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

 
We decided that the Plan does not have to pay for miscellaneous durable medical equipment, face down pillow 
(E1399) purchased February 3, 2022. 
 
You asked the Plan to pay for the face down pillow. You say that you are appealing the decision of denial of 
your request for reimbursement for monies spent for equipment rental that you need for after your surgery 
recovery. The Plan denied your request. The Plan says the services was obtained from a supplier who is a non-
Medicare certified provider. If you go to a provider who is not eligible to participate in Medicare, you will be 
responsible for the full cost of the services you receive. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for miscellaneous durable medical 
equipment, face down pillow (E1399) purchased February 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the reflexology services from February 1, 2021, to 
November 1, 2021. 
 
You asked the Plan to reimburse you for the reflexology services. You say that the reflexology appointments 
were to treat your balance. You say that it helps with the feeling in your feet and prevent falling. You also say 
that you got a prescription from your doctor for the services to be covered. The Plan denied your request. The 
Plan says reflexology services are not listed as a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a supplemental benefit that 
exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a supplemental benefit in excess of Medicare coverage, the reflexology services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for 
the reflexology services from February 1, 2021, to November 1, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 
service is not medically necessary. Our physician reviewer found the enrollee does not have documented 
skilled nursing needs or documented skilled therapy needs. The enrollee is likely at/near a new plateau in 
function. Ongoing daily skilled services are not required to establish a maintenance program or to prevent 
deterioration of the enrollees condition. The enrollees care needs, custodial and intermittent, can, as a 
practical matter, be provided 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 skilled nursing facility (SNF) care.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for an emergency department visit provided on July 14, 2021. 
 
You asked the Plan to pay for the emergency department visit. The Plan denied your request. The Plan says that 
under federal regulation, the Medicare Advantage is prohibited from paying claims for care provided to our 
Medicare Advantage Plan members by a provider or group practice who have been precluded from 
participating in Medicare at the time services were rendered. 
 
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. an emergency department visit provided on July 14, 2021. Specifically, the Plan 
has not provided proof that the provider is on a preclusion list. Therefore, we decided that the Plan has to pay 
for an emergency department visit provided on July 14, 2021.  
 
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 two aflibercept injections (J0178) provided 
on February 28, 2022, and March 3, 2022. 
 
You asked the Plan to waive the copayment for the aflibercept injections. You say that the services should be 
covered as you disagree with the coinsurance. The Plan denied your request. The Plan says the cost-sharing 
applied correctly based on the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare Part B prescription drugs.  
 
 
  You have been asked to pay a 20% coinsurance for the aflibercept injections (total allowed is $3,662.98 x 20% 
= $732.59). Aflibercept injections fall within the Medicare Part B prescription drugs benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for two aflibercept injections (J0178) provided on February 28, 
2022, and March 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy (PT), occupational 
therapy (OT), home health aide, and direct skilled nursing for home health (G0151, G0152, G0156, G0299) to 
be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve home health PT, OT, home health aide, and direct skilled nursing for home 
health. You say that the enrollee is residing in Indiana and there are no local in-network providers in the area. 
The Plan denied your request. The Plan says there are in-network (INN) providers available. The Plan allows 
for OON coverage for emergency services or when there are no INN providers available. The facilities and 
physicians are OON due to the enrollee failing to update the plan with new address. 
 
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 
home health physical therapy (PT), occupational therapy (OT), home health aide, and direct skilled nursing for 
home health (G0151, G0152, G0156, G0299) 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 waive the copayment for a visual field examination (92083) 
provided on January 14, 2022. 
 
You asked the Plan to waive the copayment for the visual field examination. You say that the services should 
be covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing 
applied correctly based on the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for Vision care.  
 
 
  You have been asked to pay a $45 copayment for the visual field examination. Visual field examinations fall 
within the Vision 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 visual 
field examination (92083) provided on January 14, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda and Docetaxel. 
 
You asked the Plan to pre-approve Keytruda and Docetaxel. 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. 
 
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 Keytruda and Docetaxel. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the combination of docetaxel 
and pembrolizumab is not a standard of care for the treatment of head and neck cancer. Use is not supported by 
the NCCN Guidelines, major drug compendia, or the NCCN Guidelines. In additon, this enrollee has 
progressed on prior immunotherapy. The service is not medically reasonable and necessary for the enrollee or 
safe and effective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda and Docetaxel have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Keytruda and Docetaxel.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laminotomy services coded 63035 provided on February 
8, 2022. 
 
You asked the Plan to pay for the laminotomy services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the code billed is not payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code the 
laminotomy services is an add-on code and has not been billed with an appropriate primary procedure code. 
Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pay for the laminotomy services coded 63035 provided on February 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for surgery on March 11, 2022. 
 
You asked the Plan to waive the coinsurance for surgery. You say that you want the plan to pay or adjust the 
coinsurance. The Plan denied your request. The Plan says the cost-sharing you are being charged 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% of 
the cost for each Medicare-covered visit to an outpatient hospital facility, certified ambulatory surgical center, 
or clinic. The provider billed in the amount of $230 and the allowed amount is $304.58. The Plan paid $243.66. 
$304.58 x 20% = $60.92. Therefore, results in the total cost-sharing amount of $60.92.  
 
You have been asked to pay a 20% coinsurance for surgery. Surgery falls 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 coinsurance for surgery on March 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for diagnostic test and office visit on March 
14, 2022. 
 
You asked the Plan to waive the copayments for diagnostic test and office visit. You say that you want to 
appeal the amount being charged. The Plan denied your request. The Plan says the cost-sharing you are being 
charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copayment for other outpatient diagnostic tests. Covered services include but are not limited to other outpatient 
diagnostic tests. You must pay a $40 copayment for specialty care physician visit. Covered services include 
consultation, diagnosis, and treatment by a specialist. $10 + $40 = $50. Therefore, results in the total cost-
sharing amount $50.  
 You have been asked to pay a $10 copayment for diagnostic test and a $40 copayment for office visit. 
Diagnostic test and office visits fall within the Outpatient diagnostic tests and therapeutic services and supplies 
and 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 copayments for diagnostic test and office visit on March 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF care for daily physician 
oversight and to maximize functional independence. The Plan denied your request. The Plan says based on 
Medicare guidelines, the requested IRF services do not meet the requirements for approval. 
 
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 that the complexity of the enrollees nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on January 25, 2022. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for this testing is correct, because laboratory tests 
related to treatment of end-stage renal disease (ESRD) are bundled into dialysis services and are not separately 
paid. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services furnished to individuals for the 
treatment of end-stage renal disease (ESRD) are included in the ESRD prospective payment system (PPS) and 
not paid separately.  
 
We looked at the file and Medicare rules. This testing was related to the treatment of ESRD; therefore, it is 
included in the ESRD PPS payment and is not separately paid. Based on this information, we decided that 
Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have 
to pay for laboratory testing provided on January 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve leg revascularization. 
 
You asked the Plan to pre-approve leg revascularization. You say that the requested leg revascularization is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested leg revascularization. 
 
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 leg revascularization. Our reviewer says 
that the enrollee does not meet criteria for the requested leg revascularization. Our physician reviewer found 
the record indicates that the enrollee has leg pain when climbing stairs. The physical examination records 
normal pulses. The primary source documentation from an arterial duplex is not provided but the record states 
there is moderate femoral stenosis bilaterally. Ankle brachia indices are not reported. The record does not 
indicate that a trial of progressive walking program has been failed. The record provided does not establish the 
medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of 
the coverage criteria are not satisfied. The requested service is not recommended. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of leg revascularization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve leg revascularization.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve high utilization of blood glucose monitoring supplies. 
 
You asked the Plan to pre-approve high utilization of blood glucose monitoring supplies. You say that the 
requested high utilization of blood glucose monitoring supplies is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet criteria for the requested high utilization of blood glucose 
monitoring supplies. 
 
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 high utilization of blood glucose 
monitoring supplies. Our reviewer says that the enrollee does not meet criteria for the requested high utilization 
of blood glucose monitoring supplies. Our physician reviewer found there is no reason given why this enrollee 
on metformin alone and a1c of 6.3 would need to check more than once per day. Hence criteria for providing a 
high utilization of blood glucose monitoring supplies are not 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 high utilization of blood glucose monitoring supplies have not been met. 
Therefore, we decided that the Plan does not have to pre-approve high utilization of blood glucose monitoring 
supplies.