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

 
We decided that the Plan does not have to pre-approve a tier exception for Durolane. 
 
You asked the Plan to pre-approve a tier exception for Durolane. You say that the exception is needed. The 
Plan denied your request. The Plan says the drug does not qualify for tier exceptions. 
 
The Plan must follow Medicare rules. Medicare rules say that tiered cost-sharing means a process of grouping 
Part D drugs into different cost sharing levels within a Part D sponsor's formulary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a tier exception for Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a tier exception for Durolane.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory drug testing (G0480, 83789) provided on 
December 6, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory drug testing. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and 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 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 laboratory drug testing (G0480, 83789) provided 
on December 6, 2021 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says additional 
services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. The file shows that 10 days of SNF care was requested. The plan has agreed to approve 7 days of care. 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 SNF services. Our physician reviewer 
found that you do not require skilled nursing and/or skilled therapy services on a daily basis. You do not have 
any parental medication; complex wound care or nutrition given via a feeding tube. You are medically stable 
without any acute exacerbations of chronic medical problems. Your physical function is at or near your 
baseline. Therefore, an admission to a SNF for inpatient skilled rehab services for an additional 3 days is 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bilateral ankle orthoses provided on February 28, 2022. 
 
You asked the Plan to pay for the bilateral ankle orthoses. You say that this claim meets all Medicare criteria. 
The Plan denied your request. The Plan says the medical records do not support the provision of these orthoses. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order,  proof of delivery, and documentation in the patients medical record to support the item.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Specifically, the medical records provided make no mention of any condition for which ankle 
orthoses may have been ordered or even any mention of any condition affecting the ankles at all. In fact, the 
records show that the patient has normal movement in and no abnormalities at all of the lower extremities.  The patient's gait and station are noted to be normal as well. Therefore, we decided that the Plan does not have to 
pay for the bilateral ankle orthoses provided on February 28, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from 
February 16, 2022, to March 17, 2022. 
 You asked the Plan to pay for the SNF care. You say that the services are coverable under the Medicare Act. 
The Plan denied your request. The Plan says the enrollee did not receive daily skilled services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 pay for the SNF care. Our reviewer says that the 
enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not 
have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled 
professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, 
knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing 
and/or skilled therapy on an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the skilled nursing facility (SNF) care provided from February 16, 2022, to March 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ostomy supplies provided on February 21, 2022. 
 
You asked the Plan to pay for the ostomy supplies. You say that these supplies are separately payable. The Plan 
denied your request. The Plan says these supplies are included in payment to the skilled nursing facility. 
 
The Plan must follow Medicare rules. Medicare rules say that for services and supplies furnished to a skilled 
nursing facility (SNF) resident covered under the Part A benefit, SNFs are not able to unbundle services to an 
outside provider of services or supplies.  Instead, the SNF must furnish the services or supplies either directly 
or under arrangement with an outside provided. The outside supplier must look to the SNF, rather than to the 
enrollee or to Medicare, for payment. It is the supplier's responsibility to check with the facility to see if the 
patient is a resident in a covered Part A stay.  If so, all supplies must be billed by the SNF. 
 
In this case, the patient was in a Part A-covered SNF stay. As a result, these supplies should be included in the 
consolidated billing of the SNF and are not separately payable by the Plan. Therefore, we decided that the Plan 
does not have to pay for ostomy supplies provided on February 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a urine polymerase chain reaction (PCR) panel provided to 
the enrollee on June 8, 2021. 
 
You asked the Plan to pay for the services. You say that this was denied as experimental in error. The Plan 
denied your request. The Plan says the provider is billing by stacking codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. 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 a urine polymerase chain reaction (PCR) panel provided to the enrollee on June 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an urgent care visit provided on March 30, 
2022. 
 
You asked the Plan to reduce the copayment for the urgent care visit. You say that you were not able to see 
your PCP and needed to be evaluated for a cough. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing 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 $50 
copayment for each urgent care facility visit.  
 
You have been asked to pay $40, which is less than the $50 copayment for the urgent care visit. The urgent 
care visit falls within the Urgently Needed 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 reduce the 
copayment for an urgent care visit provided on March 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on March 6, 
2022. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that you only went for a COVID-
19 test. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $50 
copayment for each urgent care facility visit.  
 
You have been asked to pay $23.15, which is less than the $50 copayment for the urgent care visit. The urgent 
care visit falls within the Urgently Needed 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 an urgent care visit provided on 
March 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits and testing with a dermatologist to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve office visits and testing with a dermatologist. You say that the enrollee 
would rather die of cancer than be seen by another dermatologist other the requested provider. The Plan denied 
your request. The Plan says a contracted provider can provide the service/item requested. The enrollee must use 
network providers to get her medical care and services. 
 
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 
office visits and testing with a dermatologist to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound supplies provided on April 6, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the wound supplies. You say that these supplies are a separately billable expense 
that does not require separate authorization. The Plan denied your request. The Plan says the services have been 
provided out-of-network and were not approved in advance. 
 
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 wound supplies provided on April 6, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for specialist office visits provided from 
February 9, 2022, to March 2, 2022. 
 
You asked the Plan to waive the copayments for specialist office visits. You say that your copayments should 
only be $30 not $45. The Plan denied your request. The Plan says the copayments applied are 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 $45 
copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse 
practitioner or physicians assistant or other non-physician health care professionals in a specialists office (as 
permitted under Medicare rules).  
 
 
 You have been asked to pay a total of $225 ($45 x 5 visits) copayment for specialist office visits. Specialist 
office visits fall within the Physician/Practitioner Services, Including Doctors 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 copayments for specialist office visits provided from February 9, 2022, to 
March 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on January 19, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says laboratory testing related to treatment of end-stage renal disease is bundled into dialysis services 
and is not separately reimbursable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
laboratory services provided to the enrollee on January 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce/waive the copayment for the inpatient mental health 
admission started on November 9, 2021. 
 
You asked the Plan to reduce/waive the copayment. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied 
correctly to the services provided. 
 
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 each time you are 
admitted to a psychiatric hospital for covered services, you pay $200 per day for days 1-5 and $0 after day 5. 
 
You have been asked to pay $1,000 ($200 x 5 days) for the inpatient mental health admission provided. The 
case file shows that you were inpatient for at least five days. 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 reduce/waive the copayment for the inpatient mental 
health admission started on November 9, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the manual therapy techniques and infrared therapy provided 
by an acupuncturist from May 22, 2021, through June 19, 2021. 
 
You asked the Plan to pay for the manual therapy and infrared treatments provided. You say that these services 
were medically necessary and should be covered. The Plan denied your request. The Plan says code 97140 is 
not covered without a required modifier. In addition, code 97026 is noncovered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that physical therapy services can only be provided 
by a practitioner who is a licensed physical therapist or under the supervision of a medical doctor or other 
provider licensed to provide therapy by the State. 
 
We looked at the file and Medicare rules. Though the Plan offers coverage for acupuncture services, it does not 
include coverage for therapy services by an acupuncturist. The Plan has made payment for the acupuncture 
services. Neither Medicare nor the Plan pays for the therapy services when provided by an acupuncturist. Based on this information, we decided that Medicare rules for coverage of the manual therapy and infrared 
treatments provided have not been met. Therefore, we decided that the Plan does not have to pay for the 
manual therapy techniques and infrared therapy provided by an acupuncturist from May 22, 2021, through June 
19, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for X-rays of the hand provided on January 31, 
2022. 
 
You asked the Plan to waive the copayment for the X-rays. You say that you cannot afford the copayment. The 
Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $15 
copayment for each standard X-ray service.  
 
You have been asked to pay a $15 copayment for the X-rays. The X-rays 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 X-rays of the hand provided on January 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on March 23, 
2022. 
 
You asked the Plan to pay for the services. You say that the claim should be reprocessed and paid. The Plan 
denied your request. The Plan says the services were not urgent, emergent, or approved in advance. 
 
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 laboratory services provided to the enrollee on 
March 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nebulizer with compressor (E0570) unlisted special 
service, procedure or report (99199) and sales tax S9999) purchased January 31, 2022. 
 
You asked the Plan to pay for the medical equipment. You say that the nebulizer machine is most important in 
relieving your symptoms of difficulty breathing. The Plan and Medicare has always paid for necessary medical 
equipment. Please reconsider and reimburse your purchase. The Plan denied your request. The Plan says items 
was purchased from a supplier who is not certified with 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. 
 
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 nebulizer with compressor (E0570) 
unlisted special service, procedure or report (99199) and sales tax S9999) purchased January 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiation therapy with an oncologist (77334, 77336, 
77014, 77370) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve radiation therapy. You say that the enrollee was seen in the emergency room 
and is now being treated as outpatient due to pain. The Plan denied your request. The Plan says the enrollee 
must use network providers to get medical care and services. The enrollee may obtain services from out-of-
network providers if the services are emergent/urgent or not available within the enrollees network. The 
services are available with the in-network radiation oncologist. 
 
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 radiation therapy with an oncologist (77334, 
77336, 77014, 77370) to be provided by an out-of-network (OON) provider.