Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment provided on November 25, 2019 
by an out of network (OON) provider. 
 
You asked the Plan to pay for a front wheeled walker. You say that this walker was needed for after the surgery 
as to not re-injure the joint. The Plan denied your request. The Plan says prior authorization was not obtained. 
The Plan says that the referring provider is also out-of-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 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 durable medical equipment provided on 
November 25, 2019 by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit for evaluation and management (99350) 
provided on April 30, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for home visit. You say that prior authorization is not required for telemedicine. The 
Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services 
rendered by an 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 home visit for evaluation and management 
(99350) provided on April 30, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will benefit from IRF level of care. The 
Plan denied your request. The Plan says the enrollee has not completed a full course of care in the hospital and 
thus does not meet Medicare criteria for IRF services. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. There is not a reasonable expectation that this patient will be able 
to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on April 29, 2020.You asked the Plan to pay for the nurse practitioner services.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 servicesat issue. We found no exception that would requirethe Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for nurse practitioner services provided on April 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for vision services provided on June 24, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for vision services. You say that you would like this claim reprocessed and approved 
for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says 
that there are in-network providers available for these services. 
 
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 vision services provided on June 24, 2020 by an 
out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve progressive lens, per lens (V2781 x2). 
 
You asked the Plan to pre-approve the lenses. You say that you do not like the lenses you currently have. The 
Plan denied your request. The Plan says you exhausted your benefit frequency limit. 
 
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. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the lenses have not been met. You received the lenses on June 23, 2020. The benefit is limited 
to one pair of lenses every two years. It has not yet been two years since you received the lenses. Therefore, 
we decided that the Plan does not have to pre-approve progressive lens, per lens (V2781 x2).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 80157, 80177, 80201, 80162, 
80159, and 80173 provided on February 5, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 codes 80157, 80177, 80201, 80162, 80159, and 80173 are not supported in the medical 
record. Specifically, the specimen type collected is incorrect for the billed codes. These tests are performed on 
a blood specimen collected by venipuncture. The submitted toxicology request form indicates the specimen 
was urine. Based on this information, we decided that Medicare rules for coverage of the laboratory services 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 
80157, 80177, 80201, 80162, 80159, and 80173 provided on February 5, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on December 30, 2019 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for physical therapy. You say that the member told you incorrect information; 
therefore, prior authorization was not possible. The Plan denied your request. The Plan says prior authorization 
was not obtained. The Plan says that these services could have been provided 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 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 physical therapy provided on December 30, 2019 
by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skill nursing facility (SNF) care beyond 
November 1, 2020. 
 
You asked the Plan to pre-approve the SNF admission. You say that the enrollee would benefit from continued 
Part A services on a daily basis. The Plan denied your request. The Plan says the enrollee's needs are mainly 
custodial. Daily skilled care is not necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the patient does not require ongoing 
skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse 
required to safely and effectively provide medically necessary and reasonable treatment in a SNF beyond the 
 
 
last covered date.  The patient does not have complex wound care or other ongoing SNF level SN need. The 
patient's functional level does not require skilled therapy services with the specialized skill, knowledge and 
judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable 
treatment in a SNF beyond the last covered date. The patient does not require skilled nursing or skilled therapy 
services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, this patient does 
not require the necessary services on an inpatient basis, in a skilled nursing facility setting beyond the last 
covered date. 
 
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 SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued skill nursing facility (SNF) care beyond November 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Guardant360 genomic profile panel testing provided to the enrollee on June 22, 2020.You asked the Plan to pay forthe testing. You say that this should be paid for.The Plan denied your request. The Plan says this testing requires the use of CPT 81479.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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare rules for coverage of the testing have not been met.Therefore, we decided that the Plan does not have to pay forthe Guardant360 genomic profile panel testing provided to the enrollee on June 22, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the X-ray of chest (71045) provided on January 13, 2020. 
 
You asked the Plan to pay for the X-ray of chest. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the member's claim would be covered 
under Original Medicare as it is responsible for coverage of Part B benefits until the last day of the month in 
which hospice is revoked. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on January 12, 2020. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the X-ray of chest 
(71045) provided on January 13, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric diagnosis interview examination (90792) provided on April 9, 2020 by an out of network (OON) provider. You asked the Plan to pay for psychiatric diagnosis interview examination. You say that prior authorization is not required for telemedicine. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an 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 psychiatric diagnosis interview examination (90792) provided on April 9, 2020 by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approvepersonal care services.You asked the Plan to pre-approvepersonal care services. 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 a covered benefit. ThePlan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. Custodial Care services are non-covered.We looked at the fileand Medicare rules. Based on this information, we decided that Medicare rules for coverage of personal care services have not been met.Therefore, we decided that the Plan does not have to pre-approvepersonal care services.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Xgeva for the enrollee. 
 
You asked the Plan to pre-approve Xgeva. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says that that there is no reason the enrollee can't use the plan alternatives. 
 
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 Xgeva. Our reviewer says that Xgeva is 
medically reasonable and necessary for the enrollee in this case. The records provided do not show evidence of 
this patient having tried and failed either IV pamidronate or zoledronic acid. Pamidronate or zoledronic acid 
(IV) would likely be less effective and also have more adverse effects compared to the requested Xgeva. Each 
of these is a bisphosphonate medication which works differently than Xgeva which is a human monoclonal 
antibody. Current literature shows that for those with bone metastases, such as this patient, using Xgeva 
compared to bisphosphonates provided a higher level of clinical improvement in terms of health-related quality 
of life reducing the more common side effects of bisphosphonates (pyrexia, bone pain, edema, and renal 
failure). Our physician reviewer found that the enrollee's condition meets step therapy criteria for Xgeva. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Xgeva have been met. Therefore, we decided that the Plan has to pre-approve 
Xgeva for the enrollee.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane (J7318). 
 
You asked the Plan to pre-approve Durolane. You say that Durolane is medically necessary. The Plan denied 
your request. The Plan says a trial of Orthovisc and Monovisc is required before alternatives can be considered. 
 
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 Durolane. Our reviewer says that 
Durolane is not medically necessary. Our physician reviewer found the record shows no trial of the plan 
preferred drugs or any reason why they would be unsafe or ineffective for the 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 Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durolane (J7318).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided from June 8, 2020, 
through June 10, 2020. 
 
You asked the Plan to pay for the physical therapy services. 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 physical therapy services provided from June 8, 2020, through 
June 10, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room services provided 
February 17, 2020. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that you believe that 
part of the $5000 that your auto insurance paid should be applied to pay that copay. The Plan denied your 
request. The Plan says this claim was processed with the correct copayment applied per the Evidence of 
Coverage. 
 
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 $120 
copay for Medicare covered emergency room visits for Emergency care.  
 
You have been asked to pay $120 copay for Medicare covered emergency room visits for the emergency room 
services. the emergency room services fall within the Emergency 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 the emergency room services provided February 17, 2020.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen treatment for the enrollee. 
 
You asked the Plan to pre-approve the treatment. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not have a covered condition. 
 
 
 
The Plan must follow Medicare rules. Medicare rules say that HBO therapy is covered only for specific 
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 treatment. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee does not have one of the limited covered conditions for this treatment. 
 
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 treatment have not been met. Therefore, we decided that the Plan does not 
have to pre-approve hyperbaric oxygen treatment for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve dental services. You say that this is a medical necessity. The Plan denied 
your request. The Plan says care rendered by a provider that is not part of the supplemental dental network is 
not covered. 
 
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. The Plan covers dental 
services when they provided by a contracted provider. 
 
We looked at the file and Medicare rules. The requested dental provider is not in the plan's network. Based on 
this information, we decided that the Plan's rules for coverage of dental services have not been met. Therefore, 
we decided that the Plan does not have to pre-approve dental services to be provided by an out-of-network 
provider.