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

 
We decided that the Plan does not have to waive the copayment for injections (J7326, 20610) provided May 6, 
2020. 
 
You asked the Plan to waive the copayment for the injections. You say that the copayments should be waived. 
The Plan denied your request. The Plan says the correct cost-sharing has 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 $35 
copayment for specialist visits and a 20% coinsurance for Part B drugs. 
 
You have been asked to pay a $35 copayment for a specialis t visit and a 20% coinsurance for the injections 
which fall within the Part B drugs 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 
injections (J7326, 20610) provided May 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for post-stabilization inpatient care provided December 23, 2019 
to March 19, 2020. 
 
You asked the Plan to pay for the post-stabilization inpatient care. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the facility was out-of-network and the enrollee was 
stable for transfer to a network provider for the proper level of care. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 the post-stabilization inpatient care. Our 
reviewer says that the services after December 22, 2019, were not medically necessary. Our physician reviewer 
found the records show that as of December 23, 2019 the enrollee was stable for transfer to a plan facility. 
While the enrollee required boarding care as she could not safely care for herself in the community, there were 
no medical conditions which required inpatient care by this 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 post-stabilization inpatient care have not been met. Therefore, we decided 
that the Plan does not have to pay for post-stabilization inpatient care provided December 23, 2019 to March 
19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation, bitewings, and prophylaxis 
provided on February 17, 2020. 
 
You asked the Plan to pay for the periodic oral evaluation, bitewings, and prophylaxis. You say that you have 
been going to this provider for many years, and have always been reimbursed for annual exams. The Plan 
denied your request. The Plan says this treating provider opted out of Medicare, effective June 23, 2016 to June 
23, 2022. The Plan also says that you did not contact the Plan prior to the services being rendered. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the periodic oral evaluation, bitewings, and prophylaxis provided on February 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial nursing facility care (99306) provided on February 10, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for initial nursing facility care. You say that your physician provided medically 
necessary services to the enrollee in good faith. In consideration for the services rendered, your doctor is 
seeking reimbursement. The Plan denied your request. The Plan says enrollee's must receive their medical 
services from an in-network provider with the exception being urgent or emergent services. The plan says that 
non-emergent services with non-contracted providers require prior authorization before 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 initial nursing facility care (99306) provided on 
February 10, 2020 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 medical services provided on March 13, 2020 to March 
27, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for practitioner visits. You say that your provider rendered medically necessary 
services in good faith. The Plan denied your request. The Plan says the denial of payment for these services is 
correct, because this provider is out-of-network with the Plan and authorization was not obtained. 
 
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 March 13, 2020 
to March 27, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging, tomographic (SPECT) 
(78452). 
 
You asked the Plan to pre-approve SPECT perfusion imaging. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that risk assessment of re-evaluation of disease in patients 
who are asymptomatic or have stable symptoms, with known atherosclerotic heart disease on catheterization or 
SPECT perfusion imaging, who have not had a revascularization procedure within the past two years or greater 
than 2 years since last imaging study is a covered indication. 
 
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 SPECT perfusion imaging. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found in this circumstance 
the documentation does not support the medical necessity for repeat nuclear stress testing. Coverage criteria are 
not met since there are no documented covered indications for the procedure (criteria require at least a 2-year 
period from the prior stress tests in clinically stable patients). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SPECT perfusion imaging have not been met. Therefore, we decided that the 
Plan does not have to pre-approve myocardial perfusion imaging, tomographic (SPECT) (78452).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on February 26, 
2020 and March 25, 2020. 
 
You asked the Plan to pay for the subsequent nursing facility care. 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 subsequent nursing facility care provided on February 26, 2020 
and March 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Enbrel Sureclick. 
 
You asked the Plan to pre-approve Enbrel Sureclick. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription 
coverage, therefore the criteria for self-administered drug coverage has not been met. 
 
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 Enbrel Sureclick.  
 
Benefits for Enbrel Sureclick 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a DXA bone density study provided to the enrollee on 
February 27, 2020. 
 
You asked the Plan to pay for the study. You say that this should be paid for. The Plan denied your request. 
The Plan says with the information they have, they cannot determine how the enrollee came to the servicing 
provider, or whether the services are medically necessary. 
 
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 77080 is "Dual-energy X-ray absorptiometry (DXA), 
bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine)." 
 
We find that CPT code 77080 is not supported in the medical record. Specifically, despite multiple attempts by 
the plan, medical records were not provided. There is no way to determine if the services were rendered. Based 
on this information, we decided that Medicare rules for coverage of the study have not been met. Therefore, we 
decided that the Plan does not have to pay for a DXA bone density study provided to the enrollee on February 
27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ankle-foot orthosis with sleeves (L1971, L2397) provided 
to the enrollee on March 18, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says the enrollee has previously received the same supplies within the 5-year RUL. 
 
The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of durable 
medical equipment is no less than five years. Replacement equipment may be granted when irreparable wear or 
irreparable damage is demonstrated or there has been a change in the enrollee's medical condition.  
We looked at the file and Medicare rules. In this instance, the submitted documentation indicates that the 
enrollee has received the same durable medical equipment on March 04, 2019. This orthosis is still within the 
5-year RUL and the documentation submitted does not show that the orthosis is irreparably worn, irreparably 
damaged, or that the enrollee had a change in medical condition to warrant the orthosis at issue.  Based on this 
information, we decided that Medicare rules for coverage of the orthoses have not been met. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for an ankle-foot orthosis with 
sleeves (L1971, L2397) provided to the enrollee on March 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral surgery services provided on May 16, 2019. 
 
You asked the Plan to pay for the oral surgery. You say that you were told that you could get these services and 
be reimbursed. The Plan denied your request. The Plan says this provider is privately contracted and cannot be 
paid. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the oral surgery services provided on May 16, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray of the abdomen (74018) provided November 13, 
2019. 
 
You asked the Plan to pay for the x-ray. You say that the services were medically necessary. The Plan denied 
your request. The Plan says Original Medicare is liable for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.  Therefore, 
we decided that the Plan does not have to pay for an x-ray of the abdomen (74018) provided November 13, 
2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab work provided on January 22, 2020 by an out of network 
(OON) provider. 
 
You asked the Plan to pay for lab work. 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. 
 
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 lab work provided on January 22, 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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 records do not indicate that there are significant, or complex medical/nursing issues 
that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other 
medication management, wound care, and daily therapy can be provided at a SNF. In this case, you are mostly 
minimal/standby assist for functional transfers and activities of daily (ADL's) and a less intensive, longer 
duration of therapy will allow for measurable gains to be attained within a reasonable, and predicted period. An 
IRF intensity is not warranted. 
 
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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory testing provided on May 18, 2020. 
 
You asked the Plan to pay for lab tests. You say that these medical necessary tests were ordered by the 
enrollee's treating physician. The Plan denied your request. The Plan says that the denial of payment for these 
services is correct, because this provider is out-of-network with the Plan, authorization was not obtained, and 
the records do not justify the need for these tests. 
 
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. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a 
contract provider are considered approved by the plan unless notice is provided that the services will not be 
covered. 
 
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 did not specify whether the ordering physician was in-network or out-
of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this 
testing would not be covered. Without this information, we cannot determine whether the lab order made 
constituted plan-directed care. Therefore, the Plan has not shown that its decision to deny payment for testing is 
correct or justified by Medicare rules. Therefore, we decided that the Plan has to pay for laboratory testing 
provided on May 18, 2020.  
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychiatric diagnostic evaluation (90791) provided on 
January 15, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the psychology services. You say that the provider never mentioned that she is 
out of your network. She took your copay and you thought all was well. The Plan denied your request. The 
Plan says the plan cannot pay a provider who is not eligible to participate in 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. 
 
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 psychiatric diagnostic evaluation (90791) provided 
on January 15, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment defined by codes L0650, L1851, 
L1971, L2397, L3170, L3916 and L3960 provided to the enrollee on March 20, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says the submitted records do not include an itemized shipping billing invoice or proof of 
delivery for the billed supplies; therefore, the billed service cannot be verified. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery to support medical necessity for the supplies provided in 
this case. The submitted records don't include an itemized billing/shipping invoice to verify the services. 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 durable medical equipment defined by codes 
L0650, L1851, L1971, L2397, L3170, L3916 and L3960 provided to the enrollee on March 20, 2020.