Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular screening/risk assessment panel provided 
to the enrollee on June 11, 2021. 
 
You asked the Plan to pay for the testing. You say that this was medically necessary. The Plan denied your 
request. The Plan says Medicare Part B covers cardiovascular disease screening tests when ordered by the 
physician who is treating the beneficiary for the purpose of early detection of cardiovascular disease in 
individuals without apparent signs or symptoms of cardiovascular disease. 
 
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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the review has determined that the services at issue in this case are not medically reasonable or necessary. The provider's office did not order this testing 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 the testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the cardiovascular screening/risk assessment panel provided to the enrollee on June 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc. 
 
You asked the Plan to pre-approve Synvisc. The Plan denied your request. The Plan says the enrollee has not 
tried and failed Orthovisc or Supartz FX. 
 
 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 Synvisc. Our physician reviewer found 
that the enrollee has pain related to osteoarthritis of the left knee, diagnosis confirmed with imaging studies. 
The Plan requires a trial of Orthovisc or Supartz FX before they will approve the requested drug. There is no 
indication that the enrollee has tried and failed the required drugs. There is no indication that the Plan's required 
drugs would likely be less effective 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 Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Synvisc.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sensorimotor examination (92060), visual field 
examination (92083), computerized ophthalmic diagnostic imaging (92133), outpatient office visit (99204), 
and extended ophthalmoscopy (92201) provided on January 14, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the sensorimotor examination, visual field examination, computerized 
ophthalmic diagnostic imaging, outpatient office visit, and extended ophthalmoscopy. You say that you would 
like to appeal these services. The Plan denied your request. The Plan says services provided by an OON 
provider are not covered under the Plan. 
 
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 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 the sensorimotor examination (92060), visual field 
examination (92083), computerized ophthalmic diagnostic imaging (92133), outpatient office visit (99204), 
and extended ophthalmoscopy (92201) provided on January 14, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with testosterone cypionate. 
 
You asked the Plan to pre-approve testosterone cypionate. You say that the requested drug is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered 
drugs have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with testosterone 
cypionate.  
 Benefits for testosterone cypionate 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care. 
 
You asked the Plan to pay for SNF care. You say that you need SNF care. The Plan denied your request. The 
Plan says rules for SNF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from April 1, 2022, through 
July 10, 2022. The Plan has covered 100 days of SNF care. 
 
  Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pay for SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve initial consultation services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve initial consultation services. You say that this care with an OON provider is 
medically necessary. The Plan denied your request. The Plan says there are multiple in-network providers 
available for the enrollee's care needs. 
 
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 
initial consultation 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 pre-approve an air purifier. 
 
You asked the Plan to pre-approve an air purifier. You say that this device is necessary for your condition. The 
Plan denied your request. The Plan says this item is not covered because it is not considered to be medical in 
nature. 
 
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 an air purifier.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Sutab tablets. 
 
You asked the Plan to pre-approve Sutab. You say that this drug is medically necessary. The Plan denied your 
request. The Plan says this drug is not eligible for coverage under the Part B medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Sutab tablets.  
 
Benefits for Sutab 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 25, 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 for 
payment. 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 April 25, 2022, by an 
out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided on March 26, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that you believe these drug charges should 
be covered because the pharmacy was closed, and you needed the medications. The Plan denied your request. 
The Plan says self-administered drugs are not covered while you are in the hospital. 
 
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 pay for the self-administered drugs 
provided on March 26, 2022.  
 
Benefits for the self-administered drugs 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary visit provided on April 26, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the domiciliary visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was 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 did not pre-approve the 
domiciliary visit. We found no exception that would require the Plan to pay for the domiciliary visit. The 
records provided for review do not show that the domiciliary visit was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the domiciliary visit provided on April 26, 2022, 
by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit (99343), avulsion of nail plate (11730), and 
nail debridement (11721) provided from August 19, 2021, to March 2, 2022. 
 
You asked the Plan to pay for the physician services. You say that the services should be covered. The Plan 
denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the home visit (99343), avulsion of nail plate (11730), and 
nail debridement (11721) provided from August 19, 2021, to March 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with a power tilt option. 
 
You asked the Plan to pre-approve the requested wheelchair. The Plan denied your request. The Plan says the 
requested wheelchair exceeds the enrollee's needs. 
 
The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered 
under certain medical indications.  
 
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 requested wheelchair. Our physician 
reviewer found that the enrollee is not malnourished. There are no boney prominences identified and no history 
of skin breakdown. The evaluation identified inadequate weight shifting. The enrollee has some risk factors, 
particularly impaired mobility, but per Braden scale he is at minimal risk not high risk for skin breakdown. He 
does not use a catheter. Therefore, the coverage criteria have not been met. 
 
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 requested wheelchair have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a group 3 power wheelchair with a power tilt option.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology and laboratory services provided on April 20, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the pathology and laboratory services. You say that the doctor's office failed to 
send the preauthorization form for approval. The Plan denied your request. The Plan says no prior authorization 
was 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 did not pre-approve the 
pathology and laboratory services. We found no exception that would require the Plan to pay for the pathology 
and laboratory services. The records provided for review do not show that the services at issue were urgent or 
emergent. Therefore, we decided that the Plan does not have to pay for the pathology and laboratory services 
provided on April 20, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an office visit and injection provided on 
April 5, 2022. 
 
You asked the Plan to waive the cost share for an office visit and injection. You say that you should only have 
to pay the $50 copayment for the office visit. 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 20% 
coinsurance for Medicare covered Part B drugs and $50 copayment for specialist office visit.  
 
 
 
 You have been asked to pay $29.55 which is 20% of the allowed amount for an injection. The allowed amount 
is $147.75 (20% x $147.75= $29.55). You have been asked to pay $50 copayment for the office visit. You have 
been asked to pay a total of $79.55 for the office visit and injection. The injection falls within the Medicare 
Part B Prescription Drugs benefit category. The specialist 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 cost share 
for an office visit and injection provided on April 5, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a K3 foot. 
 
You asked the Plan to pre-approve a K3 foot. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says that the requested item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a flex-walk system or equal is covered for 
beneficiaries whose functional level is 3 or above. 
 
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 a K3 foot. Our reviewer says that the 
documentation supports that the requested K3 foot is medically reasonable and necessary. Our physician 
reviewer found the enrollee has a past medical history of right below-knee amputation. The documentation 
shows that the enrollee would be a K3 level ambulator, be able to navigate terrain and cadences. This means 
the enrollee meets criteria for the requested K3 level foot. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a K3 foot have been met. Therefore, we decided that the Plan has to pre-
approve a K3 foot.  
 
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 pay for the podiatry services provided on March 25, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the podiatry services. You say that you contacted the closest doctor because you 
needed help with your foot due to an emergent situation. The Plan denied your request. The Plan says no prior 
authorization was 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 did not pre-approve the 
podiatry services. We found no exception that would require the Plan to pay for the podiatry services. 
Therefore, we decided that the Plan does not have to pay for the podiatry services provided on March 25, 2022, 
by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient procedure provided on March 
28, 2022. 
 
You asked the Plan to waive the copayment for outpatient procedure. You say that the surgery caused you a lot 
of pain after so it should be covered. The Plan denied your request. The Plan says the copayment applied is 
correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $225 
copayment for each Medicare covered outpatient hospital facility visit.  
 
 
 
 
 You have been asked to pay $225 copayment for outpatient procedure. Outpatient procedures fall within the 
Outpatient Surgery Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for outpatient procedure 
provided on March 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 7, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says Medicare does not 
separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 7, 2022.