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

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says care can be received in another setting, such as home, a long-term care facility, or 
other outpatient setting. 
 
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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee 
does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 
setting. 
 
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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shoulder-elbow-wrist-hand orthosis provided on March 
19, 2020. 
 
You asked the Plan to pay for the shoulder-elbow-wrist-hand orthosis (L3960). You say that the orthosis was 
medically necessary. The Plan denied your request. The Plan says they were unable to discover any evidence of 
an established relationship between the member and the ordering physician. 
 
The Plan must follow Medicare rules. Medicare requires that services provided/ordered/certified be 
authenticated by the persons responsible for the care of the enrollee in accordance with Medicare policies.  
You can find this in the Medicare Program Integrity Manual Chapter 3 - Verifying Potential Errors and Taking 
Corrective Actions, Section 3.3.2.4 entitled Signature Requirements. 
  
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. There are no medical records, around the date of the order, supporting medical necessity for the 
orthosis. The record shows that the Plan made several attempts to obtain the necessary documentation without 
success. Therefore, we decided that the Plan does not have to pay for the shoulder-elbow-wrist-hand orthosis 
provided on March 19, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for epigastric hernia repair (49572) provided on December 5, 2019.
You asked the Plan to pay for the epigastric hernia repair. You say that you would like reconsideration based
on the records submitted. The Plan denied your request. The Plan says that review of medical record supports
that the service was performed for a separate diagnosis and is unrelated to the global procedure, however, it
was not billed with the appropriate modifier to indicate that the denied service was unrelated and rendered
during the post-operative period.
The Plan must follow Medicare rules. Medicare rules say that services of other physicians except where the
surgeon and the other physician(s) agree on the transfer of care are not included in the global surgery package.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the epigastric hernia repair have been met. Specifically, the service at issue was provided by a
different provider than who rendered the initial service. Therefore, we decided that the Plan has to pay for
epigastric hernia repair (49572) provided on December 5, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an immunotherapy injection (95115) 
received at the provider's office on March 2, 2020. 
 
You asked the Plan to waive the copayment for an immunotherapy injection received at the provider's office. 
You say that allergy testing is not supposed to have a 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 you must pay a $20 
copayment for a visit to a specialist.  
 
You have been asked to pay a $20 copayment for an immunotherapy injection received at the provider's office. 
An immunotherapy injection received at the provider's office falls within the "Physician/Practitioner services, 
including doctor?s office visits" 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 
an immunotherapy injection (95115) received at the provider's office on March 2, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for collection of blood sample (36415) 
performed on April 9, 2020. 
 
You asked the Plan to waive the copayment for collection of blood sample. You say that you should not have 
been charged a copayment for lab tests. 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 you must pay a $35 
copayment for lab services performed at an outpatient hospital.  
 
You have been asked to pay a $35 copayment for collection of blood sample. A collection of blood sample 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 collection of blood sample (36415) performed on April 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray and a specialist office visit 
provided by a participating provider on November 21, 2019 to January 23, 2020. 
 
You asked the Plan to waive the copayment for an x-ray and a specialist office visit. You say that you do not 
agree with these charges. The Plan denied your request. The Plan says the correct copayments have been 
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 you must pay a $15 
copayment for outpatient diagnostic tests/x-rays and a $50 copayment for physician/practitioner 
services/specialist.  
 
You have been asked to pay a $15 copayment for an x-ray and a $50 copayment for a specialist office visit. 
The total amount you are being asked to pay is $65 ($15 + $50 = $65). An x-ray falls within the outpatient 
diagnostic tests/x-rays benefit category. A specialist office visit falls within the physician/practitioner 
services/specialist 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 an x-ray and a 
specialist office visit provided by a participating provider on November 21, 2019 to January 23, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 25, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for laboratory testing. You say that you were provided the specimen without 
notification that testing would require authorization, without verifying if the ordering provider was in-network 
with the Plan, and without discussion with the enrollee regarding this laboratory being out-of-network. The 
Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider 
is out-of-network with the Plan and the ordering provider is also out-of-network with the Plan. 
 
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 medical services provided on January 25, 2020 
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 hearing aids and hearing services provided on December 
14, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you have submitted all information for coverage. 
The Plan denied your request. The Plan says that you do not have out of network benefits. 
 
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 hearing aids and hearing services provided on 
December 14, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on 
November 6, 2019. 
 
You asked the Plan to pay for genetic testing. You say that the treating physician ordered this testing to 
determine if there was a more effective therapy to treat the enrollee's condition. The Plan denied your request. 
The Plan says the denial of payment for this testing is correct, because this testing was not billed with the 
appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that CGP testing should be billed with CPT code 
81479 for date of service November 6, 2019.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
comprehensive genomic profile (CGP) testing provided on November 6, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (CPT 33017) provided to the enrollee on 
April 13, 2020. 
 
You asked the Plan to pay for the services. You say that this is allowable and medically necessary. The Plan 
denied your request. The Plan says a secondary only diagnosis cannot be used as primary, first-listed or 
principal diagnosis for any procedure or 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. 
 
In this case, the CPT Code Manual definition of code 33017 is "Pericardial drainage with insertion of 
indwelling catheter, percutaneous, including fluoroscopy and/or ultrasound guidance, when performed, 6 years 
and older without congenital cardiac anomaly." 
 
We find that CPT code 33017 is not supported in the medical record. Specifically, only a secondary diagnosis 
code was billed in this case. Based on this information, we decided that Medicare rules for coverage of the 
services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (CPT 
33017) provided to the enrollee on April 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation and treatments of complications provided 
from November 6, 2019 to March 9, 2020. 
 
You asked the Plan to pay for the consultation and treatments of complications. You say that you were required 
to undergo the consultation, and you think this should be covered. You also say that if a diagnostic procedure is 
required, it should be covered. The Plan denied your request. The Plan says these services are not covered 
benefits under your insurance plan. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
consultation and treatments of complications provided from November 6, 2019 to March 9, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient rehabilitation services provided 
on December 12, 2019. 
 
You asked the Plan to waive the copayment for outpatient rehabilitation services. You say that you did not 
receive services on that day. The Plan denied your request. The Plan says the claims were processed correctly 
and you are being charged the correct 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 $40 
copayment for outpatient rehabilitation services.  
 
The medical records show that you received outpatient rehabilitation services on December 12, 2019. 
Therefore, you are responsible to pay the $40 copayment.  
 
You have been asked to pay a $40 copayment for outpatient rehabilitation services. Outpatient rehabilitation 
services fall within the outpatient rehabilitation 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 waive 
the copayment for outpatient rehabilitation services provided on December 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a breast MRI (77049) provided on July 17, 2019. 
 
You asked the Plan to pay for the breast MRI. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says CPT code 77049 is not recognized by Medicare 
for the Outpatient Prospective Payment System (OPPS). 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the breast MRI have not been met. Specifically, per OPPS, CPT code 77049 has a status indicator 
of B. This means that CPT code 77049 is not recognized by OPPS. Therefore, we decided that the Plan does 
not have to pay for a breast MRI (77049) provided on July 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a drainage of blood or fluid accumulation 
(10140) and X-ray of foot (73620) received on September 18, 2019, an established patient office or other 
outpatient visit (99212) on October 1, 2019, and an established patient office or other outpatient visit (99213) 
on February 10, 2020. 
 
You asked the Plan to waive the deductible for 3 office visits. You say that you were misinformed by a 
representative of the Plan about visiting your out-of-network provider. The Plan denied your request. The Plan 
says your charges were correctly applied to your annual deductible. 
 
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 $1000 deductible that applies to Medicare-covered services including 
those rendered by an out-of-network provider.  
 
The case record indicates that the provider you visited on September 18, 2019, October 1, 2019, and February 
10, 2020, is not in the Plan's network of providers. The Plan has followed Medicare rules by clearly disclosing 
in the contract that there is a $1,000 deductible that applies to Medicare-covered services including those 
rendered by an out-of-network provider. This cost sharing is a contractual obligation that had not been met at 
the time 3 office visits were received from September 18, 2019 to February 10, 2020. Therefore, we decided 
that the Plan does not have to waive the deductible for a drainage of blood or fluid accumulation (10140) and 
X-ray of foot (73620) received on September 18, 2019, an established patient office or other outpatient visit 
(99212) on October 1, 2019, and an established patient office or other outpatient visit (99213) on February 10, 
2020.  
 
Your complaint about misleading or erroneous information provided to you by a representative of the Plan is 
not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by 
the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary to prevent 
further anemia. The Plan denied your request. The Plan says the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee is diagnosed with breast 
cancer and chronic renal insufficiency with associated anemia. Erythropoiesis-stimulating agents are all similar 
in effectiveness and safety according to current evidence and guidelines and have to significant benefit from 
one to another. The enrollee has not tried and failed the Plan's required drug, Retacrit. The records do not show 
that Retacrit would be contraindicated or less effective; therefore, Aranesp is not reasonable or medically 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Aranesp.
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 requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an
interdisciplinary approach to rehabilitation care. The enrollee was admitted for abdominal pain and bloating.
He had a fall while in the hospital and had surgical repair of a fractured hip. Medical problems are stable. There
are no complex nursing or rehabilitation needs.
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, and an intensive rehabilitation therapy program. While the medical record supports the need for
physical and occupational therapy, it does not support the need for an intensive rehabilitation program. There is
not a reasonable expectation that this enrollee 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve testosterone cypionate injections. 
 
You asked the Plan to pre-approve the testosterone injections. You say that this is a necessary treatment. The 
Plan denied your request. The Plan says this self-injected drug is not covered by Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B 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 testosterone cypionate 
injections.  
 
Benefits for the testosterone injections may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.