Persius/hicric huggingface dataset:
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 August 5, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the provider has no prior 
knowledge of which patients he will be required to see. You also say that it is not possible to request 
authorization before services are rendered. The Plan denied your request. The Plan says this provider is out-of-
network with the Plan. The Plan also said that authorization was not obtained prior to the services being 
rendered. 
 
 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 domiciliary or rest home visit provided on 
August 5, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (88305) provided on May 26, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
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 payment for CPT code 88305 is not supported in the medical record. Specifically, code 88305 is 
assigned a PC/TC indicator of 1, which means this code has both a professional and technical component. As 
such, the services were not billed with an appropriate modifier for payment to be considered. 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 the services (88305) provided on May 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unlisted supplies and materials provided by the physician or 
other qualified health care professional (99070) provided January 18, 2022 to March 31, 2022. 
 
You asked the Plan to pay for the custodial care and transportation services. You say that you needed assistance 
with meals preparation, bathing, light cleaning, transportation to and from doctor appointments, a wheelchair 
and eventually physical therapy. The Plan denied your request. The Plan says an itemized bill was requested 
but was not received. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of unlisted supplies and materials 
provided by the physician or other qualified health care professional (99070) provided January 18, 2022 to 
March 31, 2022. have been met. The Plan made multiple attempts to obtain an itemized bill and a corrected claim form from the provider to process the correct diagnosis and CPT codes without success. Therefore, we 
decided that the Plan does not have to pay for unlisted supplies and materials provided by the physician or 
other qualified health care professional (99070) provided January 18, 2022 to March 31, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the dental services provided on April 22, 2022. 
 
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says that a core build 
up service is not a covered benefit under your Plan benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, we are unable to confirm what services were billed to determine if 
they are not covered by the Plan contract. It is the burden of the Health Plan to substantiate their denial with 
evidence. In this case, the denial has not been substantiated so we must find in your favor. Therefore, we 
decided that the Plan has to pay for the dental services provided on April 22, 2022.   
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a progressive stretch knee device provided on April 26, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the progressive stretch knee device. You say that you had a valid authorization to 
cover the service provided to the enrollee. 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 a progressive stretch knee device provided on 
April 26, 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 deductible for an eye exam and diagnostic services 
provided by out-of-network provider on February 4, 2022, and February 18, 2022. 
 
You asked the Plan to waive the deductible for eye exam and diagnostic services. You say that you had an 
infection in your eyes and had to seek treatment. You say that you spoke with a Plan representative and was 
told your insurance had out of state coverage. The Plan denied your request. The Plan says the deductible 
applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible for out-of-network services.  
 
The item or service you asked the Plan to waive the deductible for falls within the Vision Care benefit category 
and Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for out-of-network 
services. This cost sharing is a contractual obligation that had not been met at the time an out-of-network 
services were received on February 4, 2022, and February 18, 2022. Therefore, we decided that the Plan does 
not have to waive the deductible for an eye exam and diagnostic services provided by out-of-network provider 
on February 4, 2022, and February 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM) and 
supplies (K0553). 
 
You asked the Plan to pre-approve a CGM and supplies. You say that the CGM will help the enrollee get the 
best control over his insulin. The Plan denied your request. The Plan says the enrollee does not meet prior 
authorization criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 
continuous glucose monitor (CGM) and supplies (K0553).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 24, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that your records show your staff completed a prior 
authorization request. The Plan denied your request. The Plan says this provider is not a network provider with 
the Plan. The Plan also says that the services 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 laboratory services provided on March 24, 2022, 
by an out-of-network (OON) provider.
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 May 27, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the provider has no prior 
knowledge of which patients he will be required to see. You also say that it is not possible to request 
authorization before services are rendered. The Plan denied your request. The Plan says this provider is out-of-
network with the Plan. The Plan also said that authorization was not obtained prior to the services being 
rendered. 
 
 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 domiciliary or rest home visit provided on May 
27, 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 the outpatient telehealth office visits (99213) provided 
December 10, 2021 to March 22, 2022 by an out of network provider. 
 
You asked the Plan to pay for the telehealth visits. You say that you were unaware of changes to telehealth 
policy. This was not properly communicated to you in the beginning. Your doctor switched to online 
appointments during the pandemic. The Plan denied your request. The Plan says enrollees must receive their 
telehealth services from an in-network provider with the exception being urgent or emergent services.  
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
The record shows you received the outpatient services from an out-of-network provider. Though the Plan offers 
a 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 
the outpatient telehealth office visits (99213) provided December 10, 2021 to March 22, 2022 by an out of 
network provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo. 
 
You asked the Plan to pre-approve Vabysmo. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 Vabysmo. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the Plan requires a trial of drug 
bevacizumab before they will approve the requested drug. In this case, the enrollee has not tried and failed the 
required drug(s). There is no documentation provided indicating that the the plans required drug(s) would 
likely be less effective and/or likely 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 Vabysmo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vabysmo.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lens upgrades you received on February 2, 2022.  
You asked the Plan to pay for the lens upgrades. The Plan denied your request. The Plan says these services are 
not covered. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers only standard frames and lenses. Lens upgrades are not covered. 
 
We looked at the file and the Plan's rules. The records show that you were provided lens upgrades. The Plan 
only covers standard lenses. Upgrades are not covered under your plan. Based on this information, we decided 
that the Plan's rules for coverage of the lens upgrades have not been met. Therefore, we decided that the Plan 
does not have to pay for the lens upgrades you received on February 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on October 24, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that you are the only provider allowed into the 
facility where the enrollee was staying at. The Plan denied your request. The Plan says the rendering provider 
is an OON provider 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 home health visit provided on October 24, 2021, 
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 oral evaluation (D0150) provided by a 
participating provider on April 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 6, 2020. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided by a participating provider on April 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 28, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 January 28, 2022, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for perfusionist's services billed for date of service March 15, 
2022. 
 
You asked the Plan to pay for the perfusionist's services. You say that these services were medically necessary 
and should be paid. The Plan denied your request. The Plan says no separate payment is made for these 
services 
 
The Plan must follow Medicare rules. Medicare rules say that services provided by nonphysicians are included 
in the payment to the hospital for inpatients.  In this case, the patient was an inpatient at the time of these 
nonphysician perfusionist services.  Therefore, these services are not separately payable. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the perfusionist's services have not been met. Therefore, we decided that the Plan does not have to 
pay for perfusionist's services billed for date of service March 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
December 18, 2021, to December 27, 2021. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that your mom was treated 
at this hospital and could not be transported until health conditions improved and a bed opening existed. You 
say that all other services were paid except for $700, that you are requesting be paid. The Plan denied your 
request. The Plan says the copayment applied 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). The enrollees contract with the Plan clearly says that enrollees 
must pay $100 per day copayment for days 1 to 7 and $0 for the remainder of the covered hospital stay. 
 
The enrollee has been asked to pay a $700 copayment for days 1 to 7 of the 8-day hospital stay ($100/day x 7 
days). An inpatient hospital stay falls within the Inpatient Hospital Care benefit category. This means that the 
enrollee has been asked to pay the correct amount based on the contract with the Plan.  This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, 
we decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
December 18, 2021, to December 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injection services. 
 You asked the Plan to pre-approve epidural steroid injection services. You say that this procedure is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage 
have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injections are subject to the criteria 
listed 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 epidural steroid injection services. Our 
reviewer says that the requested epidural steroid injections are not medically reasonable and necessary. Our 
physician reviewer found that the enrollee is a 69-year-old female with chronic low back pain due to post-
laminectomy syndrome. The pain is rated 9/10 and is described as aching. Treatment has included medical 
therapy with opiates, nerve block and epidural steroid injections. Her provider has recommended an epidural 
steroid injection. In this case, there is no documentation of radiculopathy, radicular pain or neurogenic 
claudication. The review has determined that the requested epidural steroid injection does not meet the 
Medicare coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural steroid injection services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve epidural steroid injection services.