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

 
We decided that the Plan does not have to pre-approve Reblozyl for the enrollee. 
 
You asked the Plan to pre-approve Reblozyl. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the clinical value and effectiveness of Reblozyl for low-risk disease and in the 
absence of requirement of 2 or more blood cell unit transfusions has not been demonstrated in the peer-
reviewed literature. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Reblozyl. Our reviewer says that 
Reblozyl is not medically reasonable and necessary. Reblozyl is not FDA-approved for the enrollees diagnosis 
without prior use of Erythropoietin or transfusions. The use of Reblozyl is not supported by one of the major 
drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services approved 
medical journal. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage 
of Reblozyl. 
 
  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Reblozyl have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Reblozyl for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and 
management of an established patient (99335) rendered by the out-of-network (OON) provider on  
September 20, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established 
patient (99335) rendered by the out-of-network (OON) provider on September 20, 2021.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) care after March 3, 2022. 
 
You asked the Plan to pre-approve continued SNF care after March 3, 2022. You say that the requested 
admission to a SNF is medically necessary The Plan denied your request. The Plan says that the requested 
admission to a SNF is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the Independent Review Entity (IRE) information regarding its 
decision to deny coverage or payment. 
 
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 continued SNF care after March 3, 
2022. Our reviewer says that the provided documentation is insufficient to support the Plans denial. Our 
reviewer found that you may have an open bed sore, appear to have a new feeding tube and your current 
functional status is unknown. The Plan argues that SNF coverage is no longer required but are referencing SNF 
records that are not identified. Based on the documentation provided, the denial should be overturned. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care after March 3, 2022, have been met. The Plan must 
continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and 
proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the 
Plan has to pre-approve continued skilled nursing facility (SNF) care after March 3, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided on October 3, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the drug testing services. You say that these services should be considered in-
network because you were not aware of the need for prior authorization. The Plan denied your request. The 
Plan says neither your organization nor the ordering provider are network providers with the Plan. Neither you 
nor the ordering provider had authorization from the Plan to provide 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 provider in this case is not a network provider with the Plan. The ordering provider was 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 drug testing services provided on October 3, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 12, 2021. 
 
You asked the Plan to pay for the lab services. You say that these lab services are medically necessary. The 
Plan denied your request. The Plan says you billed an incorrect place of service (POS) code on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place 
where the sample was taken is reported as the Place of Service (POS).  In this case, you billed with POS 11, 
indicating that the sample was taken from the patient in an office setting.  However, the medical documentation 
shows that the sample was taken from the patient at a Community Mental Health Center, which is POS 53.  
The Plan has attempted to contact you multiple times for clarifying information or a corrected claim with no 
response. 
 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. Therefore, we decided that the Plan does not have to pay for lab 
services provided on April 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the alginate wound dressings provided on September 21, 
2021, billed with code A6197. 
 
You asked the Plan to pay for the wound dressings as billed. You say that this should be paid. The Plan denied 
your request. The Plan says this is not a payable code on the Physician Fee Schedule. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Code A6197 has a status indicator of "P" on the Physician Fee Schedule. This means that no separate payment 
can be made for this code. This code could be paid on the durable medical equipment (DME) fee schedule, but 
only when billed by a DME supplier.  
 
 
 
  
 
 
Based on this information, we decided that Medicare rules for coverage of the wound dressings as billed have 
not been met. Therefore, we decided that the Plan does not have to pay for the alginate wound dressings 
provided on September 21, 2021, billed with code A6197.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. 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. 
 
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 documentation does not support that there is a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
IRF. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on October 11, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the test was requested by the treating 
physician. 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 laboratory services provided on October 11, 2021, 
by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on July 15, 2021, to July 16, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health services. You say that this enrollee was listed as authorization 
not required. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the services at issue were urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for home health services provided on July 15, 2021, to July 16, 
2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgery services (procedure code 23430) provided to the 
enrollee on July 29, 2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the medical records received do not support that this procedure was distinct or 
independent from other services performed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 23430 is "Tenodesis of long tendon of biceps." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the operative report describes a 
reverse shoulder arthroscopy and biceps tenodesis performed on the left shoulder. Per coding guidelines, a 
biceps tenodesis would not be reported separately if performed on the same side. 
 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgery services (procedure code 23430) provided to the enrollee on July 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 21, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services should be paid. The Plan denied 
your request. The Plan says these services were billed with the incorrect place of service (POS) code on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place 
where the sample was taken is reported as the Place of Service (POS). In this case, you billed these lab services 
with POS code 22, which would indicate that the sample was taken from the patient at an on-campus outpatient hospital facility. However, the records show that the patient was in an inpatient hospital facility on the date of 
service. A specimen collected from a hospital inpatient should have a POS of 21. 
 
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. Therefore, we decided that the Plan does not have to pay for lab 
services provided on October 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services you received 
from June 28, 2021, to July 2, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you were in the 
hospital from June 17, 2021, to June 23, 2021.  You believe you were discharged too early and you had to 
return to the hospital.  You believe that the second hospital stay should be considered part of the first admission 
and you should not have a separate copayment. The Plan denied your request. The Plan says you were charged 
this copayment 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 you must pay a $200 
copayment per admission for inpatient hospital care.  
 You have been asked to pay a $200 copayment for the inpatient hospital services. Your contract explicitly 
states that this copayment applies each time you are admitted.  This copayment applies regardless of the reason 
for the admission. 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 inpatient hospital services you 
received from June 28, 2021, to July 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation (D4921) provided by a participating 
provider on November 16, 2021. 
 
You asked the Plan to pay for gingival irrigation. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says D4921 is not a covered benefit service. 
 
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 pay for gingival 
irrigation (D4921) provided by a participating provider on November 16, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound of the vena cava provided on 
October 5, 2021. 
 
You asked the Plan to waive the copayment for an ultrasound of the vena cava. You say that the Plan paid 
nothing, and you have to pay $140.16. You also say the Plan should pay in full. The Plan denied your request. 
The Plan says you have been charged the correct cost sharing amount. 
 
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 $160 
copayment for in-network radiological diagnostic services, including ultrasounds.  
 
 The records show the Plan approved $140.16 for the ultrasound on September 17, 2021. You have been asked 
to pay the allowed amount of $140.16, which is less than the $160 copayment for an ultrasound of the vena 
cava. An ultrasound of the vena cava falls 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 an ultrasound of the vena 
cava provided on October 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the re-cement or re-bond crown (D2920) provided on May 
27, 2021. 
 
You asked the Plan to pay for the dental service. You say that this was an emergency. You also say that your 
plan has refused to reimburse you for the services. The Plan denied your request. The Plan says re-cement or 
re-bond crown is not listed as a covered service. 
 
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 re-cement or re-bond crown is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the re-
cement or re-bond crown (D2920) provided on May 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code 81479) provided on July 
29, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. 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. CPT code 81479 remain 
not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the patient 
when the specimen was obtained. The submitted claim for indicates the laboratory specimen was obtained in a 
laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the 
specimen was obtained in an office setting POS 11. Also, the laboratory results submitted indicate the 
specimen was collected on July 13, 2021, and received by the lab on July 19, 2021, however, billed date of 
service is July 29, 2021; therefore, the billed code cannot be verified. Therefore, we decided that the Plan does 
not have to pay for the laboratory services (CPT code 81479) provided on July 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99202) provided on October 14, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you were not aware that you needed a referral to the 
chiropractor until you received the denial letter. The Plan denied your request. The Plan says the member did 
not have an active referral for the date of services listed in the appeal and the member self-referred 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 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 (99202) provided on October 14, 
2021, by an out-of-network (OON) provider.