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

 
We decided that the Plan does not have to pay for lab services provided on October 26, 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 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 October 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid provided on February 3, 2022. 
 
You asked the Plan to pay for the hearing aid. You say that you are aware the provider is not participating for 
the hearing aid benefit but would like the Plan to pay the amount that would have been paid to a participating 
provider. The Plan denied your request. The Plan says the hearing aids were not purchased from a participating 
hearing aid vendor. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when they are purchased from a participating hearing aid vendor.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aid have not been met. Specifically, the hearing aid was not purchased from a 
participating hearing aid vendor. Therefore, we decided that the Plan does not have to pay for the hearing aid 
provided on February 3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that a LTACH admission is medically 
necessary for the enrollee. The Plan denied your request. The Plan says a LTACH admission is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee appears to be more stable and improving. She should only require 
short-term additional acute care hospital services that can be safely completed at the current facility until it is 
more appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not 
already available at the current facility. There are no services at the LTACH that the enrollee requires that are 
not already available and covered at the current facility. Transfer to the LTACH is not medically necessary as it 
would not be clinically advantageous. Completion of treatment at the current facility is recommended. 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuous glucose monitor (K0554) and supply 
allowance (K0553). 
 
You asked the Plan to pre-approve the CGM and allowance. You say that maintaining your blood sugar would 
greatly hep you with your quality of life. The Plan denied your request. The Plan says the enrollee is not insulin 
treated and does not meet the Medicare criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the CGM and allowance have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the continuous glucose monitor (K0554) and 
supply allowance (K0553).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that the enrollee had good relief from 
the first injection. The Plan denied your request. The Plan says the requirements for coverage have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that repeat epidural steroid injections may be 
considered medically reasonable and necessary when the medical record documents at least 50% of sustained 
improvement in pain relief or improvement in function measured from baseline for at least three months 
following the first injection. 
 
We looked at the file and Medicare rules. The record shows that the enrollee previously received an epidural 
steroid injection on March 15, 2022. The submitted records do not document the enrollees pain relief three 
months after this injection. Based on this information, we decided that Medicare rules for coverage of an 
epidural steroid injection have not been met. Therefore, we decided that the Plan does not have to pre-approve 
an epidural steroid injection.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monoferric (CPT code J1437). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says the documentation does not show the enrollee has tried or cannot use 
Infed (iron dextran) and Venofer (iron sucrose) (step therapy requirement). 
 
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 the medication. Our reviewer says that 
the case file does not contain documentation of trial and failure of Infed (iron dextran) and Venofer (iron 
sucrose). The documentation does not support that Infed (iron dextran) and Venofer (iron sucrose) would likely 
be less effective, and/or would likely have adverse effects for the enrollee in this case.  
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Monoferric (CPT code J1437).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve parts and repair for a shower chair. 
 
You asked the Plan to pre-approve parts and repair for a shower chair. You say that this is medically necessary. 
The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve parts and repair for a shower chair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee cannot go home on the 
ventilator as the husband does not know how to perform ventilator care. The Plan denied your request. The 
Plan says the records do not show that is it safe for the enrollee to leave the hospital and they will need several 
weeks in a long term acute care hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our reviewer 
found the enrollee was admitted to the acute care hospital with sepsis, acute on chronic respiratory failure and 
cardiac arrest requiring antibiotics, bronchoscopy for mucous plugging, trach care, and ongoing mechanical 
ventilation. The enrollee appears to be currently still unstable and requires additional short-term acute care 
hospital services that can be safely completed at the current facility until more stable and appropriate for a 
lower level of care. 
 The enrollee does not require services at the LTACH that are not available at the acute care hospital where she 
is currently receiving care. 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 LTACH services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) 
services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a stair glide on November 30, 2021. 
 
You asked the Plan to pay for a stair glide. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pay for a stair glide on November 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 10, 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 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 October 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Epogen (J0885). 
 
You asked the Plan to pre-approve Epogen. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, Retacrit or Procrit. 
 
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 Epogen. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
that the enrollee has tried and failed one of the preferred drugs, Retacrit or Procrit. The reviewer found that the 
record does not indicate that the enrollee has a contraindication to or would have an adverse effect from the 
plan's preferred step one alternative. Therefore, the reviewer found that the step therapy criteria have not been 
met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Epogen have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Epogen (J0885).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for orthopedic surgery office visit on 
November 05, 2021. 
 
You asked the Plan to waive the copayment for office visit. You say that you want to dispute the amount of the 
cost share. 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 $40 
copayment for consultation, diagnosis, and treatment by a specialist. For services obtained from a specialist, or 
under certain circumstance, treatment by a nurse practitioner or physician's assistant or other non-physician 
health care professionals in a specialist's office (as permitted under Medicare rules). You pay these amounts 
until you reach the out-of-pocket maximum.  
 
 
 You have been asked to pay a $40 copayment for office visit. Office visit falls within the Physician/Practitioner 
Services, Including Doctors Office Visits benefit category. You have a $40 copayment for services obtained 
from a specialist. The allowed amount on this claim is $40. 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 orthopedic surgery office visit on November 05, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99214, 99215) and an online digital 
evaluation and management service (99423) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit and an online digital evaluation and management service. 
You say that you had your surgery at this hospital and need to have a follow up consultation with the requested 
provider. The Plan denied your request. The Plan says you must use network providers to get your medical care 
and services. The plan covers services outside the network only if it is an emergency, or there are no providers 
available in the network. In addition, there are available contracted providers with the plan that can render the 
services requested. 
 
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 office visit (99214, 99215) and an online digital evaluation and management service (99423) to be provided 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services provided on October 5, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient services. You say that you provided medical records. The Plan 
denied your request. The Plan says the rendering provider is an OON provider and there were in-network 
providers available that provide the same service. 
 
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 the outpatient services provided on October 5, 
2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide non-emergency transportation by cab. 
 
You asked the Plan to provide non-emergency transportation. You say that you are disabled and unable to get 
to your medical appointments on your own; you would like the Plan to provide and cover transportation for 
your necessary appointments. The Plan denied your request. The Plan says routine, non-emergent 
transportation to a provider's office is not covered by Medicare or by your Plan. 
 
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. 
The Plan follows the same rule.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Medicare rules for coverage of non-emergency transportation have not been met. Therefore, we 
decided that the Plan does not have to provide non-emergency transportation by cab.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive your $60 copayment mental health services rendered on 
December 21, 2021. 
 
You asked the Plan to waive your $60 copayment outpatient mental health services rendered on  
December 21, 2021. You say that you were told your doctors were In-Network. The Plan denied your request. 
The Plan says you must pay a $60 copayment for each Out-of-Network Medicare covered individual or group 
therapy visit. The Plan contract also says you must pay a $60 copayment for each Out-of-Network Medicare 
covered individual or group therapy visit with a psychiatrist. 
 
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 $60 
copayment for Outpatient Mental Health Care.  
 You have been asked to pay a $60 copayment for outpatient mental health services. Outpatient mental health 
services fall within the Outpatient Mental Health Care benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
your $60 copayment for mental health services rendered on December 21, 2021.  
 
Your complaint about being given incorrect information about the network status of the provider 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for outpatient procedure on November 09, 
2021, to November 10, 2021.  
 
You asked the Plan to waive the coinsurance for outpatient procedure. You say that you called previously to 
discuss this, UR hospital and Health Plan have not been communicating with each other on this coding issue to 
correct on the claim. The Plan denied your request. The Plan says the cost-sharing amount the enrollee is 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 20% 
coinsurance for each outpatient Hospital observation visit. Observation services are hospital outpatient services 
given to determine if you need to be admitted as an inpatient or can be discharged. For outpatient hospital 
observation services to be covered, they must meet the Medicare criteria and be considered reasonable and 
necessary. Observation services are covered only when provided by the order of a physician or another 
individual authorized by state licensure law and hospital staff bylaws to admit patients to the hospital or order 
outpatient tests.  
 You have been asked to pay 20% coinsurance for outpatient procedure. Outpatient procedure falls within the 
Outpatient Hospital Observation benefit category. The billed amount was $75,888.12. The total cost was 
$21,438.65. The Plans share was $17,150.92. Your share is $4,287.73. 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 
coinsurance for outpatient procedure on November 09, 2021, to November 10, 2021.