain a clear denial rationale nor an 
explanation of how billing errors may be corrected. It is the Plan's responsibility to substantiate its denial with 
evidence. In this case, the Plan's denial has not been substantiated, so we must find in your favor. Therefore, we 
decided that the Plan has to pay for a BiPAP device (E0471) billed for date of service August 17, 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 waive the copayment for office visit on August 01, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you want to appeal the amount being 
charged. 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 a $35 
copayment for each Medicare-covered specialist visit. Covered services include consultation, diagnosis, and 
treatment by a specialist. The provider billed in the amount of $49 and the allowed amount is $25.40. This is 
less than the copayment amount. Therefore, results in the total cost sharing amount of $25.40. 
 
You have been asked to pay a $25.40 copayment, which is less than the copayment for office visit. This 
item/service 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 office visit on August 01, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for routine transportation provided on January 11, 2022. 
 
You asked the Plan to pay for the routine transportation. You say that you are requesting reconsideration for the 
transportation. The Plan denied your request. The Plan says the service was not provided by the Plan's 
designated 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 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 routine transportation provided on January 11, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on July 6, 2022. 
 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that shortly 
after you received a bill from the provider you were informed by the Plan the claim was covered and would 
rectify the problem. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
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 July 6, 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 the ambulance response and treatment with no 
transport provided on July 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a specialist office visit. You say that there is not provider in network that 
can provide these services. The Plan denied your request. The Plan says there is a tertiary provider available. 
 
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 to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections provided on June 14, 2022. 
 
You asked the Plan to pay for injections. You say that you are requesting reconsideration. The Plan denied your 
request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for injections provided on 
June 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical supplies services provided on May 23, 2022, to May 
24, 2022. 
 
You asked the Plan to pay for surgical supplies services. You say that you are appealing the claim payment 
denial. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for surgical supplies 
services provided on May 23, 2022, to May 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for medical supplies and a magnetic resonance 
imaging (MRI) provided on September 12, 2022. 
 
You asked the Plan to waive the cost share for medical supplies and an MRI. You say that you disagree with 
the cost share. 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 a 20% 
coinsurance and a $185 copayment for outpatient diagnostic tests/Medicare-covered medical supply and 
outpatient diagnostic tests/Medicare-covered radiological diagnostic services, not including X-rays, performed 
in a physicians office.  
 
You have been asked to pay a 20% coinsurance and a $185 copayment for medical supplies and an MRI. The 
total allowed amount for the medical supplies is $25.60. You are being asked to pay $5.12 ($25.60 x 20% = $5.12). The total amount you are being asked to pay is $190.12 ($185 + $5.12 = $190.12). 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 medical supplies and a magnetic resonance imaging (MRI) provided 
on September 12, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mental health visit provided on August 24, 2022. 
 
You asked the Plan to pay for a mental health visit. You say that your brother has been seeing this provider for 
many years even though they are out of network. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a mental health visit 
provided on August 24, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance non-emergent transport 
provided on June 21, 2022. 
 
You asked the Plan to waive the copayment for ambulance non-emergent transport. You say that you do not 
understand why the enrollee has a copay when ambulance rides should be covered 100%. 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 a $150 
copayment for Ambulance services. 
 
You have been asked to pay a $150 copayment for ambulance non-emergent transport. This item/service falls 
within the Ambulance 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 
ambulance non-emergent transport provided on June 21, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cardiac rehabilitation services provided on 
September 2, 2022, to September 19, 2022. 
 
You asked the Plan to waive the copayment for cardiac rehabilitation services. You say that you disagree with 
the copayment. 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 a $50 
copayment per visit for cardiac rehabilitation services.  
 
You have been asked to pay a $50 copayment per visit for cardiac rehabilitation services. The total allowed 
amount for the cardiac rehab is $100. However, you hit your out-of-pocket maximum of $4,500. The total 
amount you are being asked to pay is $90. This item/service falls within the cardiac rehabilitation 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 cardiac rehabilitation services 
provided on September 2, 2022, to September 19, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monovisc. 
 
You asked the Plan to pre-approve Monovisc. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 Monovisc. Our reviewer says that the 
service are not medically necessary. Our physician reviewer found the enrollee has not tried and failed the 
required drugs. There is no documentation provided indicating that the plans required drugs would likely be 
less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Monovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Monovisc.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intraoral complete series of x-ray images (D0210). 
 
You asked the Plan to pre-approve the dental services. You say that this should be a covered dental benefit. The 
Plan denied your request. The Plan says this service is not a covered benefit under your dental plan. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
intraoral complete series of x-ray images (D0210).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on November 07, 2022. 
 
You asked the Plan to pay for the office visit. You say that the records provided support medical necessity. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit provided 
on November 07, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a skilled nursing facility (SNF) stay 
provided from September 1, 2022, to September 14, 2022. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you were told there would be no 
member responsibility for these services. 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 $0 
copayment per day for days 1 to 20 and a $160 copayment per day for days 21 to 100 for each inpatient 
admission to a SNF, in-network only.  
 
 
  You have been asked to pay a total copayment of $1,120 for a SNF visit ($160 per day x 7 days = $1,120). This 
item/service falls within Skilled Nursing Facility 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 a skilled nursing facility (SNF) stay provided from September 1, 2022, to September 14, 
2022.  
 
Your complaint about not being informed there would be a copayment is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left total hip replacement. 
 
You asked the Plan to pre-approve left total hip replacement. 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 left total hip replacement. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was being treated for left hip osteoarthritis. Conservative treatment 
included modified activities and assistive devices. However, detailed documentation is not evident regarding a 
trial and failure of recent, reasonable, comprehensive less invasive conservative care measures directed to the 
left hip. Additionally, there are no formal imaging studies to corroborate pathology in the left hip. There are 
limited large-scale, long-term references showing the safety and efficacy of the requested surgery in this 
clinical setting. 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 have a confirmed diagnosis/condition that meets the criteria for the requested 
left total hip replacement and the requested left total hip replacement, in this case, is not medically reasonable 
or 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 left total hip replacement have not been met. Therefore, we decided that the 
Plan does not have to pre-approve left total hip replacement.