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

 
We decided that the Plan does not have to pay for the office visit (99203) and ankle x-ray (73600) provided on 
April 14, 2021, and the drain/injection for small joint or bursa (20600), and methylprednisolone injection 
(J1030) provided on May 4, 2021, by an out-of-network (OON) podiatrist. 
 
You asked the Plan to pay for the office visit, x-ray, drain injection, and injection. You say that the enrollee 
gave you incorrect insurance information. The Plan denied your request. The Plan says the services have been 
provided out-of-network and 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 the office visit (99203) and ankle x-ray (73600) 
provided on April 14, 2021, and the drain/injection for small joint or bursa (20600), and methylprednisolone 
injection (J1030) provided on May 4, 2021, by an out-of-network (OON) podiatrist.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MammaPrint test. 
 
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says the  enrollee's records do not show that their breast cancer tumor is less than 5 cm; on 
imaging the mass appears closer to 9 cm in size; thus, the enrollee's records indicate too that their stage is likely 
III or higher. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the clinical evidence regarding the validity of MammaPrint genetic testing is insufficient at this time. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the MammaPrint test.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme (Q0138). 
 
You asked the Plan to pre-approve Feraheme. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy requirements have 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 Feraheme. Our reviewer says that the 
requirements for coverage of Feraheme have not been met. Our physician reviewer found the Plan requires a 
trial of Infed and Venofer before they will approve the requested drug. There is no indication that the enrollee 
has tried and failed the required drugs. There is also no indication that the required drugs would likely be less 
effective or have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme (Q0138).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the 
head provided on February 3, 2022. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you feel you should not have been 
charged for the procedure. 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 $225 
copayment for diagnostic radiology services, including CT scans.  
 
You have been asked to pay a $225 copayment for the CT scan. The CT scan 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 a computed tomography (CT) scan of the head provided on February 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (88341, 88342, 88360, 88365) provided August 
5, 2021. 
 
You asked the Plan to pay for the lab services. You say that the lab services were medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
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 CPT codes 88341, 88342, 88360, & 88365 are not supported in the medical record. Specifically, 
the codes billed have a professional component / technical component indicator of 1. This service was billed in 
a facility setting. The claim was missing a required modifier (26). No corrected claim was received. 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 (88341, 88342, 88360, 88365) provided August 
5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 8, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services 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 December 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99204) provided on January 5, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the enrollee benefited from these services. The Plan 
denied your request. The Plan says the services have been provided out-of-network and 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 the office visit (99204) provided on January 5, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have waive the $129.09 deductible for your outpatient clinic visit on 
September 30, 2021. 
 
You asked the Plan waive the $129.09 deductible for your outpatient clinic visit on September 30, 2021. You 
say that you believe an error has been made. The Plan denied your request. The Plan says you are responsible 
to pay this amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. The 
contract with the Plan says that there is a $750 deductible which applies to Outpatient Hospital Services.  
 
The item or service you asked the Plan waive the $129.09 deductible for falls within the benefit category 
Outpatient Hospital Services. The Plan has followed Medicare rules by clearly disclosing in the contract that 
there is a $750 deductible which applies to Outpatient Hospital Services. At the time this claim was processed 
you had not met your deductible. This cost sharing is a contractual obligation that has not yet been met. 
Therefore, we decided that the Plan does not have waive the $129.09 deductible for your outpatient clinic visit 
on September 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Cimzia (J0717). 
 
You asked the Plan to pre-approve Cimzia. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step therapy rules for the requested drug have 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 Cimzia. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of drugs Remicade, Avsola, or Simponi Aria before they will approve the requested drug, 
Cimzia. There is no indication that the enrollee has tried and failed the required drugs. Based on the medical 
records provided, there is no indication that the Plan's required drugs 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 Cimzia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Cimzia (J0717).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (0037U) provided February 17, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this service is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing panels that include the FANCC 
gene are non-covered. 
 
We looked at the file and Medicare rules. The panel performed included FANCC gene testing and is non-
covered. 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 (0037U) provided February 
17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevator (E2300) and backpack holder 
(E1399) for a power wheelchair. 
 
You asked the Plan to pre-approve the power seat elevator and backpack holder.. You say that these features 
are medically necessary. The Plan denied your request. The Plan says these items are not primarily medical in 
nature and are non-covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevator (E2300) and backpack holder (E1399) 
for a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual pump-operated enema system identified with 
code A4459. 
 
You asked the Plan to pre-approve a manual pump-operated enema system. You say that you meet all of the 
requirements. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that enema systems identified with code A4459 is 
non-covered.  
 
We looked at the file and Medicare rules. The requested item is strictly not covered. Based on this information, 
we decided that Medicare rules for coverage of a manual pump-operated enema system have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a manual pump-operated enema system 
identified with code A4459.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for  Medicare-covered, primary care doctor in 
office visit on March 7, 2022. 
 
You asked the Plan to waive the copayment for in-network primary care office visit. You say that when you 
signed up for this plan, you thought the copay amounts would be less. You feel you should not have to pay for 
the $5 copayment due to this. The Plan denied your request. The Plan says there is a $5 copayment for each 
Medicare covered, in network primary care doctor in-office visit. 
 
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 $5 
copayment for each Medicare-covered primary care doctor in office visit. 
 
You have been asked to pay $5 copay for in-network primary care office visit. In-network primary care office 
visit falls within the Medicare-covered primary care doctor in office visit 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  Medicare-covered, primary care 
doctor in office visit on March 7, 2022.  
 
Your complaint about the insurance representative giving misinformation is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit. 
 
You asked the Plan to pre-approve Retacrit. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug is 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.  
 
The Plan uses Local Coverage Determination (LCD) L34633 to support their denial. However, LCD L34633 is 
not valid for Medicare Part B for California. Therefore, we are unable to use LCD L34633 to substantiate our 
decision. 
 
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 Retacrit. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has a diagnosis of macrocytosis and anemia. Based on the medical records 
provided and the Medicare-approved major drug compendia there is no documentation that the Retacrit meets 
Medicare criteria for medically reasonable and necessary for the enrollee. The provided records do not 
document vitamin B12 and folate levels or results of a bone marrow biopsy confirming the diagnosis of 
myelodysplastic syndrome or the presence of any other medically accepted indication for the drug. Therefore, 
the enrollee does not meet criteria for the requested drug. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Retacrit.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI), of the orbit, face, and/or 
neck; without contrast material(s) (70450). 
 
You asked the Plan to pre-approve this service. You say that this service is medically necessary. The Plan 
denied your request. The Plan says this service is not medically necessary as the records do not show a failed 
six week trial of treatment prescribed by your doctor. Additionally, the records do not show that a surgery on 
your jaw is being planned. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
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 this service. Our reviewer says that this 
service is medically necessary. Our physician reviewer found that you have persistent symptoms of 
temporomandibular joint (TMJ) dysfunction and the computed tomography (CT) scan provided has shown 
there is no fracture. In order to evaluate the temporomandibular joint discs, a disorder of which is commonly 
associated with the symptoms you have, the preferred test is an MRI of the temporomandibular joint with both 
an open and closed mouth technique. This procedure will determine whether bracing or operative management 
will be 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 this service have been met. Therefore, we decided that the Plan has to pre-
approve magnetic resonance imaging (MRI), of the orbit, face, and/or neck; without contrast material(s) 
(70450).  
 
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 the morphometric analysis services coded 88374 provided on 
June 24, 2021. 
 
You asked the Plan to pay for the morphometric analysis services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are a duplicate. 
 
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 CPT code 88374 is not supported in the medical record. Specifically, the documentation shows 
that nine units of this code were previously billed and paid. The documentation does not support that more than 
nine units of this code were provided. This means this is a duplicate claim and therefore, not payable. Based on 
this information, we decided that Medicare rules for coverage of the morphometric analysis services have not 
been met. Therefore, we decided that the Plan does not have to pay for the morphometric analysis services 
coded 88374 provided on June 24, 2021.
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 you are appealing the denial of admission to IRF. 
The Plan denied your request. The Plan says according to Medicare guidelines, admission to acute 
rehabilitation is not medically necessary. 
 
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 was hospitalized after suffering a fall with weakness and confusion. 
There are no complex nursing or rehabilitation needs. While they have 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 inpatient rehabilitation facility (IRF) admission and services.