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

 
We decided that the Plan does not have to waive the copayment for podiatry services provided on April 7, 
2023. 
 
You asked the Plan to waive the copayment for podiatry services. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for podiatry services.  
 
You have been asked to pay a $35 copayment for podiatry services. This item/service falls within the podiatry 
services benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for podiatry services provided 
on April 7, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for Medicare Part B prescription drugs and 
outpatient diagnostic tests provided on March 1, 2023. 
 
You asked the Plan to waive the cost share for Medicare Part B prescription drugs and outpatient diagnostic 
tests. You say that you disagree with the cost share. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare Part B prescription drugs and a $300 copayment for outpatient diagnostic tests.  
 You have been asked to pay a 20% coinsurance for Medicare Part B prescription drugs and a $300 copayment 
for outpatient diagnostic tests. The total allowed amount for the prescription drugs is $13.60. You are being 
asked to pay $2.72 ($13.60 x 20% = $2.72). This item/service falls within the Medicare Part B prescription 
drugs and outpatient diagnostic tests 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 
Medicare Part B prescription drugs and outpatient diagnostic tests provided on March 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B prescription drugs 
provided on September 30, 2022, to April 14, 2023. 
 
You asked the Plan to waive the coinsurance for Medicare Part B prescription drugs. You say that you disagree 
with the coinsurance. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance for Medicare Part B prescription drugs. The total allowed 
amount for the prescription drugs is $10,808.86. You are being asked to pay $2,161.77 ($10,808.86 x 20% = 
$2,161.77). This item/service falls 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 coinsurance for Medicare Part B prescription drugs provided on September 30, 
2022, to April 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits provided from September 28, 2022, to March 
16, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the physician services. You say that you have been seeing this doctor for several 
years. You also say that there are no neurologists in your area who accept your insurance. The Plan denied your 
request. The Plan says prior authorization was not 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 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 office visits provided from September 28, 
2022, to March 16, 2023, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided on June 11, 2022, to July 9, 2022.  
 
You asked the Plan to pay for the home health services. You say that full payment is due, please review the 
submitted records and pay at the full allowable amount. The Plan denied your request. The Plan says that the 
services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer says 
that the services are medically reasonable and necessary. Our physician reviewer found clinical documentation 
shows the enrollee has completed all appropriate home health skilled therapy goals, still requiring physical 
assist with bed mobility and transfers and evaluation. It is documented that the enrollee has neurological 
weakness due to spinal stenosis thus the complexity of the case would support 3 additional hours of home 
health physical therapy sessions during the time period of June 11, 2022 to July 9, 2022. The record shows that 
skilled therapy services were required to effectively provide treatment, care, and/or services in order to improve 
the enrollee's level of function, or to establish/perform a maintenance program to maintain the enrollee's level 
of function and/or prevent deterioration. 
 
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 home health services have been met. Therefore, we decided that the Plan has 
to pay for the home health services provided on June 11, 2022, to July 9, 2022.   
 If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the office visit, and the collagenase 
injection provided on March 21, 2023. 
 
You asked the Plan to waive the cost sharing for the office visit, and the injection. You say that you had this 
service done in the past and was not charged this cost share. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 
 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance of the cost for Part B covered prescription drugs, and a $40 copayment for each specialist visit for 
Medicare-covered benefits. 
 
You have been asked to pay a $1125.18 coinsurance for the injection ($5625.90 allowed amount x .20 = 
$1125.18). This item/service falls within the Medicare Part B prescription drugs benefit category. You have 
also been asked to pay a $40 copayment for the office visit. This item/service falls within the 
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 waive the cost sharing for the office visit, and the collagenase injection provided on March 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Lynx Ultra Lightweight Wheelchair and Elevating 
Leg Rest. 
 
You asked the Plan to pre-approve the Lynx Ultra Lightweight Wheelchair and Elevating Leg Rest.. You say 
that the item should be covered. The Plan denied your request. The Plan says this is not the Plan's preferred 
brand. 
 
The Plan follows Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the Durable Medical Equipment 
(DME) to only those preferred brands and manufacturers. 
 
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 Lynx Ultra Lightweight Wheelchair 
and Elevating Leg Rest.. Our reviewer says that the enrollee does not need these items. Our physician reviewer 
found the medical records do not indicate the requested brand is medically necessary over the Plan's preferred 
brand. 
 
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 Lynx Ultra Lightweight Wheelchair and Elevating Leg Rest. have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the Lynx Ultra Lightweight Wheelchair 
and Elevating Leg Rest.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine transportation (A0120). 
 
You asked the Plan to pre-approve routine transportation. You say that you are facing medical issues and you 
need immediate assistance with transportation to travel to the providers office/facility. The Plan denied your 
request. The Plan says routine transportation is not covered by your benefit plan. 
 
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. 
The Plan follows the same rule.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Medicare rules for coverage of routine transportation have not been met. Specifically, routine 
transportation is not covered by your Plan. Therefore, we decided that the Plan does not have to pre-approve 
routine transportation (A0120).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency room visit (99285) provided on December 14, 
2022. 
 
You asked the Plan to pay for 99285. You say that you are appealing with supporting records. The Plan denied 
your request. The Plan says the records indicate there was not a detailed history and exam done and the medical 
decision-making was minimal. 
 
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, the CPT Code Manual definition of code 99285 is emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function. 
 
We asked our coder 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 99285. Our reviewer says that this code does not meet 
criteria for payment. Our reviewer found the record supports comprehensive history, comprehensive 
examination, and medical decision-making of moderate complexity. There is a more appropriate code to report 
for the service provided. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 99285 have not been met. Therefore, we decided that the Plan does not have to 
pay for an emergency room visit (99285) provided on December 14, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room visit, and an x-ray 
provided on March 22, 2023, to March 23, 2023. 
 
You asked the Plan to waive the copayment for emergency room visit and an x-ray. You say that you disagree 
with the copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $125 
copayment for emergency care and a $20 copayment for outpatient diagnostic tests/x-rays.  
 
You have been asked to pay a $125 copayment for emergency room visit and a $20 copayment for an x-ray. 
The total amount you are being asked to pay $145 ($125 + $20 = $145). This item/service falls within the emergency care and outpatient diagnostic tests/x-rays 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 emergency room visit, and an x-ray provided on March 22, 2023, to March 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro orthosis (L8702). 
 
You asked the Plan to pre-approve a MyoPro orthosis. You say that this item is medically necessary. The Plan 
denied your request. The Plan says this item is considered experimental. 
 
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 a MyoPro orthosis. Our reviewer says 
that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found this item is considered experimental. 
 
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 MyoPro orthosis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a MyoPro orthosis (L8702).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
February 6, 2023, to February 9, 2023. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you have not had to pay 
for an inpatient stay in the past. 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 $175 
copayment per day, for days 1 to 3 and a $0 copayment for additional Medicare-covered days of an inpatient 
stay. 
 You have been asked to pay a $175 copayment per day, for days 1 to 3 of the inpatient hospital stay. You have 
been asked to pay a total of $525 ($175 copayment x 3 days = $575). You have not been charged for any 
additional days. This item/service falls within the inpatient hospital 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 an inpatient hospital stay provided from February 6, 2023, to 
February 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug injection provided on November 14, 2022, by an 
OON provider.   
 
You asked the Plan to pay for the drug injection. You say that you are requesting reconsideration based on 
medical necessity. The Plan denied your request. The Plan says the services were not authorized. 
 
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 drug injection provided on November 14, 
2022, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 15, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for the genetic testing. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says enrollees must receive their care from a network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the item/service 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 this item/service. Therefore, 
we decided that the Plan does not have to pay for the genetic testing provided on February 15, 2023, by an out-
of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo intravitreal injections. 
 
You asked the Plan to pre-approve Vabysmo intravitreal injections. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested injections are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Vabysmo intravitreal injections are only covered for 
certain indications. 
 
Review of the file shows that the LCA cited above states that certain diagnoses meet criteria for Vabysmo 
injections. However, the LCA does not state that any diagnosis not listed 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 Vabysmo intravitreal injections. Our 
reviewer says that the documentation does not support that the requested injections are medically reasonable or 
necessary. Our physician reviewer found the enrollee has a diagnosis of retinal vein occlusion with macular edema of the right eye. The requested use of Vabysmo intravitreal injections is not Food and Drug 
Administration-approved for the enrollee's diagnosis. The use of Vabysmo intravitreal injections for treatment 
of retinal vein occlusion with macular edema is not supported by one of the major drug compendia or by 
clinical research that appears in a CMS-approved medical journal. Therefore, the enrollee does not meet criteria 
for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vabysmo intravitreal injections have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Vabysmo intravitreal injections.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation mileage (A0170). 
 
You asked the Plan to pre-approve additional routine transportation mileage. You say that you disagree with 
the denial and request reconsideration. The Plan denied your request. The Plan says you are requesting an 
additional 60 miles for a total of 110 miles and your benefit only allows 50 miles. The Plan also says you have 
exceeded your benefit limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers up to 72 one-way trips and each one-way trip must not exceed 50 miles of driving 
distance.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of additional routine transportation mileage have not been met. Specifically, 
trips over 50 miles are not covered. Therefore, we decided that the Plan does not have to pre-approve additional 
routine transportation mileage (A0170).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on August 30, 2022. 
 
You asked the Plan to pay for the nursing facility care. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the nursing facility care 
provided on August 30, 2022.