Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pre-approve additional taxi services. 
 
You asked the Plan to pre-approve the taxi services. You say that the requested transportation is necessary to 
see a specialist. The Plan denied your request. The Plan says that this request exceeds the limit of your 
supplemental benefit. 
 
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. The Plan did not provide the correct Evidence of Coverage (EOC) for this 
request. Without the correct EOC we are unable to determine if the services were denied correctly according to 
your Plan benefits. Therefore, we decided that the Plan has to pre-approve additional taxi services.  
 
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 pre-approve a tiering exception for MONOVISC (J7327) 
 
You asked the Plan to pre-approve a tiering exception for MONOVISC . You say that the medications cost is to 
high and the enrollee needs a tier exception. The Plan denied your request. The Plan says tier exceptions 
reviews are not available for Part B drugs. 
 
The Plan must follow Medicare rules. Medicare rules state that tiering exceptions cannot apply to Part B drugs. 
Tiering exceptions are only applicable to Part D drugs. The drug(s) you are requesting is considered a Part B 
drug. As a result, no tiering exceptions can be made. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a tiering exception for MONOVISC have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a tiering exception for MONOVISC (J7327)
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy visits provided from October 15, 2022, to 
January 7, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for psychotherapy visits. You say that some of your visits have been covered, and 
some have not, please re-access and pay for these services. The Plan denied your request. The Plan says there 
was no preauthorization by a primary care provider (this is different than a referral) for an out-of-network 
(OON) provider or facility, and this was not an emergency. 
 
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 psychotherapy visits provided from October 15, 
2022, to January 7, 2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on April 19, 2022. 
 
You asked the Plan to pay for wound care supplies. You say that you are requesting reconsideration for the 
services provided. 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 wound care supplies 
provided on April 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prefabricated post and core (D2954) provided on April 12, 
2023. 
 
You asked the Plan to pay for the dental service. You say that the tooth was broken, and you needed to get the 
service again. 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 the core buildup (D2950) on March 5, 2021; therefore, your benefit for the requested 
item or service was exhausted on the date of service of March 5, 2021. Therefore, we decided that the Plan 
does not have to pay for a prefabricated post and core (D2954) provided on April 12, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve the PET scan. You say that the records provided support medical necessity. 
The Plan denied your request. The Plan says that the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
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 the PET scan. Our reviewer says that 
the service is medically necessary. Our physician reviewer found the enrollee has a poorly differentiated 
malignant lesion on the leg with unknown extent in a high-risk lesion such as this. Further, this is unclear 
whether this is a metastatic implant. Therefore, a PET scan is necessary to determine extent of tumor to 
determine anti-tumor treatment plan. 
 
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 PET scan have been met. Therefore, we decided that the Plan has to pre-
approve a positron emission tomography (PET) scan.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 20, 2022, to 
March 28, 2022, by an out-of-network (OON) provider.  
  You asked the Plan to pay for the home health services. You say that you are an in-network provider with the 
Plan and would like the claim paid. The Plan denied your request. The Plan says it was verified that the 
rendering provider is an OON provider and there was no approved authorization. Also, the services rendered 
were not urgent or emergent. 
 
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 the home health services provided from March 20, 
2022, to March 28, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for foot orthotics provided on August 08, 
2022. 
 
You asked the Plan to waive the coinsurance for foot orthotics. You say that 2022 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 20% 
coinsurance for prosthetic devices and related supplies. 
 
You have been asked to pay 20% coinsurance for foot orthotics. This item/service falls within the prosthetic 
devices and related supplies benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The total you owe is $131.85 ($659.24 allowed amount x 20% = $131.85). Therefore, we 
decided that the Plan does not have to waive the coinsurance for foot orthotics provided on August 08, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Femtosecond laser procedure. 
 
You asked the Plan to pre-approve a Femtosecond laser procedure. You say that you need this additional 
procedure to help with your eye pain. The Plan denied your request. The Plan says this is not a covered benefit. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a Femtosecond laser procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Femtosecond laser procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Tetanus, Diphtheria Toxoids and Acellular Pertussis vaccine 
provided on March 10, 2023, to May 21, 2023. 
 
You asked the Plan to pay for Tetanus, Diphtheria Toxoids and Acellular Pertussis vaccine. You say that it is 
medically necessary. The Plan denied your request. The Plan says the Medicare Part B program covers the 
Tetanus, Diphtheria Toxoids and Acellular Pertussis vaccine as part of a therapeutic regimen of an injury. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide Tetanus, Diphtheria 
Toxoids and Acellular Pertussis vaccine. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to Tetanus, 
Diphtheria Toxoids and Acellular Pertussis vaccine. Therefore, we decided that the Plan does not have to pay 
for Tetanus, Diphtheria Toxoids and Acellular Pertussis vaccine provided on March 10, 2023, to May 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a crown (D2740), and a crown fused to predominate-
base metal (D2751), provided on December 27, 2022. 
 
You asked the Plan to pay more for D2740 and D2751. You say that you believe the Plan should pay more for 
these crowns. 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% 
coinsurance for dental services/class 2 basic services.  
 You have been asked to pay a 50% coinsurance of the allowed amount for D2740. D2751 could have been 
provided with a less expensive alternate treatment. The Plan paid $771 towards D2751. You are responsible for 
any amount over the allowed amount for D2751. This item/service falls within the dental 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 pay more for a crown (D2740), and a crown fused to predominate-base 
metal (D2751), provided on December 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine provided on April 3, 2023. 
 
You asked the Plan to pay for the shingles vaccine. You say that it is medically necessary. The Plan denied 
your request. The Plan says the shingles vaccine is not a covered service under your medical Part B benefit 
plan. The service is eligible for payment or reimbursement under your Part D prescription benefit plan. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the shingles 
vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine provided on April 3, 
2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency services provided on April 23, 2022. 
 
You asked the Plan to pay for the emergency services. You say that you want this claim to be reviewed 
pursuant to the industry standards for an out-of-network providers (Free standing Emergency) or open it up for 
negotiation. The Plan denied your request. The Plan says as the provider is not enrolled with Medicare with an 
active Centers for Medicare & Medicaid Services (CMS) Certification Number (CCN), the Medicare rule for 
reimbursement of this April 23, 2022, claim has not been met.  
The Plan must follow Medicare rules. Medicare rules say that Medicare payment cannot be made to a provider 
that is not enrolled in the Medicare program. Medicare rules also say that Medicare covers services in an 
emergency department only if the emergency clinic is affiliated with the hospital.  
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. The documentation provided also states that the facility in question is not an actual hospital and has 
no affiliation with a hospital. Therefore, we decided that the Plan does not have to pay for the emergency 
services provided on April 23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from November 1, 
2022, through November 2, 2022. 
 
You asked the Plan to pay 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 the acute inpatient hospital care provided was 
not medically necessary.   
 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 these services. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee had a closed pilon fracture of the right tibia with routine healing. He was 
operated on November 1, 2022. He denied fevers and chills. He stated that he had been compliant with his 
weight-bearing restrictions in the right lower extremity. The hospital course per Orthopedics stated, "Patient 
admitted overnight for observation. He was discharged home on November 2, 2022 in stable condition. The 
review indicates that the record did not show that at the time of the inpatient admission the admitting physician 
reasonably expected that the enrollees necessary hospital care (including earlier ED and/or observation care) 
would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient hospital care provided from November 1, 2022, through November 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for manual wheelchair provided on September 01, 2022. 
 
You asked the Plan to pay for manual wheelchair. You say that you say that this is the first wheelchair that has 
been provided through the insurance. 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 manual wheelchair 
provided on September 01, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for manual wheelchair provided on May 01, 2023. 
 
You asked the Plan to pay for manual wheelchair. You say that you say that this is the first wheelchair that has 
been provided through the insurance. 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 manual wheelchair 
provided on May 01, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that this is medically necessary. The 
Plan denied your request. The Plan says there is no documentation provided to support the expectation the 
enrollee will require a greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the enrollee is approved for a total shoulder arthroplasty. The record does 
not document that the treating physician has a reasonable expectation of a length of stay spanning 2 or more 
midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that bone marrow aspirate is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says bone marrow aspirate is 
experimental/investigational. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that bone marrow aspirate is experimental when used as bone graft material in spine surgery.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate (20939).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator for 9 months (E0466). 
 
You asked the Plan to pre-approve a ventilator for 9 months. 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 ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator for 9 months. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found provided records document 
that the home ventilator is being requested for use in a volume assured pressure support (IVAPS) mode which 
is a modality that could be provided by a bilevel positive airway pressure (BiPAP) device with average volume 
assured pressure support (AVAPS) and a back-up rate. Provided records do not document trial and failure of a 
BiPAP device with AVAPS and a back-up rate. 
 
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 ventilator for 9 months have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a ventilator for 9 months (E0466).