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

 
We decided that the Plan does not have to pre-approve Rocklatan. 
 
You asked the Plan to pre-approve Rocklatan. You say that you would like the Plan to reconsider their denial. 
The Plan denied your request. The Plan says Rocklatan is not covered by the enrollee's Medicare  
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Rocklatan.  
 
Benefits for Rocklatan may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says with 
limited exceptions, while you are a member of our plan you must use network providers to get your medical 
care and services. The only exceptions are emergencies, urgently needed services when the Plan network is not 
available (generally, when you are out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes use of out-of-network providers. 
 
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 
physician?s services. 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 physician's services provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the podiatry services (99213, 11721, 11056) provided by 
an out of network (OON) provider. 
 
You asked the Plan to pay for the podiatry services. You say that the services were provided were medically 
necessary. 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 podiatry services (99213, 11721, 11056) 
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 the complete blood cell count (85025) provided, by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the complete blood cell count. 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 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 complete blood cell count (85025) 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 the subsequent nursing facility visit (99308) provided, by 
an out of network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing facility visit. 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 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 subsequent nursing facility visit (99308) 
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 the established patient office or other outpatient visit (99213) 
provided, by an out of network (OON) provider. 
 
You asked the Plan to pay for the established patient office or other outpatient visit. 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 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 office or other outpatient 
visit (99213) provided, by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oral appliance to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve an oral appliance. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services 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 
item 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-approve 
an oral appliance 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 the sleep monitoring of patient (6 years or older) in sleep lab 
with continued pressured respiratory assistance by mask or breathing tube (95811) provided, by an out of network (OON) provider. 
 
You asked the Plan to pay for the sleep study. You say that the services are medically necessary. 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 sleep monitoring of patient (6 years or older) 
in sleep lab with continued pressured respiratory assistance by mask or breathing tube (95811) provided on 
 by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the thirty minutes of psychotherapy (90832) provided on by 
an out of network (OON) provider. 
 
You asked the Plan to pay for psychotherapy. 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 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 thirty minutes of psychotherapy (90832) 
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 the psychotherapy (90837) provided, by 
an out of network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy. You say that you were not aware prior authorization was 
required 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 psychotherapy (90837) provided, by an 
out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve continued use of a continuous positive airway pressure (CPAP) 
device. 
 
You asked the Plan to pre-approve the continued CPAP use. You say that the enrollee has received benefit 
from this device and is compliant in its use. The Plan denied your request. The Plan says that the 
documentation showed that the enrollee only used the device for four or more hours on 53% of the nights of the 
trial. As such, continued CPAP coverage is denied. 
 
The Plan must follow Medicare rules. Medicare rules say that in order to continue CPAP coverage beyond the 
three-month trial, there must be noted improvement in symptoms and proof that the device is being used for 
more than 4 hours on at least 70% of nights.  
 
In this case, the download from the CPAP that was originally reviewed showed on 53% use; however, this 
download only showed data from the first month of CPAP treatment. A more recent download shows data from 
the entire three-month trial and documents that the device is used on 93% of nights and for at least four hours 
on 75.6% of nights. Based on this information and the subjective reports from the provider of improved 
symptoms, we find that the criteria for continued coverage of the CPAP have been met. Therefore, we decided 
that the Plan has to pre-approve continued use of a continuous positive airway pressure (CPAP) 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the colonoscopy and biopsy (45380) provided by an 
out of network (OON) provider. 
 
You asked the Plan to pay for colonoscopy and biopsy. You say that the services rendered were medically 
necessary. The Plan denied your request. The Plan says in-network providers must be utilized unless emergent 
or urgent. 
 
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 colonoscopy and biopsy (45380) provided on  by 
an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forarthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft (CPT Code 27130) provided on November 18, 2019.You asked the Plan to pay forthe service. You say that the claim should be paid.The Plan denied your request. The Plan says the services are not supported by the records.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.Current Procedural Terminology (CPT) code 27130 AS LT remains not supported. The submitted medical records do not include the credentials of the assistant; therefore, eligibility and the use of modifiers AS/LT cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. Of note, per CMS/Medicare guidelines, the services of Surgical Technicians (LSA) and RN First Assists (RNFA) are not eligible for separate reimbursement. 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 pay forarthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft (CPT Code 27130) provided on November 18, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided. 
 
You asked the Plan to pay for the physician's 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 
physician?s services. 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 physician's services provided.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office outpatient visit (99201), radiologic examination 
(X-Ray) of spine (72040),  X-Ray mandible (70100) and X-Ray of swallowing function (74230) provided on 
June 15, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for office outpatient visit and radiologic examination's (X-Ray) of spine, mandible 
and swallowing function. 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 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 office outpatient visit (99201), radiologic 
examination (X-Ray) of spine (72040),  X-Ray mandible (70100) and X-Ray of swallowing function (74230) 
provided on June 15, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care services (11046) provided January 3, 2020. 
 
You asked the Plan to pay for wound care services. You say that the documentation supports the billed 
services. The Plan denied your request. The Plan says the medical records do not support the billing of code 
11046. 
 
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 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 pay for wound care services. Our reviewer says that 
the billed service is not supported. Our physician reviewer found there is insufficient information in the 
medical records to confirm the size of the debridement area, therefore, this service cannot be verified. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wound care services have not been met. Therefore, we decided that the Plan 
does not have to pay for wound care services (11046) provided January 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the limited oral evaluation. 
 
You asked the Plan to pre-approve the limited oral evaluation. You say that you have been waiting to be seen 
by an oral surgeon since June. You say that you need to have extractions done and are afraid to have it done by 
a regular dentist. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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, only preventive oral exams are 
covered. The limited oral evaluation is not considered a preventive service. Therefore, we decided that the Plan 
does not have to pre-approve the limited oral evaluation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a skin debridement (11042) performed on 
January 21 and February 4, 2020. 
 
You asked the Plan to waive the copayment for a skin debridement. You say that the enrollee did not receive 
these services at a surgical center but at the doctor's office. 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $250 copayment for Medicare-covered outpatient hospital services.  
 
The enrollee has been asked to pay a $250 copayment for each of 2 instances of skin debridement. A skin 
debridement falls within the "Outpatient hospital services" benefit category. This means that the enrollee has 
been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for a skin debridement (11042) performed on January 21 and February 4, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on June 4, 2020. 
 
You asked the Plan to pay for the physician's 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 
physician's services. 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 physician's services provided on June 4, 2020.