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

 
We decided that the Plan does not have to pay for the vision services provided on October 8, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the vision services provided by an OON provider. You say that you would like 
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network 
care. 
 
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 vision services provided on October 8, 2021, 
by an out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Monoferric. 
 
You asked the Plan to pre-approve Monoferric. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan 
requires a trial of Infed and Venofer before it will approve Monoferric. 
 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 Monoferric. Our reviewer says that the 
enrollee does not meet the Medicare criteria for a step therapy exception for Monoferric. Our physician 
reviewer found the enrollee has not tried and failed the Plan's preferred drugs of Infed and Venofer. The record 
does not show that these drugs would likely be less effective and/or have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Monoferric have not been met. Therefore, we decided that the Plan does not 
have to pre-approve use of Monoferric.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT scan, lower extremity; without contrast material (CPT 
code 73700-26-LT) provided on September 17, 2021. 
 
You asked the Plan to pay for the CT scan. You say that the diagnosis code was appropriate for date of service. 
The Plan denied your request. The Plan says the diagnosis code is inappropriately coded. 
 
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 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 CT scan. Our reviewer found the documentation 
submitted was reviewed and does not meet criteria. Documentation has a conflict with procedure code reported.  
Provider reported diagnosis code ICD 10 M25.561 Pain in right knee, however radiology report documents 
"CT lower extremity wo contrast left CT left lower extremity without iv contrast; indication: Patient presents 
with left leg cellulitis and elevated white blood cell count. Evaluate for necrotizing fasciitis". Therefore, pain in 
right knee conflicts with services performed.  
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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pay for the CT scan, lower extremity; without contrast material (CPT code 73700-26-LT) provided on 
September 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endosteal implants (D6010). 
 
You asked the Plan to pre-approve the endosteal implants. You say that the enrollee has lost all of her teeth and 
is suffering in pain. The Plan denied your request. The Plan says this service is not covered under the enrollee's 
benefit plan. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
endosteal implants (D6010).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (83789) provided on September 27, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
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. 
 
We looked at the file and Medicare rules. Review of the file shows the claim was billed with an inappropriate 
place of service 11. According to claims history, the specimen was obtained in a Community Mental Health 
Center. Therefore, we decided that the Plan does not have to pay for the laboratory services (83789) provided 
on September 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between the approved power 
tilt seating system and the drive control (E2310) and two amputee support gel pads (K0108). 
 
You asked the Plan to pre-approve the electronic connection and support gel pads. You say that it is felt that the 
requested items are necessary. The Plan denied your request. The Plan says the components which remain 
denied exceed the enrollee's medical need. 
 
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 the electronic connection and support 
gel pads.  Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the documentation indicate the patient has 5/5 bilateral upper extremity strength 
which is sufficient to control any power options through their own switches. The gel cover exceeds the patient's 
medical need as the documentation does not reveal extenuating factors that indicate why standard pads would 
not be adequate to meet the patient's needs. 
 
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 electronic connection and support gel pads have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an electronic connection between the approved power 
tilt seating system and the drive control (E2310) and two amputee support gel pads (K0108).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve swing bed services. 
 
You asked the Plan to pre-approve swing bed services. You say that you are unable to care for your brother 
alone at home. You say that there are no long-term care facilities available. You say that the enrollee needs to 
remain in the current facility until the end of his week so that you can arrange for home care. The Plan denied 
your request. The Plan says the clinical documentation provided indicates that long term care would be 
appropriate. The Plan says that there is no evident medically necessity for continued care in the swing bed 
setting. 
 
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 pre-approve swing bed services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have 
documented skilled nursing needs. The enrollees dressing is to be changed thrice weekly. The enrollee does 
not have documented skilled therapy needs. The enrollee is walking household distances. Daily skilled services 
are not required to establish a maintenance program or to prevent deterioration of the enrollees condition. The 
enrollees care needs, custodial and intermittent, can, as a practical matter, be provided 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 swing bed services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve swing bed services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 16, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
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 laboratory 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 the laboratory services provided on August 16, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xiidra. 
 
You asked the Plan to pre-approve Xiidra. You say that the enrollee has been on this medication with good 
results. The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by the 
Medicare Part B plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xiidra.  
 
 
 Benefits for Xiidra 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care services provided on October 4, 
2021. 
 
You asked the Plan to waive the copayment for urgent care services. You say that it was not an urgent care 
visit, so the copayment should be waived. The Plan denied your request. The Plan says the provider is an 
urgent care facility and that the copayment amount 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 $50 
copayment for each Medicare-covered urgent care provider visit.  
 
 
 
 
 
 You have been asked to pay a $50 copayment for urgent care services. Urgent care services fall 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 urgent care 
services provided on October 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hearing aids. 
 
You asked the Plan to pre-approve hearing aids. The Plan denied your request. The Plan says you reached your 
benefit maximum of $1,500 with the hearing aid you received on September 15, 2020. You will not be eligible 
for coverage of a hearing aid(s) again until after September 16, 2023. 
 
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 every 3 years. 
 
We looked at the file and the Plan's rules. The file shows that you received the hearing aid benefit on 
September 15, 2020 and you will not be eligible to receive the benefit until after September 16, 2023. Based on 
this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we 
decided that the Plan does not have to pre-approve hearing aids.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 15, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you were unaware that an authorization was 
needed, and the referring provider ordered the testing. The Plan denied your request. The Plan says the 
rendering and referring providers are both out-of-network 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 the laboratory services provided on October 15, 
2021, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that the records provided support the need for SNF 
care. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says 
that the services required can safely be received at a different setting. 
 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 pre-approve SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, 
had stable vital signs with bradycardia, and clear lungs. The enrollee received physical therapy and 
occupational therapy. The enrollee was at a supervision to contact guard assist level for functional mobility, 
including gait to 175 feet with a rolling walker. The enrollee required varying assist with activities of daily 
living. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service 
needs, but they are not required on a daily basis. The enrollee does not meet the severity of illness or intensity 
of service criteria for 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electroencephalogram (EEG) during non-intracranial surgery 
(95955) and continuous intraoperative neurophysiology monitoring, from outside the operating room (remote 
or nearby), per patient, (attention directed exclusively to one patient) each 15 minutes (list in addition to 
primary procedure) (G0453) provided June 10, 2021. 
 
You asked the Plan to pay for the diagnostic testing. You say that these codes are necessary when billing the 
technical and professional component for this procedure. Please reconsider this claim and process it for 
payment. The Plan denied your request. The Plan says these services as experimental and investigational. 
 
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 pay for the diagnostic testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case, there was no specific clinical rationale provided for the Intraoperative 
Neurophysiologic Monitoring The review has determined that the medical records provided did not meet the 
requirements listed in the LCD for Medicare coverage. 
 
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 diagnostic testing have not been met. Therefore, we decided that the Plan 
does not have to pay for electroencephalogram (EEG) during non-intracranial surgery (95955) and continuous 
intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby), per patient, 
(attention directed exclusively to one patient) each 15 minutes (list in addition to primary procedure) (G0453) 
provided June 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hydrocodone/APAP. 
 
You asked the Plan to pre-approve Hydrocodone/APAP. The Plan denied your request. The Plan says this drug 
is not covered under the enrollee's plan under any normal circumstances. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Hydrocodone/APAP.  
 
Benefits for Hydrocodone/APAP 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression appliance. 
 
You asked the Plan to pre-approve a pneumatic compression appliance. You say that the records provided 
support the need for the requested device. The Plan denied your request. The Plan says the records fail to 
document that the enrollee has persistent and severe chronic lymphedema, physical findings of severe 
lymphedema, or the failure of four weeks of conservative treatment. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
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 pneumatic compression appliance. 
Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee's 
diagnosis is bilateral leg lymphedema, improved following diuresis. The medical record fails to document the 
enrollee has persistent and severe chronic lymphedema, physical findings of severe lymphedema, or the failure 
of four weeks of conservative treatment. The medical record states the enrollee's lymphedema improved 
following diuresis and the enrollee's symptoms are otherwise mild. The review has determined that the 
requested device is not medically necessary for the treatment of lymphedema and/or for the treatment of 
chronic venous insufficiency with venous stasis ulcers. 
 
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 pneumatic compression appliance have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a pneumatic compression appliance.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a physician office visit (99213) with urinalysis (81002) 
provided on September 1, 2021, by an out-of-network provider. 
 
You asked the Plan to pay for a physician office visit with urinalysis. You say that the services at issue were a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for out-of-
network care have not been met. 
 
 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 physician office visit (99213) with urinalysis 
(81002) provided on September 1, 2021, by an out-of-network provider.