Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine eye exam provided on February 20, 2023. 
 You asked the Plan to pay for the routine eye exam. You say that you were never advised that the provider was 
out-of-network. You say you were told the provider was in-network. The Plan denied your request. The Plan 
says the service was not a covered benefit. 
 
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 provided 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 routine eye exam have not been met. 
Therefore, we decided that the Plan does not have to pay for the routine eye exam provided on February 20, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that the enrollee needs this item. The 
Plan denied your request. The Plan says the height adjustment feature of a fully electric hospital bed is a 
convenience feature and therefore is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 99053 billed for date of service September 
18, 2022. 
 
You asked the Plan to pay for procedure code 99053. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says procedure code 99053 is considered bundled 
and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service September 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on September 29, 2022. 
 
You asked the Plan to pay for nursing facility care. You say that this is supported in the records. 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 nursing facility care 
provided on September 29, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continued use of Keytruda infusion. 
 
You asked the Plan to pre-approve the continued use of Keytruda infusion. You say that the continued use of 
Keytruda infusion is medically necessary for the enrollee. The Plan denied your request. The Plan says the 
continued use of Keytruda infusion does not meet medical necessity. 
 
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 continued use of Keytruda infusion. 
Our physician reviewer says that the requested use of Keytruda is not Food and Drug Administration-approved 
for the enrollee's diagnosis and is not supported by one of the major drug compendia or by a CMS-approved 
medical journal. The continued use of Keytruda in this case does not meet Medicare criteria due to disease 
progression. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued use of Keytruda infusion have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the continued use of Keytruda infusion.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occupational therapy, and related services provided on 
September 27, 2022. 
 
You asked the Plan to pay for occupational therapy, and related services. You say that these services were 
medically necessary. 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 occupational therapy, 
and related services provided on September 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a hospital outpatient clinic visit, and 
physician's services provided on January 10, 2023. 
 
You asked the Plan to waive the coinsurance for the hospital outpatient clinic visit and physician's services. 
You say that you cost share is higher than normal for this provider. 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. Your 
contract with the Plan says that there is a $100 deductible and a $500 out-of-pocket maximum. 
 
The services you asked the Plan to waive the coinsurance for falls within the covered medical benefit category. 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $100 deductible and a 
$500 out-of-pocket maximum. This cost sharing is a contractual obligation that had not been met at the time the 
hospital outpatient clinic visit and physician's services were received on January 10, 2023. Therefore, we 
decided that the Plan does not have to waive the coinsurance for a hospital outpatient clinic visit, and 
physician's services provided on January 10, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo (J9299). 
 
You asked the Plan to pre-approve Opdivo. You say that Opdivo is medically necessary. The Plan denied your 
request. The Plan says that the requested drug is not medically reasonable and necessary. 
 
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 Opdivo 
is not medically necessary, safe, and effective for the enrollee. Our physician reviewer found that the requested 
use of Opdivo is not FDA approved for the enrollees diagnosis due to the lack of biomarker testing showing 
microsatellite instability-high (MSI-H) or mismatch repair deficient (dMMR) metastatic colorectal cancer. The use of Opdivo for treatment of rectal cancer without MSI-H or dMMR biomarkers is not indicated, supported, 
or recommended in any of the drug compendia. 
 
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 (J9299).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tetanus-Diphteria-Pertussis (Tdap) vaccine provided on 
November 30, 2022. 
 
You asked the Plan to pre-approve Tetanus-Diphteria-Pertussis vaccine. You say that it is medically necessary. 
The Plan denied your request. The Plan says this is not covered by Part B coverage.  
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide Tetanus-Diphteria-
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-Diphteria-
Pertussis vaccine. Therefore, we decided that the Plan does not have to pre-approve Tetanus-Diphteria-
Pertussis (Tdap) vaccine provided on November 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation system (E0483). 
 
You asked the Plan to pre-approve a high frequency chest wall oscillation system. You say that the vest was 
prescribed to help manage the enrollee's complicated respiratory needs at home. You also say that the enrollee 
has no other clinical alternatives for high frequency chest wall oscillation or airway clearance therapy. The Plan 
denied your request. The Plan says according to the records, the enrollee is being treated for asthma, and not a 
diagnosis for which a high frequency chest wall oscillation system is indicated. 
 The Plan must follow Medicare rules. Medicare rules say that high frequency chest wall oscillation devices are 
covered only for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 
 
The record does not show that the enrollee has cystic fibrosis, bronchiectasis, or a covered neuromuscular 
disease. This means that the enrollee does not have a medical condition for which a high frequency chest wall 
oscillation device can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to 
pre-approve a high frequency chest wall oscillation system (E0483).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ultrasound provided on November 08, 2022. 
 
You asked the Plan to pay for an ultrasound. You say that this was medically necessary and should be covered. 
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 an ultrasound provided 
on November 08, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says the requested documentation was not received. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not require daily skilled nursing or therapy services. The 
enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a skilled 
nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan.  
 
You asked the Plan to pre-approve the PET scan. You say that a PET scan is medically necessary for the 
enrollee to establish a definitive diagnosis and treatment plan. The Plan denied your request. The Plan says the 
criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 not medically necessary. Our physician reviewer found that the provided records did not readily 
support that the enrollee would meet the diagnostic criteria for either AD or FTD, let alone both conditions. 
 
 
 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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve a PET scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontic - porcelain fused to high noble metal (D6240) 
and retainer crown - porcelain fused to high noble metal (D6750 x3). 
 
You asked the Plan to pre-approve the pontic - porcelain fused to high noble metal and retainer crown - 
porcelain fused to high noble metal. The Plan denied your request. The Plan says the documentation does not 
meet the Plan's criteria for approval. 
 
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.  
 The Plan covers the pontic - porcelain fused to high noble metal and retainer crown - porcelain fused to high 
noble metal  when the services are medically necessary and reasonable.  
 
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 pontic - porcelain fused to high 
noble metal and retainer crown - porcelain fused to high noble metal. Our reviewer says that the requested 
dental services are not medically necessary Our physician reviewer found coverage for fixed bridges may be 
considered to replace a single maxillary anterior tooth or two adjacent mandibular anterior teeth if no posterior 
teeth are missing in the arch. In this case there are multiple missing mandibular posterior teeth bilaterally. The 
documentation provided does not meet the criteria for coverage for a fixed bridge replacing tooth #25. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the pontic - porcelain fused to high noble metal and retainer crown - porcelain 
fused to high noble metal  have not been met. Therefore, we decided that the Plan does not have to pre-approve 
pontic - porcelain fused to high noble metal (D6240) and retainer crown - porcelain fused to high noble metal 
(D6750 x3).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve WavelinQ. 
 
You asked the Plan to pre-approve WavelinQ. You say that the services are necessary. The Plan denied your 
request. The Plan says that medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve WavelinQ. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found WaveLinQ, as noted in the journal of Vascular Access Sept 2020 study had superior outcomes 
in a single center trial. It has the advantage of being less invasive, quicker healing, and has comparable or 
superior outcomes. This procedure through minimal incision is considerably less traumatic to enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of WavelinQ have been met. Therefore, we decided that the Plan has to pre-
approve WavelinQ.  
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient mental health care provided on 
April 12, 2022, to September 15, 2022. 
 
You asked the Plan to waive the copayment for outpatient mental health care. 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 $475 
copayment for outpatient mental health care. 
 
You have been asked to pay a $475 copayment for outpatient mental health care. This item/service falls within 
the outpatient mental health 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. You are being asked to pay $25 per visit. The total amount you are being asked 
to pay is $475 ($25 x 19 visits = $475). Therefore, we decided that the Plan does not have to waive the 
copayment for outpatient mental health care provided on April 12, 2022, to September 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar medial branch blocks. 
 
You asked the Plan to pre-approve lumbar medial branch blocks. You say that lumbar medial branch blocks are 
medically necessary. The Plan denied your request. The Plan says the medical records do not show pictures of 
lower back (lumbar magnetic resonance imaging (MRI) or computed tomography (CT)) that show there are no 
other reasons for his lower back pain.  
 
The Plan follows Medicare rules.  
 
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 lumbar medial branch blocks. Our 
reviewer says that the requested lumbar medial branch blocks are not considered medically necessary in this 
case. Our physician reviewer found the enrollee does not have recent imaging. Therefore, that the enrollee does 
not meet LCD criteria and 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 lumbar medial branch blocks have not been met. Therefore, we decided that the 
Plan does not have to pre-approve lumbar medial branch blocks.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anticoagulant management provided on January 27, 2023. 
 
You asked the Plan to pay for anticoagulant management. You say that you did not this this service would need 
a prior authorization. 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 anticoagulant 
management provided on January 27, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Zioptan solution. 
 
You asked the Plan to pre-approve Zioptan. You say that the requested drug is a medical necessity for the 
enrollee. 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 drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Zioptan 
solution.  
 
Benefits for Zioptan may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.