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

 
We decided that the Plan does not have to pay for laboratory services provided on April 14, 2021, by an OON 
provider. 
 
You asked the Plan to pay for laboratory services. You say that you disagree with the denial and would like the 
Plan to reconsider payment. The Plan denied your request. The Plan says the out-of-network services were not 
authorized. 
 
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 on April 14, 2021, by 
an OON provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on May 5, 2022. 
 
The enrollee asked the Plan to pay for the ambulance response and treatment with no transport. The Plan 
denied the enrollees request. The Plan says the enrollee refused ambulance transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 5, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on May 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on March 30, 2022. 
 
You asked the Plan to pay for a domiciliary or rest home visit. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are 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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a domiciliary or rest home visit provided on March 30, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tezspire. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the submitted records and Medicare-
approved drug compendia do not document that Tezspire is reasonable and medically necessary when used in 
combination with Dupixent. This treatment is also not suported by the current clinical guidelines. The services 
are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Tezspire.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the StrataNGS genetic testing services provided on 
September 21, 2021. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
for medical necessity. The Plan denied your request. The Plan says this claim has not been billed as required by 
Medicare billing regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must enter the appropriate DEX Z-
CodeTM identifier on the claim for molecular testing.  
We looked at the file and Medicare rules. In this case, the appropriate DEX Z-CodeTM identifier was not 
provided with this claim. Based on this information, we decided that Medicare rules for coverage of the genetic 
testing services have not been met. Therefore, we decided that the Plan does not have to pay for the StrataNGS 
genetic testing services provided on September 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's medical management and rehabilitation 
needs require and inpatient rehabilitation stay and close physician supervision. The Plan denied your request. 
The Plan says based on Medicare guidelines, the inpatient rehabilitation facility services you are requesting do 
not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 Our physician reviewer found the enrollee has a medical history of diabetes mellitus type II, hypertension, 
hyperlipidemia, and osteoporosis. The enrollee was admitted to the hospital on September 26, 2022, for a left 
greater trochanteric hip fracture after falling and required no surgical intervention. Prior to admission to the 
hospital the enrollee was independent with activities of daily living and mobility. As of September 30, 2022, 
the enrollee required minimal assistance with bed mobility and is ambulating 12 feet with a rear walker. There 
are no complex nursing or rehabilitation needs. While the enrollee has a need for physical or occupational 
therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an inpatient hospital stay from May 24, 
2022, to May 25, 2022. 
 
You asked the Plan to reduce the copayment for an inpatient hospital stay. You say that you already paid $300. 
The Plan denied your request. The Plan says the cost share has been applied correctly 
 
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 for an in-network 
inpatient hospital stay you must pay a $350 copayment for per day for days 1 to 5: $0 copayment for days 6 to 
90.  
 
You have been asked to pay a $350 copayment for an inpatient hospital stay. An inpatient hospital stay falls 
within the Inpatient Hospital 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 reduce the copayment for 
an inpatient hospital stay from May 24, 2022, to May 25, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99222 billed for date of service March 29, 
2022. 
 
You asked the Plan to pay for procedure code 99222. You say that this service was medically necessary. The 
Plan denied your request. The Plan says procedure code 99222 is considered bundled and 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 procedure code. 
 
We find that procedure code 99222 has a status indicator of B on the Physician Fee Schedule. This means that procedure code 99222 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99222 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99222 billed for date of service March 29, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on June 3, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you felt 
fine by the time the ambulance arrived, and no longer needed their service. The Plan denied your request. The 
Plan says you were not transported by the ambulance to an appropriate medical facility. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 3, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on June 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam (92004) and determination of refractive state 
(92015) provided on May 28, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the eye exam and determination of refractive state. The Plan denied your request. 
The Plan says these services were rendered by a non-participating provider, and there is no referring provider. 
The Plan also says that none of the provided services were authorized by the Plan. 
 
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 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 eye exam (92004) and determination of 
refractive state (92015) provided on May 28, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes [insert code at issue] billed for date of 
service March 7, 2022. 
 
You asked the Plan to pay for procedure codes [insert code at issue]. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT codes 64490, & 64491 
 is 1. The MAI value for this code is 2. You billed 2 units of these codes, exceeding the MUE. Based on this 
information, we decided that Medicare rules for coverage of procedure codes [insert code at issue] have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure codes [insert code at issue] 
billed for date of service March 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 23, 2022, by an OON 
provider. 
 
You asked the Plan to pay for an office visit. You say that the medical records that were submitted with the 
appeal show medical necessity and to support not having an authorization. The Plan denied your request. The 
Plan says the out-of-network services were not authorized. 
 
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 February 23, 2022, by 
an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you need the ankle support to help alleviate pain 
that you're experiencing in your ankle and leg. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 11, 2021 billed 
with codes 81225, 81226, 81230, 81240, 81241, 81249, 81291, 81335, and 81408. 
 
You asked the Plan to pay for the genetic testing billed. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
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 the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
September 11, 2021 billed with codes 81225, 81226, 81230, 81240, 81241, 81249, 81291, 81335, and 81408.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Oxycodone tablets. 
 
You asked the Plan to pre-approve Oxycodone tablets. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says Oxycodone tablets are not covered under the enrollee's 
Medicare Part B benefit. 
 
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 Oxycodone tablets.  
 
Benefits for Oxycodone tablets 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is medically necessary for the enrollee to go to 
inpatient rehabilitation. The Plan denied your request. The Plan says based on Medicare guidelines, the 
inpatient rehabilitation facility services you are requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 
 Our physician reviewer found the clinical documentation shows that the enrollee is medically stable and there 
is no information to suggest they would continue to require inpatient hospitalization or close medical 
supervision on an inpatient basis. IRF criteria has not been met or is 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5261) and hearing aid or assistive 
listening device/supplies/accessories (V5267) provided on October 26, 2021, by a provider who is not part of 
the Plans hearing network. 
 
You asked the Plan to pay for the hearing aids and hearing aid or assistive listening device/supplies/accessories. 
You say that the treating provider is an approved hearing provider, and feel the Plan should help with the cost 
of the hearing aids. The Plan denied your request. The Plan says these hearing aids were purchased from a 
provider who is not part of the Plan's hearing network. The Plan also says you did not contact the Plan's hearing 
vendor for the purchase of your hearing aids. 
 
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 you use the Plan's 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 aids and hearing aid or assistive listening device/supplies/accessories have not been 
met. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5261) and hearing aid or 
assistive listening device/supplies/accessories (V5267) provided on October 26, 2021, by a provider who is not 
part of the Plans hearing network.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency ambulance service (A0427) provided on 
March 18, 2022. 
 
You asked the Plan to pay for emergency ambulance service. You say that the enrollee is a resident at an 
assisted living facility, lost consciousness, and the staff was unable to revive them. You also say that the 
emergency medical services were called and able to revive the enrollee, and transportation was not necessary. 
The Plan denied your request. The Plan says the enrollee refused treatment and was not transported. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 18, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The record shows that the enrollee was advised to go to the hospital, but stated they were fine and did not feel it 
was necessary. Therefore, we decided that the Plan does not have to pay for the emergency ambulance service 
(A0427) provided on March 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the hospital bed to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the hospital bed. You say that you were told the hospital bed was covered 
and you would like to be reimbursed. The Plan denied your request. The Plan says the provider is out-of-
network. 
 
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 hospital bed. We found no exception that would require the Plan to pre-approve 
the hospital bed. Therefore, we decided that the Plan does not have to pre-approve the hospital bed to be 
provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Tecentriq. 
 
You asked the Plan to pre-approve Tecentriq. You say that you need this treatment. The Plan denied your 
request. The Plan says you do not have a medically-accepted indication for Tecentriq. 
 
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 Tecentriq. Our reviewer says that you 
do not meet the Medicare criteria for the requested use of Tecentriq. Our physician reviewer found Tecentriq is 
not Food & Drug Administration (FDA) approved for your diagnosis. The requested use is not supported by 
one of the major drug compendia or by clinical research appearing in a Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Tecentriq have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Tecentriq.