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

 
We decided that the Plan does not have to pay for genicular nerve block injections. 
 
You asked the Plan to pay for genicular nerve block injections. You say that it is medically necessary for the 
enrollee's medical condition. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for genicular nerve block 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 block injections have not been met. Therefore, we decided that 
the Plan does not have to pay for genicular nerve block injections provided on May 18, 2023 .
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mattress (E1399) purchased on February 24, 2023. 
 
You asked the Plan to pay for a mattress. You say that the item was medically necessary. The Plan denied your 
request. The Plan says there was no order or prescription from your physician. 
 
The Plan must follow Medicare rules. The rules say that hospital beds are covered only with a physicians 
prescription and sufficient documentation in the patients medical records to establish medical necessity. 
 We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a mattress have not been met. Specifically, there is no prescription for this specific mattress. 
Therefore, we decided that the Plan does not have to pay for a mattress (E1399) purchased on February 24, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat epidural steroid injections. 
 
You asked the Plan to pre-approve repeat epidural steroid injections. You say that the enrollee had this 
injection before, and it reduced their pain by half and the doctor wants to give them another one. The Plan 
denied your request. The Plan says this is not 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 repeat epidural steroid injections. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the documentation 
indicates that the enrollee experienced improvement in her pain after the first set of lumbar injections at a 
suboptimal 40%. There is no documentation that the enrollee has had at least 50% of sustained improvement in 
pain relief and/or improvement in function measured from baseline using same scale for at least three months. The notes do not show that the enrollee's pain decreased by 50% for three months. The notes also do not show 
that the enrollee was able to perform her normal activities for at least three months. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of repeat epidural steroid injections have not been met. Therefore, we decided that 
the Plan does not have to pre-approve repeat epidural steroid injections.
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 December 14, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that regardless 
of whether you were transported, the emergency services were called and care was administered at the scene. 
You also say that you feel you are being penalized for being a good steward of healthcare dollars and saving 
both the plan and CMS from unnecessary charges. 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 December 14, 2022. 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 December 14, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on May 4, 2023. 
 
You asked the Plan to pay for medical services. You say that this should be covered. The Plan denied your 
request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for medical services provided on May 4, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on 
September 3, 2022, to September 4, 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 September 
3, 2022, to September 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth visit provided on May 1, 2023, by an OON 
provider.  
 
You asked the Plan to pay for a telehealth visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says the service was 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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
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 a telehealth visit provided on May 1, 2023, by an 
OON provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo. 
 
You asked the Plan to pre-approve Opdivo. 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 must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Opdivo. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found Opdivo is not FDA-approved for this 
indication and documentation does not support that criteria outlined for coverage are 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 Opdivo have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Opdivo.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on 
November 1, 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 November 
1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gas permeable contact lenses provided on May 12, 2023. 
  
You asked the Plan to pay for the gas permeable contact lenses . You say that this should be billed as durable 
equipment and not as routine eyewear. The Plan denied your request. The Plan says the benefit has been 
exhausted. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services up to $100 reimbursement. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid $100 towards the contact lenses on May 
12, 2023, which exhausted the benefit. Based on this information, we decided that the Plan's rules for coverage 
of the gas permeable contact lenses have not been met. Therefore, we decided that the Plan does not have to 
pay for the gas permeable contact lenses provided on May 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit, the scanning computerized ophthalmic 
diagnostic imaging, and the ophthalmic ultrasound provided on June 7, 2023, by an out-of-network (OON) 
provider.  
 
You asked the Plan to pay for the office visit, the scanning computerized ophthalmic diagnostic imaging, and 
the ophthalmic ultrasound. You say that you attached the paper referral for claim reconsideration. The Plan 
denied your request. The Plan says the provider was not a network provider, and the services were not referred 
by 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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the office visit, the scanning computerized ophthalmic diagnostic 
imaging, and the ophthalmic ultrasound provided on June 7, 2023, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ED services provided on September 9, 2022. 
 
You asked the Plan to pay for the ED services. You say that this should be covered. 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 ED services provided on September 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat epidural steroid injections. 
 
You asked the Plan to pre-approve repeat epidural steroid injections. You say that the enrollee had the first 
injection and it helped with some of the pain. The Plan denied your request. The Plan says this is not 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 repeat epidural steroid injections. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the LCD criteria 
requires 3 months of 50% or more pain relief.  This was not achieved and 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 repeat epidural steroid injections have not been met. Therefore, we decided that 
the Plan does not have to pre-approve repeat epidural steroid injections.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the personal care services 
 
You asked the Plan to pre-approve the personal care services. You say that you need help with your medication 
and the requested services are medically necessary. The Plan denied your request. The Plan says the requested 
services are not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the personal care services have not been met. Specifically, we find that the services at issue in this 
case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve the 
personal care services
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an in-network hip replacement surgery 
provided on March 16, 2023. 
 
You asked the Plan to waive the coinsurance for an in-network hip replacement surgery. You say that you 
should not have to pay all these percentages on top of your copayment, it should all be covered under that. 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 outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay 20% coinsurance for an in-network hip replacement surgery. This item/service 
falls within the outpatient diagnostic tests and therapeutic services and 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 $288.57 
($1,442.84 x 20% = $288.57). Therefore, we decided that the Plan does not have to waive the coinsurance for 
an in-network hip replacement surgery provided on March 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve A Cala Trio tremor stimulator device (K1018) and 
monthly supplies for use with the device (K1019). 
 
You asked the Plan to pre-approve A Cala Trio tremor stimulator device and monthly supplies for use with the 
device. You say that the items are medically necessary. The Plan denied your request. The Plan says this device 
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 Cala Trio tremor stimulator device 
and monthly supplies for use with the device. Our reviewer says that the requested items are not considered 
medically reasonable and necessary in this case. Our physician reviewer found this device 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 Cala Trio tremor stimulator device and monthly supplies for use with the 
device have not been met. Therefore, we decided that the Plan does not have to pre-approve A Cala Trio tremor 
stimulator device (K1018) and monthly supplies for use with the device (K1019).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the deluxe frames and the bifocal lens provided on April 25, 
2023.  
You asked the Plan to pay for the deluxe frames and the bifocal lens. You say that there is only one in-network 
provider on the island, and you refuse to be seen by this provider because of the extreme pricing of eyewear. 
The Plan denied your request. The Plan says the items are not covered benefits. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when received by a network provider. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the deluxe frames and the bifocal lens have not 
been met. Therefore, we decided that the Plan does not have to pay for the deluxe frames and the bifocal lens 
provided on April 25, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Freestyle Libre 3 sensor. 
 
You asked the Plan to pre-approve the Freestyle Libre 3 sensor. You say that the enrollee meets the criteria as 
they had an appointment with endocrinology in May and see the doctor every 6 months. The Plan denied your 
request. The Plan says that there was no medical rationale provided as to why the preferred product of Freestyle 
Libre 2 cannot be used. 
 
The Plan must follow 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 3 sensor. Our 
reviewer says that this item is medically necessary. Our physician reviewer found the enrollee is using insulin 
and hence coverage for the CGM are met. Either the Libre 2 or 3, which are not both covered by Medicare, 
would be reasonable for the enrollee to use. 
 
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 3 sensor have been met. Therefore, we decided that the Plan 
has to pre-approve a Freestyle Libre 3 sensor.  
 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endoscopic rhizotomy. 
 
You asked the Plan to pre-approve endoscopic rhizotomy. 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 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 endoscopic rhizotomy. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found no compelling rationale is presented or extenuating circumstances noted to support 
the medical necessity of this request as an exception. Therefore, the requested endoscopic rhizotomy is not 
medically reasonable or 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 endoscopic rhizotomy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve endoscopic rhizotomy.
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 May 13, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
ambulance was called because you became unresponsive. You also say that the emergency medical technician 
gave you sugar by mouth and 2 intravenous therapy of insulin and you seemed to be fine.  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 May 13, 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 May 13, 2023.