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

 
We decided that the Plan does not have to pay for the established patient assisted living visit (99335) provided 
on July 3, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the established patient assisted living visit. You say that you provided medically 
necessary services and would like this claim reprocessed and approved for payment. The Plan denied your 
request. The Plan says prior authorization was not obtained by the facility or the provider; therefore, payment 
has been correctly denied. 
 
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 has network providers 
available who can provide 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 established patient assisted living visit (99335) 
provided on July 3, 2020, by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan of the thorax (71250) and an 
evaluation of wheezing (94060) performed on January 24, 2020. 
 
You asked the Plan to waive the copayment for a CT scan of the thorax and an evaluation of wheezing. You 
say that this claim reflects an inaccurate copayment and should be covered with a $50 copayment. The Plan 
denied your request. The Plan says the correct copayment was applied. 
 
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 if you receive more 
than one covered service during a single visit to an outpatient facility, you will pay the highest single copay for 
all services received. Your contract also says that you must pay a $325 copayment for CT scans.  
 
You have been asked to pay a $325 copayment for a CT scan of the thorax and an evaluation of wheezing. A 
CT scan of the thorax and an evaluation of wheezing 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. Therefore, we decided that the Plan does not have to waive the copayment for a 
CT scan of the thorax (71250) and an evaluation of wheezing (94060) performed on January 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe eyewear services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe eyewear services. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says the requestedservices are neither emergent nor urgent to seek out-of-network care. The Plan says there are in-network providers available to you that can provide the services you are requesting.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-approvethe eyewear services 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 pay for a home visit provided on May 26, 2020. 
 
You asked the Plan to pay for the home visit. The Plan denied your request. The Plan says non-emergent, non-
urgent services with out-of-network providers require prior authorization.  
 
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 a home visit provided on May 26, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided  that  the  Plan  does not  have to waive  the cost sharing  forthe osteotomy  surgery  you  had at an outpatient hospital  facility  on February  12, 2020, and the  foot x-ray  you  had on April  28, 2020, at your podiatrist's  office.You asked the  Plan to waive  the cost sharing  forthe outpatient  surgery  and  the x-ray.  You say  that you  do not understand  why  these  claims  were  processed as out-of-network.The  Plan  denied  your  request.  The Plan  says you  were charged  this  cost sharing  correctly.   The  plan  also  states  that  because the  allowed  amount  for  the x-ray ($31.37) is  less  than  your  copayment  obligation,  you  are responsible  for  the  full  amount  for this  service.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 $50 copayment  for  x-rays  received  in  a specialist's  office.  Your  contract  also  says that  you  pay 25% coinsurance  for surgery  at an outpatient  hospital  facility.You  have  been asked to pay a $50 copayment  for  the  x-ray and 25% coinsurance  for the  outpatient  surgery. These  cost sharing  amounts  are the same  for  both  in-network  and out-of-network  providers.  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  forthe osteotomy  surgery  you  had at an outpatient  hospital  facility  on February  12, 2020, and the foot  x-ray  you  had on April  28, 2020, at your  podiatrist's  office.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care, per day (99233) provided on 
January 11, 2019. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the claim was submitted past the allowable 
twelve 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 subsequent hospital care provided was not filed until May 6, 2020. 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 the subsequent hospital care, per day (99233) 
provided on January 11, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA1 (BRCA1, DNA repair associated) (eg, 
hereditary breast and ovarian cancer) gene analysis; known familial variant (CPT Code 81215). 
 
You asked the Plan to pre-approve the service. You say that you are attempting to avoid having any cancer by 
seeking testing. The Plan denied your request. The Plan says testing enrollees with no personal history of 
breast, ovarian, fallopian tube, primary peritoneal, pancreatic, or prostate cancer is considered screening and 
excluded from coverage. 
 
 
 
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 service. Our physician reviewer 
found based on the documentation provided, the health plan's denial should be upheld. You underwent BRCA 
testing because your daughter has a BRCA1 mutation. You are not noted to have breast, ovarian, pancreatic or 
prostate cancer. As such, such testing is not medically necessary to diagnose or treat you. The testing was for 
screening and, therefore, is not covered. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve BRCA1 (BRCA1, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene 
analysis; known familial variant (CPT Code 81215).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp (J0882). 
 
You asked the Plan to pre-approve Aranesp. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the criteria for coverage has not been met. The Plan also says that the step 
therapy requirements have not been met. 
 
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 Aranesp. Our reviewer says that the 
requested drug is not medically necessary. Our physician reviewer found Aransesp can only be approved as 
part of step therapy. The reviewer found that the enrollee has not failed to tolerate or failed to respond to 
Retacrit therapy. Therefore, the reviewer found that the requested drug 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 Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp (J0882).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator (SCS) trial. 
 
You asked the Plan to pre-approve a SCS trial. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a spinal cord stimulator is only covered for certain 
indications.
  
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 SCS trial. Our reviewer says that the 
documentation does not support that the requested services are medically reasonable or necessary. Our 
physician reviewer found the enrollee has chronic neck and back pain. The enrollee is taking Gabapentin and 
Percocet for pain. The enrollee had a prior SCS implanted and then explanted. The enrollee was seen by a 
psychologist who noted depression with suggested psychotherapy but cleared the enrollee anyway. The 
enrollee does not have any evidence based indication for a SCS trial and further, had a prior SCS that was 
explanted. Therefore, the enrollee does not meet criteria for the requested services. 
 
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 SCS trial have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a spinal cord stimulator (SCS) trial.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the comprehensive oral evaluation, intraoral x-ay and 
prophylaxis provided on June 24, 2020 and July 2, 2020. 
 
You asked the Plan to pay more for the comprehensive oral evaluation, intraoral x-ay and prophylaxis. You say 
that you were told to write a check for the services, and you would be reimbursed later. You say that you 
should be reimbursed more. The Plan denied your request. The Plan says the claims processed correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for a $40 
copayment for dental services and any amount greater than the payment made by the Plan when the provider is 
out-of-network. Therefore, we decided that the Plan does not have to pay more for the comprehensive oral 
evaluation, intraoral x-ay and prophylaxis provided on June 24, 2020 and July 2, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the services provided to you on September 16, 2019. 
 
You asked the Plan to pay for the services. You say that you were active on this date of service. The Plan 
denied your request. The Plan says that you were ineligible on this date. 
 
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 Plan has not provided documentation showing that you were inactive with 
the Plan for the date of service in question. Without supporting documentation, the Plans denial cannot be 
substantiated. Therefore, we decided that the Plan has to pay for the services provided to you on September 16, 
2019.  
 
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 pay for the patient lift, hydraulic or mechanical, includes any seat, 
sling, strap or pad (E0630) purchased on May 29, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the patient lift. You say that you are appealing the denial of the service. You 
need the lift for daily use. You have a prescription for the hoyer lift and you were told that it would be covered. 
The Plan denied your request. The Plan says if you go to a provider who is not eligible to participate in 
Medicare, you will be responsible for the full cost of the services you receive. 
 
The Plan must follow Medicare rules. Medicare rules say that the plan will generally cover your medical care 
as long as the care you receive is considered medically necessary and you receive your care from a provider 
who is eligible to provide services under Original Medicare. As a member of the Plan you can receive your 
care from either a network provider or an out-of-network provider. 
 
The requested provider in this case is not certified for Medicare. If you go to a provider who is not eligible to 
participate in Medicare, you will be responsible for the full cost of the services you receive. 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 patient lift, hydraulic or mechanical, includes any seat, sling, strap or pad (E0630) 
purchased on May 29, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services provided to the enrollee on November 16, 
2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider failed to obtain prior authorization prior to the services being rendered. 
 
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 has network providers 
available who can provide 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 hospital services provided to the enrollee on 
November 16, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mental health evaluation provided on December 16, 2019 
by an out of network (OON) provider. 
 
You asked the Plan to pay for mental health evaluation. You say that the services rendered were medically 
necessary. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent 
services rendered by n out-of-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 has network providers 
available who can provide 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 mental health evaluation provided on 
December 16, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve the ESI. You say that the enrollee has tried therapy in the past and it was not 
helpful. There is no reason to believe that it would help now. ESI is warranted to reduce her symptoms. The 
Plan denied your request. The Plan says there must be a recent trial of physical therapy. 
 
The Plan follows Medicare rules. The rules say that ESIs are covered for enrollees with pain of certain causes 
when conservative management has failed.  
 
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 ESI. Our reviewer says that the 
requested ESI is not considered reasonable and necessary based on LCD criteria. Our physician reviewer found 
the enrollee has chronic low back pain. She is taking Percocet and or Tylenol#3 for pain. She had PT for her 
pain in 2018 that was discontinued due to increased pain. She has had pedicle screws placed with interbody 
spacers at L4-S1, and laminectomies. She has a documented disc protrusion.  
 
The patient has not had a recent trial of conservative therapy and therefore, does not meet the criteria of the 
LCD. The requested procedure 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 ESI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a lumbar epidural steroid injection (ESI).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the x-ray of the lower leg you had on June 
3, 2020 at a specialist's office. 
 
You asked the Plan to waive the copayment for the x-ray. You say that you say that you did not have x-rays on 
that date. The Plan denied your request. The Plan says you were charged this copayment correctly.  The plan 
says that because the allowed amount for this service ($28.15) is less than your copayment obligation, you are 
responsible for the full amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for x-rays in a specialist's office.  
 
You have been asked to pay a $35 copayment for the x-ray. The medical records from this date of service 
clearly indicate that you received an x-ray of the left lower leg. 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 the x-ray of the lower leg you had on June 3, 2020 at a specialist's office.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services (71275) provided on June 4, 2020 
 
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the claim was submitted with an invalid place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 71275 is not supported in the medical record. Specifically, place of service 23- 
Emergency Room - is not a valid place of service for a routine service. Based on this information, we decided 
that Medicare rules for coverage of the radiology services have not been met. Therefore, we decided that the 
Plan does not have to pay for the radiology services (71275) provided on June 4, 2020