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

 
We decided that the Plan does not have to reduce the copayment for the specialist office visit provided on June 
13, 2023. 
 
You asked the Plan to reduce the copayment for the specialist office visit. You say that you should only have a 
$5 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 $40 
copayment for in-network physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $40 copayment for the specialist office visit. This item/service falls within the 
in-network physician/practitioner services, including doctors 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 reduce the copayment for the specialist office visit provided on June 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unspecified preventive procedure (D1999) provided on June 
1, 2023, and June 15, 2023. 
 
You asked the Plan to pay for unspecified preventive procedure. You say that this should be covered. The Plan 
denied your request. The Plan says this is not a covered service. 
 
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 pay for 
unspecified preventive procedure (D1999) provided on June 1, 2023, and June 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the reline of a complete lower denture (D5751) provided on 
May 22, 2023. 
 
You asked the Plan to pay for the dental service. You say that according to your benefit book only 1 reline is 
covered a year and it does not make any sense. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows the Plan paid for a reline of a complete upper denture (D5750) on May 22, 2023; therefore, your benefit 
for the requested item or service was exhausted on the date of service of May 22, 2023. Therefore, we decided 
that the Plan does not have to pay for the reline of a complete lower denture (D5751) provided on May 22, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CMT; spinal, 3-4 regions received on June 7, 2023. 
 
You asked the Plan to pay for chiropractic service. You say that this should be covered because you were told 
the provider was in-network. The Plan denied your request. The Plan says this is not a covered chiropractic 
service. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the CMT; spinal, 3-4 regions received on June 7, 2023.
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 services are medically necessary. The Plan 
denied your request. The Plan says the enrollee has not completed their course at the inpatient rehabilitation 
center. 
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5257) purchased on 
March 14, 2023.  
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable as 
they were rendered by an out-of-network provider.  
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of this item have not been met. Specifically, the Plans contract states that hearing aids are covered 
only when purchased from the Plans select hearing aid provider. However, the hearing aids in this case were 
rendered by an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids (V5257) purchased on March 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve branch injections. 
 
You asked the Plan to pre-approve genicular nerve branch injections. You say that this is medically necessary. 
The Plan denied your request. The Plan says under Medicare, the service is not medically necessary. We cannot 
approve until efficacy of this procedure has been established. 
 
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 genicular nerve branch injections. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found both genicular nerve blocks and RFA of the genicular nerves are 
considered experimental therapies.  Therefore, the request is deemed not medically reasonable and 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 genicular nerve branch injections have not been met. Therefore, we decided that 
the Plan does not have to pre-approve genicular nerve branch injections.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on 
October 12, 2022. 
 
You asked the Plan to pay for the ED services. You say that you are requesting the claim be reviewed and 
reprocessed for payment. The Plan denied your request. The Plan says Medicare payment cannot be made to 
this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare. 
However, during the COVID-19-PHE, such providers were allowed to enroll as temporary hospitals and could 
be paid for services during this period. 
 
We looked at the file and Medicare rules. We find that the provider at issue has not enrolled as a temporary 
hospital as allowed during the PHE. As such, this provider is not eligible for Medicare payment. Therefore, we 
decided that the Plan does not have to pay for the emergency department (ED) services provided on October 
12, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve craniectomy surgery. 
 
You asked the Plan to pre-approve craniectomy surgery. You say that the services are necessary. The Plan 
denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 craniectomy surgery. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the record indicates that the enrollee has invasive squamous cell carcinoma of the occipital 
skull and requires re-excision craniectomy. The record provided establishes the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria 
are satisfied. The requested service is 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 craniectomy surgery have been met. Therefore, we decided that the Plan has to 
pre-approve craniectomy surgery.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from May 30, 2023, 
through June 1, 2023. 
 
You asked the Plan to pay for this medication. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this medication is not covered as a medical 
benefit under 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 provided in this case 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 from May 30, 2023, through June 1, 2023.  
 
Benefits for this medication 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on 
October 11, 2022. 
 
You asked the Plan to pay for the ED services. You say that you are requesting the claim be reviewed and 
reprocessed for payment. The Plan denied your request. The Plan says Medicare payment cannot be made to 
this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare. 
However, during the COVID-19-PHE, such providers were allowed to enroll as temporary hospitals and could 
be paid for services during this period. 
 
We looked at the file and Medicare rules. We find that the provider at issue has not enrolled as a temporary 
hospital as allowed during the PHE. As such, this provider is not eligible for Medicare payment. Therefore, we 
decided that the Plan does not have to pay for the emergency department (ED) services provided on October 
11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee-shin system, powered and programmable 
flexion/extension assist control add-on (L5859). 
 
You asked the Plan to pre-approve a knee- shin pro flex/extend add-on. You say that the item is medically 
necessary. The Plan denied your request. The Plan says this item exceeds the enrollee's needs. 
 
The Plan follows Medicare rules. Medicare rules say that L5859 (addition to lower extremity prosthesis, 
endoskeletal knee-shin system, powered and programmable flexion/extension assist control, includes any type 
of motor(s)) is only covered when the beneficiary meets all of the criteria below:  
1. Has a microprocessor (swing and stance phase type (L5856)) controlled (electronic) knee  2. K3 functional level only  
3. Has a documented comorbidity of the spine and/or sound limb affecting hip extension and/or quadriceps 
function that impairs K-3 level function with the use of a microprocessor-controlled knee alone  
4. Is able to make use of a product that requires daily charging  
5. Is able to understand and respond to error alerts and alarms indicating problems with the function of the unit 
 
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 knee- shin pro flex/extend add-on. 
Our reviewer says that the item is not medically necessary. Our physician reviewer found the documentation 
does not reveal a comorbidity of the spine and sound limb affecting hip extension and/or quadricep function 
that impairs K3 function with the microprocessor knee alone. 
 
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 knee- shin pro flex/extend add-on have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a knee-shin system, powered and programmable flexion/extension 
assist control add-on (L5859).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the weight management classes (S9949) 
purchased on January 1, 2023. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that you have not 
submitted proof of payment for an eligible service.  
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
The Plans rules for coverage of gym benefits have not been met because you have not submitted proof of 
payment for an eligible service. Therefore, we decided that the Plan does not have to issue reimbursement for 
the weight management classes (S9949) purchased on January 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SpaceOAR (55874). 
 
You asked the Plan to pre-approve SpaceOAR. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that polyethylene-glycol (PEG) hydrogel 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 SpaceOAR. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the records show that extreme 
hypofractionation" at 8 Gy per day (to 40 Gy) is planned by the provider. Thus, the LCD would not allow for 
coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SpaceOAR have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SpaceOAR (55874).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on August 
27, 2022. 
 
You asked the Plan to pay for the ED services. You say that you are requesting the claim be reviewed and 
reprocessed for payment. The Plan denied your request. The Plan says Medicare payment cannot be made to 
this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare. 
However, during the COVID-19-PHE, such providers were allowed to enroll as temporary hospitals and could 
be paid for services during this period. 
 
We looked at the file and Medicare rules. We find that the provider at issue has not enrolled as a temporary 
hospital as allowed during the PHE. As such, this provider is not eligible for Medicare payment. Therefore, we 
decided that the Plan does not have to pay for the emergency department (ED) services provided on August 27, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve branch injections. 
 
You asked the Plan to pre-approve genicular nerve branch injections. You say that this is medically necessary, 
The Plan denied your request. The Plan says this does not meet the criteria for coverage. 
 
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 genicular nerve branch injections. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this is considered experimental therapy.  It is the subject of ongoing clinical 
trials.  Therefore, the request is deemed not medically reasonable and 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 genicular nerve branch injections have not been met. Therefore, we decided that 
the Plan does not have to pre-approve genicular nerve branch injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre Kit 2. 
 
You asked the Plan to pre-approve the FreeStyle Libre Kit 2. You say that the records support the medical 
necessity for the FreeStyle Libre Kit 2. The Plan denied your request. The Plan says the enrollee is not on 
insulin and does not have documentation of problematic hypoglycemia. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the FreeStyle Libre Kit 2. Our reviewer 
says that this item is not medically necessary. Our physician reviewer found coverage criteria for CGM require 
insulin use or low blood glucose sugar. The enrollee is not having low blood glucose sugar that we are told of 
and is not on medications that usually cause low blood glucose sugar. We are not told why the enrollee needs 
the CGM and why a fingerstick monitor would not work. 
 
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 FreeStyle Libre Kit 2 have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a FreeStyle Libre Kit 2.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea. 
 You asked the Plan to pre-approve Eylea. You say that the requested medication is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee did not meet the step therapy requirements. 
 
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 the injections. Our physician reviewer 
found that the Plan requires a trial of Avastin and Byooviz before they will approve Eylea. Our physician 
reviewer found that based on the medical records provided there is no indication that the enrollee has tried and 
failed the required drugs. Our physician reviewer found that there is no indication 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 Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea.
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 June 10, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
paramedics insisted on treating you at the house and never stated or insisted on taking you to the emergency 
room. 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 June 10, 2023. 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 June 10, 2023.