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

 
We decided that the Plan does not have to pay for the injections provided on February 2, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the injections. 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 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 injections provided on February 2, 2023, by an 
OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost sharing for the extracapsular cataract removal, and 
the phenylephrine ophthalmic solution provided by an in-network provider on May 9, 2023, and May 10, 2023.   
 
You asked the Plan to reduce the cost sharing for the cataract removal and the ophthalmic solution. You say 
that you were told that the cost sharing would be lower. 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 $225 
copayment for each in-network Medicare-covered outpatient surgery or procedure at an ambulatory surgical 
center, and a 20% coinsurance for each in-network Medicare-covered Part B drug. 
 
You have been asked to pay a $450 copayment for the cataract removal ($225 copayment x 2 services = $450). 
These items/services fall within the outpatient surgery, including services provided at hospital outpatient 
facilities and ambulatory surgical centers benefit category. You have also been asked to pay a $153.96 
coinsurance for the ophthalmic solution ($769.84 allowed amount x .20 = $153.96 rounded down). These 
items/services fall within the Medicare Part B prescription drugs benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to reduce the cost sharing for the extracapsular cataract removal, and the phenylephrine ophthalmic solution 
provided by an in-network provider on May 9, 2023, and May 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cervical x-ray provided on July 14, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the cervical x-ray. 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 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 cervical x-ray provided on July 14, 2023, by 
an OON provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the take home supply of methadone (G2078) provided on 
May 15, 2023, by an OON provider.  You asked the Plan to pay for the take home supply of methadone. 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 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 take home supply of methadone (G2078) 
provided on May 15, 2023, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for right heart catheterization including measurement and 
injections provided on June 22, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for right heart catheterization including measurement and injections. You say that 
this service is supported in the records proving medical necessity. The Plan denied your request. The Plan says 
this 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 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 right heart catheterization including measurement 
and injections provided on June 22, 2023, by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the care management services provided on May 8, 2023, by 
an OON provider.  
 
You asked the Plan to pay for the care management services. You say that you are appealing the denial with 
supporting documentation. 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 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 care management services provided on May 8, 
2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visits to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve the office visits. You say that you would like to see this provider. The Plan 
denied your request. The Plan says you must receive your 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the office visits to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve the office visit. You say that you would like to see this provider. The Plan 
denied your request. The Plan says you must receive your 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the item/service at issue in this appeal. We found no exception that would require 
the Plan to pre-approve this item/service. Therefore, we decided that the Plan does not have to pre-approve the 
office visit to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (D9310) provided on August 10, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
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 a 
consultation (D9310) provided on August 10, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ondansetron tablets. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee is to take 1 tablet by mouth every 
8 hours as needed for nausea and vomiting. The Plan denied your request. The Plan says the 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 requested here are not among the types which are covered by 
Medicare Part B. Specifically, the documentation shows that the requested ondansetron is not to be 
administered within 2 hours of the chemotherapy administration, but is to be initiated as needed for intractable 
nausea and vomiting, and may exceed 48 hours. The record also shows that the ondansetron will not be used as 
a full therapeutic replacement for intravenous anti-emetic drugs that would have been administered at the time 
of the chemotherapy treatment. Therefore, we decided that the Plan does not have to pre-approve ondansetron 
tablets.  
 
Benefits for the 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on January 19, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that after an internal audit it was found that the 
original claim was coded incorrectly. You also say to please review the submitted documents. The Plan denied 
your request. The Plan says the claim was submitted past the allowed 12 month timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the ambulance services was not filed until June 29, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for ambulance services provided on January 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three levels of bilateral lumbar Intra-articular Facet 
Joint Therapeutic Steroid injections (64493, 64494, 64495). 
 
You asked the Plan to pre-approve three levels of bilateral lumbar Intra-articular Facet Joint Therapeutic 
Steroid injection. You say that the services are medically necessary. The Plan denied your request. The Plan 
says the services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that this service is covered when the criteria listed in the 
Medicare Rules section is 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 three levels of bilateral lumbar Intra-
articular Facet Joint Therapeutic Steroid injection. Our reviewer says that the service is not medically 
necessary. Our physician reviewer found the enrollee has clearly documented radiculopathy as well as other 
spine pathology. Thus, he does not meet the LCD criteria that there are not other causes of low back pain.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of three levels of bilateral lumbar Intra-articular Facet Joint Therapeutic Steroid 
injection have not been met. Therefore, we decided that the Plan does not have to pre-approve three levels of 
bilateral lumbar Intra-articular Facet Joint Therapeutic Steroid injections (64493, 64494, 64495).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair with multiple 
power option (K0861) and additional items and accessories (codes E0955, E1007, E1012, E1028, E2300, 
E2311, E2313, E2361, E2377, E2607, E2620, and K0040). 
 
You asked the Plan to pre-approve a Group 3 standard power wheelchair (K0861) and additional items and 
accessories. You say that the requested items are medically reasonable and necessary. The Plan denied your 
request. The Plan says the enrollee does not have a qualifying diagnosis causing mobility limitation for which a 
group 3 power wheelchair is medically needed. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair (PWC) with multiple 
power options (such as code K0861) is covered if the criteria listed in the Medicare rules section of this letter 
are met. Medicare rules also say that if the PWC base is not covered, then related accessories will be denied. 
 
 
  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 Group 3 standard power wheelchair 
(K0861) and additional items and accessories. Our reviewer says that the Group 3 power wheelchair with 
power tilt and recline and power elevating leg rests is not medically necessary. Our physician reviewer found 
the enrollee is functionally non-ambulatory and cannot use a cane or walker for mobility given their weakness 
and risk for falling. They cannot functionally propel a manual wheelchair due to upper extremity weakness and 
limited range of motion. The enrollee cannot use a power scooter due to poor sitting balance and inability to 
safely transfer. Our reviewer found that it is understandable that the enrollee may desire a power wheelchair. 
However, the enrollee is currently receiving caregiver assistance and is dependent or requires maximum 
assistance for mobility and daily activities. Our physician reviewer also found that it is unclear how the power 
wheelchair will significantly improve the enrollees level of independence and therefore require significantly 
less caregiver assistance or allow them to live independently. 
 
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 Group 3 standard power wheelchair (K0861) and additional items and 
accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 
standard power wheelchair with multiple power option (K0861) and additional items and accessories (codes 
E0955, E1007, E1012, E1028, E2300, E2311, E2313, E2361, E2377, E2607, E2620, and K0040).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628). 
 
You asked the Plan to pre-approve an Intracept procedure. 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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no magnetic resonance imaging (MRI) showing only modic changes. The 
cause of the pain is not clear. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the 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 requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Entyvio.   
Benefits for the 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires a pulmonary 
rehabilitation program at the LTACH level. The Plan denied your request. The Plan says the enrollee is 
currently unstable to transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to require additional acute care services that can safely be 
provided at the current facility until more stable and appropriate for transfer. The enrollee does not require 
services at the LTACH level that are not already available at the current facility. Transfer to an LTACH is not medically necessary and would not be clinically advantageous. Completion of treatment at the current facility 
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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the transthoracic echocardiography (C8929) and sulfur hexafluoride 
lipid microspheres injection (Q9950) provided on June 26, 2023. 
 
You asked the Plan to pay for the transthoracic echocardiography and sulfur hexafluoride lipid microspheres 
injection. You say that you were unaware that there was a $2,500 limit on coverage when out of state. The Plan 
denied your request. The Plan says that based on your claims history, you have met the $2,500 limit. 
 
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 records do not show that you have met the maximum Convenience Care 
benefit of $2,500 for the 2023 plan year. This means that the Plan has not provided a valid reason for denying 
payment of the services. It is the burden of the Plan to substantiate their denial with evidence. In this case, the 
denial has not been substantiated. Therefore, we decided that the Plan has to pay for the transthoracic 
echocardiography (C8929) and sulfur hexafluoride lipid microspheres injection (Q9950) provided on June 26, 
2023.  
 
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.