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

 
We decided that the Plan does not have to pay for laboratory services provided on September 14, 2021. 
 
You asked the Plan to pay for laboratory services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on September 5, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on September 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 23, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you rely on the facility to obtain prior authorization for 
services. The Plan denied your request. The Plan says services from a non-participating provider are not 
covered unless preauthorized. 
 
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 provided on March 23, 2022, by an 
out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services (procedure code 97112) provided 
to the enrollee from May 2, 2022, to May 11, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says this code required a modifier. 
 
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 97112 is "Therapeutic procedure, 1 or more areas, each 
15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or 
proprioception for sitting and/or standing activities." 
 
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 that the medical record does not 
include sufficient documentation to confirm therapy and time performed for CPT 97112, and therefore a 
modifier cannot be verified.  
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 physical therapy services (procedure code 97112) provided to the enrollee from May 2, 2022, to 
May 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for specialist visit provided on August 8, 2022. 
 
You asked the Plan to waive the deductible for specialist visit. You say that you are disputing the share cost. 
The Plan denied your request. The Plan says this cost sharing was charged 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 $110.85 
deductible for physician/practitioner services, including doctor's office visits. Your deductible is $750. This is 
the amount you have to pay out-of-pocket before the Plan will pay their share for your covered medical 
services. 
 
You have been asked to pay $110.85 deductible for specialist visit. This item/service falls within the 
physician/practitioner services, including doctor's office visits 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 deductible for specialist visit provided on August 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient visit provided on May 10, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for outpatient visit. You say that the provider performed an emergency surgery, and 
the enrollee was told they could see the provider for post-op visits up to three months after the surgery on 
March 3, 2022. The Plan denied your request. The Plan says the service can be provided by an in-network 
provider. 
 
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 at issue in this case is not a network provider with the Plan. 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 pay for outpatient visit. Our physician reviewer found the requested office visits from an 
out-of-network provider, in this case, is 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 outpatient visit have not been met.  
 
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 pay for outpatient visit. Therefore, we decided that the Plan does 
not have to pay for outpatient visit provided on May 10, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and a panoramic 
radiographic image (D0330) provided on September 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that you provided your insurance card to the front 
office, which no one advised you that it was too soon for you to schedule to have the routine cleaning 
performed. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service November 17, 2020. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and a 
panoramic radiographic image (D0330) provided on September 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient office visit (code 99205) provided on  
February 14, 2022. 
 
You asked the Plan to pay for the new patient office visit. The Plan denied your request. The Plan says a new 
patient procedure code cannot be billed within three years of the claim for date of service December 17, 2021. 
 
The Plan must follow Medicare rules. Medicare rules say that the phrase "new patient" means a patient who has 
not received any professional services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) 
from the physician or physician group practice (same physician specialty) within the previous 3 years. 
 
We looked at the file and Medicare rules. The file shows that a new patient code was billed to the Plan by 
providers in the same medical group and same specialty within the previous 3 years. Based on this information, 
we decided that Medicare rules for coverage of the new patient office visit have not been met. Therefore, we 
decided that the Plan does not have to pay for a new patient office visit (code 99205) provided on 
February 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth services provided on August 30, 2022. 
 
You asked the Plan to pay for the telehealth services. You say that you were unable to obtain authorization due 
to staffing issues. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the telehealth services 
provided on August 30, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for molecular pathology provided on December 16, 2021. 
 
You asked the Plan to pay for molecular pathology. You say that the service was medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for molecular pathology 
provided on December 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation. 
 
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 evidence of mononeuritis or complex regional pain syndrome. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this is considered experimental and investigational therapy. Therefore, the request is deemed not 
medically reasonable and 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 genicular nerve radiofrequency ablation.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for external patient and, when performed, auto activated 
electrocardiographic rhythm derived event recording with symptom-related memory loop with remote 
download capability up to 30 days, 24-hour attended monitoring; recording (includes connection, recording, 
and disconnection) provided to the enrollee on July 14, 2022. 
 
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 there was a more appropriate code for these services. 
 
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 93270 is "External patient and, when performed, auto 
activated electrocardiographic rhythm derived event recording with symptom-related memory loop with remote 
download capability up to 30 days, 24-hour attended monitoring; recording (includes connection, recording, 
and disconnection)." 
 
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 that the enrollee had a previous 
stroke. There is no supportive evidence that the ordering practitioner documented any standard, non-mobile 
cardiac telemetry (MCOT) ambulatory electrocardiogram monitoring. 
 
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 external patient and, when performed, auto activated electrocardiographic rhythm derived event 
recording with symptom-related memory loop with remote download capability up to 30 days, 24-hour 
attended monitoring; recording (includes connection, recording, and disconnection) provided to the enrollee on 
July 14, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Vabysmo (J2777). 
 You asked the Plan to pre-approve Vabysmo. 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 coverage of 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 Vabysmo. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Medicare-approved drug compendia do not limit the use of the requested drug to monotherapy. However, the 
requested drug is a new start. The provided records do not indicate that the enrollee has tried and failed the 
Plan's preferred step-one alternative. The record does not indicate that the enrollee has a contraindication to, or 
would have an adverse effect from, the Plan's preferred step-one alternative. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vabysmo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Vabysmo (J2777).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the parenteral nutrition administration (B4224), parenteral 
nutrition solution (codes B4185 and B4197) provided from April 8, 2022, to April 14, 2022. 
 
You asked the Plan to pay for the services. You say that this is the most appropriate and safest option for the 
enrollee. The Plan denied your request. The Plan says the records do not show a serum albumin less than 3.2, 
problems with the enrollee's stomach and unable to tolerate eating nor an involuntary weight loss. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee does not have a malabsorption problem and is not a candidate for tube feeds. It is not 
documented that the enrollee has tried regular enteral nutrition as she is currently eating by mouth. Although the patient has a permanent kidney impairment related to her poor appetite, the poor appetite itself does not 
appear to be fully treated with less invasive support. Also, the records do not show a serum albumin less than 
3.2, problems with the enrollee's stomach and unable to tolerate eating nor an involuntary weight loss. 
Therefore, the parenteral nutrition will be considered 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 pay for the parenteral nutrition administration (B4224), parenteral nutrition solution (codes B4185 and 
B4197) provided from April 8, 2022, to April 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on May 20, 2022. 
 
You asked the Plan to pay for a nursing facility visit. You say that we depend on the facility staff to verify 
eligibility and to obtain authorization. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a nursing facility visit 
provided on May 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on May 26, 2022. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available and requires authorization for certain 
services. No medical necessity for an out-of-network provider such as an urgent or an emergent situation that 
has been documented.   
 
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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on May 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility visit provided on May 16, 2022. 
 
You asked the Plan to pay for nursing facility visit. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for nursing facility visit 
provided on May 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on May 11, 2022. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit provided on 
May 11, 2022.