Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 17, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the Plan covers medically necessary services, and 
you would like the claim reprocessed for payment. The Plan denied your request. The Plan says the rendering 
provider is an OON provider and there was no referral from an in-network provider or an approved 
authorization. Also, the service rendered was not urgent or emergent. 
 
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 an office visit provided on May 17, 2022, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180), teeth 
cleaning (D1110), and topical application of fluoride (D1208) provided on April 19, 2022, by an out-of-
network provider. 
 
You asked the Plan to pay for the dental services. You say that you want the Plan to pay for the services. The 
Plan denied your request. The Plan says the dental services were received from an out-of-network provider and 
are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a comprehensive periodontal evaluation (D0180), teeth cleaning (D1110), and topical application of 
fluoride (D1208) provided on April 19, 2022, by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mammogram provided on December 8, 2021. 
 
You asked the Plan to pay for the mammogram. The Plan denied your request. The Plan says the benefit limit 
has been exceeded. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The contract with the Plan clearly says that one screening 
mammogram is covered every 12 months.  
 
Review of the file shows that the enrollee was provided a screening mammogram on December 8, 2021. The 
records also show that the enrollee received a covered mammogram on August 9, 2021. The Plan only covered 
one screening mammogram every 12 months. This means that the benefit limit was exhausted prior to the mammogram at issue in this case. Therefore, we decided that the Plan does not have to pay for the 
mammogram provided on December 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (denosumab) injections. 
 
You asked the Plan to pre-approve the Prolia injections. You say that you need Prolia for your osteoporosis. 
The Plan denied your request. The Plan says you have not tried and failed the Plan's preferred drug. 
 
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 Prolia injections. Our reviewer says 
that the requested treatment is not considered medically reasonable and necessary based on step therapy 
criteria. Our physician reviewer found there is no indication that the patient has tried and failed intravenous 
bisphosphonates, which are the Plan's preferred agent for this condition. Based on the medical records provided 
and the Medicare-approved major drug compendia, there is no indication that the plan's required drug(s) would 
likely be less effective and/or likely have adverse effects for the patient. 
 
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 Prolia injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Prolia (denosumab) injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extra-spinal manipulation (988943) and therapy technique 
(97530) provided on March 30, 2022. 
 
You asked the Plan to pay for the manipulation and therapy technique. You say that you were given incorrect 
information about your chiropractor visits. The Plan denied your request. The Plan says you reached your 
maximum enhanced chiropractic services on your March 28, 2022, visit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The Plan offers a chiropractic benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
We looked at your request, the file, and rules. Based on this information we have determined that criteria for 
payment have not been met. Though the Plan offers a chiropractic  benefit in excess of Medicare coverage, 
certain limitations apply. The record shows your benefit for the requested item or service was exhausted on 
date of service March 28, 2022. Therefore, we decided that the Plan does not have to pay for extra-spinal 
manipulation (988943) and therapy technique (97530) provided on March 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 15, 2022, and billed 
with codes 81194, 81301, 81455, and 81479. 
 
You asked the Plan to pay for genetic testing. You say that this testing is a lifesaving tool. The Plan denied 
your request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on March 
15, 2022, and billed with codes 81194, 81301, 81455, and 81479.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a colonoscopy provided on April 8, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the colonoscopy. You say that the service provided to the enrollee was medically 
necessary and you would like the claim paid. The Plan denied your request. The Plan says the rendering and 
referring providers are both OON providers and there was no approved authorization. Also, the service 
rendered was not urgent or emergent. 
 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 a colonoscopy provided on April 8, 2022, by an 
out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on October 8, 
2021. 
 
You asked the Plan to pay for nursing facility care. The Plan denied your request. The Plan says original 
Medicare is responsible 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 subsequent nursing facility care provided on October 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit and a chiropractic manipulative 
treatment provided on May 9, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a specialist office visit and a chiropractic manipulative treatment. You say that 
the enrollee is enrolled in a Medicare plan and is entitled to all Medicare approved services. The Plan denied 
your request. The Plan says services from non-participating providers are not covered under open access unless 
preauthorized. 
 
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 a specialist office visit and a chiropractic 
manipulative treatment provided on May 9, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pembrolizumab for the enrollee. 
 
You asked the Plan to pre-approve pembrolizumab. You say that this is medically necessary. The Plan denied 
your request. The Plan says that the use of Pembrolizumab for glioblastoma is not FDA approved or listed in 
the Medicare approved sources. 
 
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 pembrolizumab. Our reviewer says that 
pembrolizumab is not medically reasonable and necessary. Pembrolizumab is not FDA-approved for the 
enrollees diagnosis. The use supported of pembrolizumab is not supported by one of the major drug 
compendia or by clinical research that appears in a CMS-approved medical journal. Our physician reviewer 
found that the enrollee's condition does not meet criteria for coverage of pembrolizumab. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of pembrolizumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve pembrolizumab for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on April 6, 2022. 
 
You asked the Plan to pay for psychotherapy. You say that the medical records support the medical necessity of 
the services provided. You say that the claim should be reviewed and reprocessed for payment. The Plan 
denied your request. The Plan says Licensed Professional Counselors are not able to be reimbursed by 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that there are certain individuals and entities that 
frequently attempt to enroll in Medicare but are not eligible to do so.  
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy have not been met. Specifically, Licensed Professional Counselors are not eligible 
for Medicare payment. Therefore, we decided that the Plan does not have to pay for psychotherapy provided on 
April 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vision supply, accessory and/or service component of 
another HCPCS vision code provided on April 14, 2022. 
 
You asked the Plan to pay for vision supply, accessory and/or service component of another HCPCS vision 
code. The Plan denied your request. The Plan says this service is non covered  for eyeglasses or contact lenses 
and is not covered by the Plan. 
 Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
We looked at the file and the Plan's rules. The file shows that this service is not a covered vision benefit. 
Therefore, we decided that the Plan does not have to pay for vision supply, accessory and/or service component 
of another HCPCS vision code provided on April 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services provided on December 9, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the radiology services. You say that the enrollee's primary care provider referred 
the enrollee to you. The Plan denied your request. The Plan says the rendering provider is an OON provider, 
and it was confirmed with the enrollee's primary care provider that they did not refer the enrollee to an OON 
provider. Also, the service rendered was not urgent or emergent nor were they 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 radiology services provided on December 9, 
2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies (A6446, A6196, A6010, A4450) 
provided on December 17, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the wound care supplies. You say that the items should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the items 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 wound care supplies (A6446, A6196, A6010, 
A4450) provided on December 17, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extra-spinal manipulation (98943) and therapy technique 
(97530) provided on April 4, 2022. 
 
You asked the Plan to pay for the manipulation and therapy technique. You say that you were given incorrect 
information about your chiropractor visits. The Plan denied your request. The Plan says you reached your 
maximum enhanced chiropractic services on your March 28, 2022, visit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The Plan offers a chiropractic benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
 We looked at your request, the file, and rules. Based on this information we have determined that criteria for 
payment have not been met. Though the Plan offers a chiropractic benefit in excess of Medicare coverage, 
certain limitations apply. The record shows your benefit for the requested item or service was exhausted on 
date of service March 28, 2022. Therefore, we decided that the Plan does not have to pay for extra-spinal 
manipulation (988943) and therapy technique (97530) provided on April 4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care (99232) billed for date of service March 15, 
2022. 
 You asked the Plan to pay for hospital care. You say that this care should not be included in the global surgery 
period, as the debridement procedure has a global surgery period of 0 days, and this care was provided on the 
day before the procedure. The Plan denied your request. The Plan says this service is included in the global 
surgery period for this service and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that the 57 modifier is not 
used with services provided for minor surgeries, and the decision to perform a minor procedure is considered a 
routine pre-operative service and a visit or consultation is not billed in addition to the procedure. 
 
We find that the hospital care provided on March 15, 2022, is not supported in the medical record for separate 
payment. Specifically, the record shows that this was the consultation which resulted in the decision to perform 
the minor procedure and therefore it is considered a routine preoperative service and is not billed in addition to 
the procedure. In addition, the use of the 57 modifier is inappropriate in relation to a minor procedure. Based 
on this information, we decided that Medicare rules for coverage of hospital care have not been met. Therefore, 
we decided that the Plan does not have to pay for hospital care (99232) billed for date of service March 15, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 4, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility.  
 
 
 
 
  
Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on January 4, 
2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continued inpatient skilled nursing facility (SNF) care 
provided from March 4, 2022, through April 2, 2022. 
 You asked the Plan to pay for the SNF care. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the continued inpatient skilled nursing facility 
care provided was 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. 
 
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 
continued inpatient SNF care provided was not considered medically reasonable and necessary. Our physician 
reviewer found that at the time of discharge from the hospital the enrollee had stabilized medically. The 
enrollee did not require any skilled nursing or rehabilitation services on a daily basis at an inpatient level of 
care. The enrollee did not require skilled therapy to establish a safe and effective maintenance program. As a 
practical matter, the enrollee did not require any skilled services on an inpatient basis, at a SNF level of care.  
 
Additionally, the enrollee did not have any parental medications, complex wound care or nutrition given via a 
feeding tube. He was medically stable without any acute exacerbations of chronic medical problems. His 
physical function was at or near his baseline and he could have received further services at a lower level of 
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 SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the continued inpatient skilled nursing facility (SNF) care provided from March 4, 2022, 
through April 2, 2022.