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

 
We decided that the Plan does not have to pre-approve a vitrectomy chair (E1399). 
 
You asked the Plan to pre-approve a vitrectomy chair. You say that you request reconsideration of the face 
down pillow authorization to be granted so you can carry on with the healing process needed from this chair for 
the healing from your surgery. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a vitrectomy chair (E1399).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 17, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on November 17, 2021.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Neulasta. 
 
You asked the Plan to pre-approve Neulasta. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this use is not supported. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Neulasta. Our reviewer says that the 
requested use of Neulasta is supported. Our physician reviewer found the record indicates that the enrollee has 
a diagnosis of nasopharyngeal carcinoma.  The record indicates that the enrollee will be receiving a 
chemotherapeutic regimen with a clinically significant risk of febrile neutropenia.  The Food and Drug 
Administration has stated that the requested drug is indicated for the enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Neulasta have been met. Therefore, we decided that the Plan has to pre-approve 
Neulasta.  
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Gelsyn-3. 
 
You asked the Plan to pre-approve Gelsyn-3. You say that you do not want to take the alternate recommended 
drugs because of a condition with your heart. The Plan denied your request. The Plan says the denial of 
authorization for this drug is correct, because the Plan requires a trial of Orthovisc, Synvisc, or Synvisc-One 
before it will approve Gelsyn-3. 
 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 Gelsyn-3. Our reviewer says that you 
do not meet the Medicare criteria for a step therapy exception for Gelsyn-3. Our physician reviewer found you 
have not tried and failed the Plan's preferred drugs of Orthovisc, Synvisc, or Synvisc-One. The record does not 
show that these drugs would likely be less effective and/or have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Gelsyn-3.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99213) provided on June 30, 
2021. 
 
You asked the Plan to pay for the hospital care. You say that the enrollee was discharged from hospice on June 
5, 2021. You also say that the services should be covered. The Plan denied your request. The Plan says the 
enrollees claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits 
starting on the date of election until the last day of the month in which hospice is revoked.  The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services 
and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
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 June 5, 2021. 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 subsequent hospital care 
(99213) provided on June 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Foresee Home visual field self-monitoring. 
 
You asked the Plan to pre-approve Foresee Home visual field self-monitoring. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 Foresee Home visual field self-
monitoring. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has a diagnosis of stable nonexudative age-
related macular degeneration of the left eye, intermediate dry stage. The Georgia Retina note on February 7, 
2022 documents a plan that included AREDS2 multivitamins and regular use of an Amsler grid. The clinical 
utility of Foresee Home visual field self-monitoring has been shown to be limited. Therefore, the requested 
services are not 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 Foresee Home visual field self-monitoring have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Foresee Home visual field self-monitoring.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cardiovascular stress test provided on 
February 7, 2022. 
 
You asked the Plan to waive the copayment for cardiovascular stress test. You say that you feel that this charge 
should be covered. The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $250 
copayment for Medicare-covered sleep studies and stress tests.  
 
 
 
 
 
 
 You have been asked to pay $250 copayment for cardiovascular stress test. Cardiovascular stress tests fall 
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 cardiovascular stress test provided on February 7, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting 
from January 28, 2022, to January 30, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that you were never advised you needed to 
go home to get your medications. You say that you are on a fixed income. You also say that you are swimming 
in medical bills. The Plan denied your request. The Plan says the claim processed correctly. 
 
 
 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 pay for the self-administered drugs 
provided in an outpatient setting from January 28, 2022, to January 30, 2022.  
 
Benefits for the self-administered drugs 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Ultrasound on February 07, 2022. 
 
You asked the Plan to waive the copayment for ultrasound. You say that you feel that you should not owe it. 
The Plan denied your request. The Plan says the cost-sharing amount you are being charged is correct. 
 
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 $100 
copayment for Diagnostic procedures and tests, outpatient hospital. Other outpatient diagnostic tests (such as 
nerve conduction studies, electroencephalogram (EEG) and electromyography).  
 
 
 
 
 
 
 You have been asked to pay a $100 copayment for ultrasound. Ultrasound 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 Ultrasound on February 07, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99233) provided on September 7, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a duplicate 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be exact duplicates of another claim or claim line are denied.  We looked at the file and Medicare rules. The services in question were billed on a duplicate claim to one 
previously processed and paid by the Plan. Duplicate claims are not payable. 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 the services (99233) provided on September 7, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapy services you received on January 28, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider is not 
enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the therapy services you received on 
January 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dialysis to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve dialysis. You say that you do not want to change renal centers because you 
are comfortable with the staff. The Plan denied your request. The Plan says the denial of authorization for this 
service is correct, because this provider is out-of-network with the Plan and you can be treated by an in-
network renal center. 
 
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 
dialysis to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 24, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on May 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT scan (70450) provided on February 9, 2022. 
  You asked the Plan to pay for the CT scan (70450). You say that the enrollee had multiple exams on this date 
of service and the reports support the level of service. You say that the claim should be considered for 
processing. The Plan denied your request. The Plan says an appropriate modifier was not billed with this code 
edit. 
 
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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the CT scan (70450) provided on February 9, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the enterectomy (44120) and colectomy (44143) provided on February 
4, 2022. 
 
You asked the Plan to pay for the enterectomy (44120) and colectomy (44143). The Plan denied your request. 
The Plan says that procedure codes 44120 and 44143 are not supported by the medical records submitted. 
 
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 44120 is enterectomy, resection of small intestine; single resection and anastomosis. In this case, the CPT 
Code Manual definition of code 44143 is colectomy, partial; with end colostomy and closure of distal segment 
(Hartmann type procedure). 
 
We asked our coder 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 enterectomy (44120) and colectomy (44143). Our 
reviewer says that the medical documentation does support the enterectomy (44120) and colectomy partial with 
end colostomy (44143).  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the enterectomy (44120) and colectomy (44143) have been met. Therefore, we 
decided that the Plan has to pay for the enterectomy (44120) and colectomy (44143) provided on February 4, 
2022.  
 
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 pay for Psychiatric diagnostic evaluation provided on March 11, 
2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Psychiatric diagnostic evaluation. You say that the services provided were 
medically necessary. The Plan denied your request. The Plan says services were not ordered or performed by 
an in-network provider and the authorization is invalid/missing. 
 
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 had network providers 
available who could have provided 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 provided on 
March 11, 2022 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion Interspinous device. 
 
You asked the Plan to pre-approve a Vertiflex Superion Interspinous device. You say that the current medical 
data supports the efficacy of this procedure for lumbar spinal stenosis. The Plan denied your request. The Plan 
says medical studies haven't proven this item is helpful for the treatment of the enrollee's health problem. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 a Vertiflex Superion Interspinous 
device. Our reviewer says that a Vertiflex Superion Interspinous device is not considered medically reasonable 
and necessary in this case. Our physician reviewer found the Vertiflex Superion Interspinous device is 
experimental. More research is needed to show safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Vertiflex Superion Interspinous device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Vertiflex Superion Interspinous device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for the durable medical equipment (DME) provided on 
February 5, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to reimburse for the DME. You say that when you purchased the DME you were unaware 
the provider was OON, and you would like a refund for the amount you paid. The Plan denied your request. 
The Plan says the rendering provider is an OON provider, and the services were not approved in advance. The 
Plan also says that the enrollee has an SNP plan, and the provider can bill Medicaid. 
 
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 reimburse 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 had network providers 
available who could have provided 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 reimburse for these items/services. 
Therefore, we decided that the Plan does not have to reimburse for the durable medical equipment (DME) 
provided on February 5, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says you do not meet criteria for the requested item. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 The file shows that the enrollees condition can be improved by a walker, cane or manual wheelchair. In 
addition, the power scooter is being requested for use outside of the home. This means that Medicare rules for 
coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
power scooter.