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

 
We decided that the Plan does not have to reduce the copay for the ambulance transportation provided on June 
16, 2023, and June 17, 2023. 
 
You asked the Plan to reduce the copay for the transportation services. You say that you should not be charged 
two times. 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 $275 
copay for each one-way Medicare-covered ambulance transport.  
 
The file shows that you received two ambulance transports. You have been asked to pay a $275 copay for each 
one-way Medicare-covered ambulance transport. The services fall within the ambulance 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 reduce the copay for the ambulance transportation provided on June 16, 
2023, and June 17, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approved a high frequency chest wall oscillation device (HFCWOD) 
(Volara system-high frequency oscillation lung expansion device). 
 
You asked the Plan to pre-approved a HFCWOD. You say that you would like this device to be approved for 
the enrollee, as they have been using and benefiting from this device. The Plan denied your request. The Plan 
says that based on Medicare guidelines, the device requested does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
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-approved a HFCWOD. Our reviewer says that 
the Volara device is medically reasonable and necessary for the enrollee. Our physician reviewer found the 
enrollee has bronchiectasis, has failed several convention therapies for airway clearance, and appears to be 
having a good response and compliance with Volara device. Therefore, the enrollee should continue Volara 
therapy for airway clearance. 
 
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 HFCWOD have been met. Therefore, we decided that the Plan has to pre-
approved a high frequency chest wall oscillation device (HFCWOD) (Volara system-high frequency oscillation 
lung expansion device).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prosthetic leg components. 
 
You asked the Plan to pre-approve prosthetic leg components. You say that you received a prosthesis in 2021 
but could not tolerate it, so you want a prosthesis replacement from the company you originally used because 
that is the one you tolerate best. The Plan denied your request. The Plan says your current prosthesis is less 
than 5 years old and is in good condition so is not eligible for replacement. 
 
The Plan must follow Medicare rules. Medicare rules say that durable medical equipment, prosthetics, 
orthotics, and supplies (DMEPOS) items are not eligible for replacement within the reasonable useful lifetime 
of the item, which may not be less than 5 years. Prosthetics may be replaced if there is a change in the 
physiological condition of the enrollee, irreparable damage, or required repairs that would be more than 60 
percent of the cost of a replacement. 
 
We looked at the file and Medicare rules. You received your current lower limb prosthesis in 2021, which was 
less than 5 years ago. The record does not show that you have undergone a physiological change, or that the 
prosthesis experienced irreparable damage or requires repairs that would be more than 60 percent of the cost of 
a replacement. Based on this information, we decided that Medicare rules for coverage of prosthetic leg 
components have not been met. Therefore, we decided that the Plan does not have to pre-approve prosthetic leg 
components.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for practitioner services provided on March 26, 2023, to March 27, 2023, 
billed with procedure code 43246-51. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says that documentation does not support the billed 
code. 
 
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 43246-51 is esophagogastroduodenoscopy, flexible, transoral; with directed placement of percutaneous 
gastrostomy tube. 
 
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 the practitioner services provided. Our reviewer says that 
documentation does support the billed code. Our reviewer found that the medical record includes 
documentation of procedure billed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the practitioner services provided have been met. Therefore, we decided that the 
Plan has to pay for practitioner services provided on March 26, 2023, to March 27, 2023, billed with procedure 
code 43246-51.  
 
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 pay for the medication assisted treatment (G2067) provided on April 
17, 2023, by an OON provider.  
 
You asked the Plan to pay for the medication assisted treatment. 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 medication assisted treatment (G2067) 
provided on April 17, 2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on May 19, 
2023. 
 
You asked the Plan to pay for the subsequent 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 subsequent nursing 
facility care provided on May 19, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a laminectomy procedure with implantation of the 
Coflex interspinous device to L4-L5 level. 
 
You asked the Plan to pre-approve the laminectomy procedure with Coflex interspinous device. You say that 
the enrollee suffers from severe low back pain. You also say that this should be done as soon as possible to 
give the enrollee relief from the pain. The Plan denied your request. The Plan says this is experimental and 
therefore is not covered. 
 
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 the laminectomy procedure with Coflex interspinous device. Our reviewer says that the requested Coflex interspinous device is not considered 
medically reasonable and necessary in this case. Our physician reviewer found the Coflex device is considered 
experimental. Therefore, the reviewer found that the Coflex device 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 the laminectomy procedure with Coflex interspinous device have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a laminectomy procedure with implantation 
of the Coflex interspinous device to L4-L5 level.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the thorax and a CT scan of the chest and 
abdomen to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a CT scan of the thorax and a CT scan of the chest and abdomen. You say 
that the enrollee has cancer and cannot wait. The Plan denied your request. The Plan says that the CT scans are 
available in network. 
 
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 
a CT scan of the thorax and a CT scan of the chest and abdomen 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 the vision supply service provided on May 31, 2023. 
 You asked the Plan to pay for the vision supply service. You say that the new lenses were paid for on May 31, 
2023, and the previous lenses were paid out for the previous calendar year on June 2, 2022. 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 when up to $300 combined allowance for eyeglasses and contact 
lenses every 24 months. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid for eyewear on June 2, 2022, which 
exhausted the benefit. Based on this information, we decided that the Plan's rules for coverage of the vision 
supply service have not been met. Therefore, we decided that the Plan does not have to pay for the vision 
supply service provided on May 31, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea. 
 You asked the Plan to pre-approve Eylea. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Eylea. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has age related exudative macular degeneration with active choroidal neovascularization. 
The documentation does not support that the enrollee has tried and failed bevacizumab (Avastin) and Byooviz. 
The documentation does not support that bevacizumab (Avastin) and Byooviz would likely be less effective 
and/or likely have adverse effects for the enrollee. 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 Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom iSleeve and neoprene impact guards for a 
manual wheelchair. 
 
You asked the Plan to pre-approve a custom iSleeve and neoprene impact guards. You say that the requested 
items are a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested items 
do not primarily serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The items at issue in this appeal do not serve a purpose that is primarily medical in nature. These items are 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a custom iSleeve and neoprene impact guards for a manual 
wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on May 11, 
2023, to May 15, 2023. 
 
You asked the Plan to waive the copayment for inpatient hospital 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 $200 
copayment for inpatient hospital care.  
 
You have been asked to pay a $200 copayment for inpatient hospital care. 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 inpatient 
hospital care provided on May 11, 2023, to May 15, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting an expedited 
reconsideration as the enrollee currently meets LTACH admission criteria. The Plan denied your request. The 
Plan says the enrollee does not meet the guidelines for care in 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 is receiving appropriate care in the current acute care setting as provided 
by the Plan. The documentation does not support that LTACH services are medically appropriate at this time. 
 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 long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical eye examination (92014) 
provided on March 22, 2023. 
 
You asked the Plan to waive the copayment for a medical eye examination (92014). You say that you have the 
same plan as last year, which you were reimbursed $75 for the examination. You also say that you do not have 
any paperwork telling you of any changes that were made. 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 $60 
copayment for each non-Medicare covered eye examination and each follow-up diabetic eye examination.  
 You have been asked to pay a $60 copayment for a determination of refractive state (92015). This item/service 
falls within the non-Medicare covered eye examination and each follow-up diabetic eye examination benefit 
category. The record shows this was a medical eye examination, not a routine eye examination. 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 a medical eye examination (92014) provided on March 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on January 18, 2023. 
 
You asked the Plan to pay for the home visit. You say that the enrollee was residing in an assisted living 
facility when services were provided. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the home visit provided 
on January 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crutch substitute (E0118). 
 
You asked the Plan to pre-approve a crutch substitute. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a crutch substitute has not been met. Specifically, this item is not a covered benefit of Medicare or 
the Plan. Therefore, we decided that the Plan does not have to pre-approve a crutch substitute (E0118).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the nuclear medicine stress test provided 
on June 5, 2023. 
 
You asked the Plan to waive the cost sharing for the nuclear medicine stress test. You say that you did not pay 
this much for this service 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. Your 
contract with the Plan says that there is a $750 deductible which applies to outpatient diagnostic tests and 
therapeutic services. Your contract with the Plan also says that you must pay a $200 copayment after meeting 
the deductible for advanced imaging services. 
 
 You have been asked to pay $606.68 towards the deductible. The item or service you asked the Plan to waive 
the cost sharing for falls within the outpatient diagnostic tests and therapeutic services benefit category. The 
Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which 
applies to outpatient diagnostic tests and therapeutic services. This cost sharing is a contractual obligation that 
had not been met at the time the nuclear medicine stress test was received on June 5, 2023.  
 
You have also been asked to pay a $200 copayment for the nuclear medicine stress test. You have been asked 
to pay a total of $806.68 ($606.68 deductible + $200 copayment = $806.68). 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 nuclear medicine stress test provided on June 5, 2023.