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

 
We decided that the Plan does not have to pay for drug testing provided on November 18, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for drug testing. You say that the services were requested by the enrollee's physician. 
The Plan denied your request. The Plan says the denial of payment for this service is correct, because this 
provider is out-of-network with the Plan and the ordering physician was also out-of-network with the Plan. 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 drug testing provided on November 18, 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 evaluation provided on September 22, 2021, by an OON 
provider. 
 
You asked the Plan to pay for the evaluation. You say that you feel it is too high and you should not be 
responsible. The Plan denied your request. The Plan says the services were 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 evaluation provided on September 22, 2021, 
by an OON provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care after April 8, 2022. 
 
You asked the Plan to pre-approve SNF care after April 8, 2022. You say that the continued admission to a 
SNF is medically necessary. The Plan denied your request. The Plan says the continued 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. 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 care after April 8, 2022. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have daily 
skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an 
inpatient basis in a SNF 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 care after April 8, 2022, have not been met. Therefore, we decided that the 
Plan does not have to pre-approve skilled nursing facility (SNF) care after April 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

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

 
We decided that the Plan does not have to pre-approve the continuous glucose monitor (CGM) supplies 
(K0553). 
 
You asked the Plan to pre-approve the CGM supplies. You say that the items are medically necessary. The Plan 
denied your request. The Plan says you do not meet the criteria for this item. 
 
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. Based on this information, we decided that Medicare rules for coverage of 
the CGM supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
continuous glucose monitor (CGM) supplies (K0553).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Cyclobenzaprine. 
 
You asked the Plan to pre-approve the Cyclobenzaprine. You say that the drug is medically necessary. The 
Plan denied your request. The Plan says this is a self-administered drug. 
 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 the Cyclobenzaprine.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses and lens upgrades (V2781, V2203, V2750, 
V2784) provided on December 13, 2021. 
 
You asked the Plan to pay for the eyeglasses. You say that these lens add-ons should be covered because they 
will be useful for night driving and safety. The Plan denied your request. The Plan says your benefit covers a 
maximum of $100 toward the cost of routine eyewear every year. The Plan has paid the full $100 benefit limit, 
and you are responsible for the remaining cost. 
 
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 pays up to $100 toward the cost of routine eyewear every year. 
 
We looked at the file and the Plan's rules. The record shows that the Plan has covered the full $100 benefit limit 
toward the cost of your eyewear, and you are being asked to pay the remaining amount. Therefore, we decided 
that the Plan does not have to pay any additional amount for the eyeglasses and lens upgrades (V2781, V2203, 
V2750, V2784) provided on December 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Ondansetron Tablet. 
 
You asked the Plan to pre-approve the Ondansetron Table. You say that the drug is medically necessary. The 
Plan denied your request. The Plan says this is considered a self-administered drug and does not meet Medicare 
criteria for coverage 
 
 
 
  
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 the Ondansetron Tablet.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274) provided 
October 27, 2021. 
 
You asked the Plan to pay for the bitewing x-rays. You say that you were surprising your routine x-rays were 
not covered. The Plan denied your request. The Plan says you have exceeded the frequency limit for the x-rays. 
 
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. The Plan covers the bitewing 
x-rays once per plan year.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that bitewing x-rays were 
previously covered July 22, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the bitewing x-rays has been exceeded. Therefore, we decided that the Plan does not have to pay 
for the bitewings - four radiographic images (D0274) provided October 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit (99336) provided on 
November 24, 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 member is in a nursing facility, 
therefore, no referral should be needed. The Plan denied your request. The Plan says This provider is not a 
network provider with the Plan, and the services were not referred by a network provider or rendered in an in-
network facility. The Plan also says they have also determined that these services are not urgent or emergent, 
nor were they approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 (99336) provided 
on November 24, 2021, by an out-of-network (OON) provider.
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 this is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says rules for IRF care have 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 based on the medical records provided the complexity of the patient's nursing, 
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The patients medical conditions are stable on outpatient medications with no 
issues that require a physicians evaluation three or more times per week. While the patient does require 
physical therapy and occupational therapy services, the medical records provided do not clarify why the patient 
requires an intensive inpatient rehabilitation therapy program. Provided records do not explain why the 
intensive inpatient rehabilitation therapy program is necessary and why therapy at a lower level of care such as 
in a skilled nursing facility is not appropriate for the patient. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on June 8, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the office visit should be paid for by the Plan. The 
Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider 
is out-of-network with the Plan and the ordering physician was also out-of-network with the Plan. 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 provided on June 8, 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 the back brace (L0464). 
 
You asked the Plan to pre-approve the back brace. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the spinal orthosis is included in the payment to the hospital if the need for 
the orthosis begins during the hospital stay, such as after spinal surgery. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 Records show that the back brace is being requested for use in a SNF or hospital. Therefore, we decided that 
the Plan does not have to pre-approve the back brace (L0464).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an arthroplasty and occupational therapy 
visit provided on November 16, 2021. 
 
You asked the Plan to waive the copayment for the arthroplasty and occupational therapy visit. You say that the 
services should be covered as you disagree with the charges. The Plan denied your request. The Plan says the 
cost-sharing applied correctly based on the services provided. 
 
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 $30 
copayment for Outpatient rehabilitation services and a $250 copayment for Outpatient surgery, including 
services provided at hospital outpatient facilities and ambulatory surgical centers.  
 
 
  You have been asked to pay a $250 copayment for the arthroplasty and a $30 copayment for an occupational 
therapy visit. Arthroplastys fall within the Outpatient surgery, including services provided at hospital 
outpatient facilities and ambulatory surgical centers 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 arthroplasty and occupational therapy visit provided on November 16, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on January 
20, 2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you have a membership with 
a different local ambulance service that you wanted to transport you, but that's not who the hospital called. You 
also say that a billed amount of $840 is outrageous when you were not being transported far. 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 ambulance services.  
 
 The record shows you received ambulance transportation services on January 20, 2022. You have been asked 
to pay a $225 copayment for ambulance services. Ambulance services falls within the Ambulance 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 ambulance services provided on 
January 20, 2022.  
 
Your complaint about the billing amount and the hospital not calling your preferred ambulance service 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on July 10, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the service was medically necessary. 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 service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the office visit provided on July 10, 2021, by an out-of-network 
(OON) provider.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for ultrasound guidance services provided to the enrollee on October 25, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the code has a status indicator of "A" which means "Bundled Codes." 
 
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 76942 is "Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), 
imaging supervision and interpretation." 
 
The plan is stating that a status indicator of "A" means that the code cannot be paid separately. Actually, a 
status indicator of "A means that the code is active and can be paid separately if covered. It is appropriate to 
report the denied code separately. The plan has not substantiated their denial with appropriate reasoning. Based 
on this information, we decided that Medicare rules for coverage of the services have been met. Therefore, we 
decided that the Plan has to pay for ultrasound guidance services provided to the enrollee on October 25, 2021.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued physical therapy 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 there is no clinical evidence to support the medical necessity of this examination or that 
the enrollee meets Medicare criteria for continued physical therapy services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 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 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that in this case, the enrollee has previously been treated with 
outpatient therapies and should be independent with a home exercise program.  There is no documentation of a 
recent injury or decline in function. The additional therapy services are not an appropriate duration and 
frequency for treatment of the enrollees medical condition and therefore are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued physical therapy services for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the additional routine transportation. 
 
You asked the Plan to pre-approve the additional routine transportation. You say that you need this service. The 
Plan denied your request. The Plan says you have exhausted the Plan benefit for this service. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve the additional routine transportation.