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

 
We decided that the Plan does not have to pay for lab services provided on May 7, 2021. 
 
You asked the Plan to pay for the lab services. You say that these lab services are covered by Medicare and 
were medically necessary. The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the claim. 
 
 
 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 lab 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 lab services provided on May 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Berkeley shell foot insert. 
 
You asked the Plan to pre-approve foot orthotics. You say that your right foot has gone completely flat due to 
walking with a cane. The Plan denied your request. The Plan says the services are not covered. 
 
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 a Berkeley shell foot insert.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve SNF services. You say that the patient's condition requires him to be in a 
SNF for rehabilitation services before returning home. The Plan denied your request. The Plan says based on 
Medicare guidelines, the SNF services do not meet the requirements for approval. 
 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 medically necessary. Our physician reviewer found that from a nursing 
perspective, the enrollee received oral medications. The enrollee had stable vital signs. He was treated for a 
urinary tract infection. Regarding rehabilitation services, the enrollee received physical therapy (PT) and 
occupational therapy (OT). The enrollee was at a modified independent level for rolling and moderate assist of 
two for transfers. The enrollee required varying assist with activities of daily living. He had poor safety 
awareness. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy 
service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. As a practical 
matter, this enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a 
skilled nursing facility 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 SNF services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 12, 2021. 
 
You asked the Plan to pay for the lab services. You say that Medicare covers this service, so the claim should 
not have been denied. The Plan denied your request. The Plan says you billed with an incorrect place of service 
on the claim. 
 
 
 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 lab 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 lab services provided on May 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a service animal. 
 
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 animal has not been trained as a service animal and does not qualify for 
coverage. 
 The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The Plan contract says that a service dog is covered when services are provided by a trained 
service dog as described under the Americans with Disabilities Act (ADA). 
 
The item at issue is a service dog. This item is not covered by Medicare; however, the Plan offers a 
supplemental benefit for services dogs. The file shows that the requested animal does not meet the definition of 
a trained service animal under the ADA. For this reason, we found that the Plans rules for coverage of these 
services are not met. Therefore, we decided that the Plan does not have to pre-approve a service animal.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit with injections provided on November 23, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit with injections. You say that the diagnosis was correct and should 
not be denied for the local coverage determination. The Plan denied your request. The Plan says the rendering 
and referring providers are both out-of-network 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 an office visit with injections provided on 
November 23, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Myriad Colaris Plus with MyRisk Gene testing. 
 
You asked the Plan to pre-approve a Myriad Colaris Plus with MyRisk Gene testing. You say that the clinical 
information provided supports the need for the requested genetic testing. The Plan denied your request. The 
Plan says the requested genetic testing is not medically necessary. 
 
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 a Myriad Colaris Plus with MyRisk 
Gene testing. Our reviewer says that a Myriad Colaris Plus with MyRisk Gene testing is not considered 
medically reasonable and necessary in this case. Our physician reviewer found the documentation does not 
support that the enrollee has a high-risk colorectal cancer syndrome.  
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 Myriad Colaris Plus with MyRisk Gene testing have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a Myriad Colaris Plus with MyRisk Gene testing.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis. 
 
You asked the Plan to pre-approve Eliquis. You say that this is medically necessary. The Plan denied your 
request. The Plan says coverage of this medication is the responsibility of your prescription drug 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 Eliquis.  
 
Benefits for Eliquis 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the specialist office visit. You say that you have seen this provider for a 
long time and would like to continue to see the same provider. The Plan denied your request. The Plan says the 
last several visits were denied, and the enrollee was self-referred to the provider. A list of in-network providers 
was authorized for this service and was given to the enrollee along with an appointment made for the enrollee 
to be seen. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a specialist office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services (99204) provided on October 18, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for ophthalmological services. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says this was denied due to no prior authorization for date of 
service October 18, 2021, and the Plan did not authorize any services for this provider. The Plan also says that 
the rendering provider is a non-participating provider, and there is no referring provider in these services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 ophthalmological services (99204) provided on 
October 18, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the urgent care visit on December 18, 2021. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that were told by the staff at the 
facility that you would not have a copay. 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). Your contract with the Plan clearly says that you must pay a $65 
copay for each urgent care visit.  
 
 
 
 You have been asked to pay a $65 copay for the urgent care visit. The urgent care visit falls within the 
Urgently needed services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the urgent 
care visit on December 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a diagnostic radiology scan provided on March 30, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the radiology scan. You say that you would like a reconsideration of the claim 
and for it to be processed for payment. The Plan denied your request. The Plan says both the rendering and 
referring providers are out-of-network 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 diagnostic radiology scan provided on March 30, 
2021, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not support the need for a skilled physical therapist to make more home 
visits at this time. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found the enrollee does 
not have documented ongoing home health physical therapy needs. The enrollee is functioning at a level 
commensurate with a lower level of care, such as a home exercise program or outpatient therapy. As such, the 
requested ongoing services are not medically reasonable or 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home health services for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve GenVisc 850 (J7320). 
 You asked the Plan to pre-approve GenVisc 850. You say that the requested drug is medically necessary. The 
Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, OrthoVisc, 
SynVisc, and/or SynVisc-One. 
 
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 GenVisc 850. Our reviewer says that 
the step therapy criteria have not been met. Our physician reviewer found that the documentation indicates that 
she previously received hyaluronic acid injections in 2020. The documentation also indicates that the enrollee 
was to receive GenVisc in April 2021. As such, there is no evidence that the enrollee has met either the health 
plans step therapy criteria or exception criteria. Furthermore, assuming that GenVisc was previously provided, 
the Food and Drug Administration (FDA) label states that The effectiveness of repeat treatment cycles of 
GenVisc 850 has not been established.  As such, the request for treatment with GenVisc is not medically 
necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of GenVisc 850 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve GenVisc 850 (J7320).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 2, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the referring provider ordered the laboratory 
testing out of medical necessity. The Plan denied your request. The Plan says the rendering and referring 
providers are both out-of-network providers and there was no prior authorization. 
  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 November 2, 
2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee walker. 
 
You asked the Plan to pre-approve a knee walker. You say that you are unable to walk on your own and this 
would help you get around. The Plan denied your request. The Plan says that this is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that there is insufficient published clinical literature 
demonstrating safety and effectiveness in the Medicare population to establish the medical necessity for crutch 
substitutes (E0118). 
 
We looked at the file and Medicare rules. The DME MAC, the contractor responsible for coverage of medical 
equipment in the State of Florida has decided that the knee walker coded as E0118 is not medically reasonable 
and necessary. Based on this information, we decided that Medicare rules for coverage of a knee walker have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a knee walker.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visits and an X-ray 
provided on November 19, 2021, to December 17, 2021. 
 
You asked the Plan to waive the copayment for specialist office visits and an X-ray. You say that the pain in 
your arm originated from your COVID vaccine, so the charges should be waived. The Plan denied your 
request. The Plan says 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 $35 
copayment for medical care or surgery services in a Specialty Physician's office, and a $35 copayment for each 
Medicare-covered X-ray. 
 
You have been asked to pay a total of $103.48 for two specialist office visits and an X-ray ($35 copayment for 
each specialist office visit and a $33.46 copayment for the X-ray, which is less than the Plan's EOC 
documented $35 copayment for X-rays). Specialist office visits and fall within the Physician/Practitioner 
Services, Including Doctors Office Visits benefit category. X-rays fall within the Outpatient Diagnostic Tests 
and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for specialist office visits and an X-ray provided on November 19, 2021, to December 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that these stockings are medically 
necessary. The Plan denied your request. The Plan says these stockings are not covered. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.