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

 
We decided that the Plan does not have to pre-approve Livalo. 
 
You asked the Plan to pre-approve Livalo. The Plan denied your request. The Plan says this drug is not eligible 
for coverage under the Part B benefit. 
 
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 Livalo.  
 
 
 Benefits for Livalo may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy treatment provided on 
October 7, 2021. 
 
You asked the Plan to waive the coinsurance for chemotherapy treatment. You say that your treatments should 
be covered. The Plan denied your request. The Plan says the coinsurance was applied correctly. The allowed 
amount totals $4,604.16, resulting in coinsurance of $920.83.  
 
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 20% 
coinsurance for Medicare-covered Part B Chemotherapy drugs and other Part B drugs. 
 
You have been asked to pay a total of $920.83 for chemotherapy treatment. Chemotherapy treatment falls 
within the Medicare Part B prescription drugs 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 
coinsurance for chemotherapy treatment provided on October 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99232) provided on January 1, 
2021. 
 
You asked the Plan to pay for code 99232. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered 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. In this case, we have confirmed that code 99232 
is a column II code to column I code 99221 with a modifier indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for the subsequent hospital care (99232) provided on January 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan (71250) 
provided on December 21, 2021. 
 
You asked the Plan to waive the copayment for the CT scan. 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 $180 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 You have been asked to pay a $110.68 copayment for a CT scan, which is less than the standard $180. CT 
scans fall within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for a computed tomography (CT) scan (71250) provided on 
December 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) and the scanning computerized 
ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral (92133) 
rendered by the out-of-network (OON) provider on December 23, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. 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 the office visit (99213) and the scanning computerized ophthalmic diagnostic 
imaging, posterior segment, with interpretation and report, unilateral or bilateral (92133) rendered by the out-
of-network (OON) provider on December 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the injection, of a diagnostic or therapeutic 
substance (62323) rendered by the out-of-network (OON) provider on January 10, 2022. 
 
You asked the Plan to issue reimbursement. 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 issue reimbursement for the injection, of a diagnostic or therapeutic substance (62323) 
rendered by the out-of-network (OON) provider on January 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services (G0480, 80307, 83789) rendered by 
the out-of-network (OON) provider on January 6, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. 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 the drug testing services (G0480, 80307, 83789) rendered by the out-of-network 
(OON) provider on January 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit services (99204) provided on April 12, 2021 
(claim number 33217811-00). 
 
You asked the Plan to pay for code 99204. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the records submitted do not indicate that two separate 
services were performed on April 12, 2021. The Plan paid one claim for code 99204 for this provider and this 
date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. In this case, there were no medical records provided confirming that 
two separate office visits (99204) were provided April 12, 2021, by this provider. The file shows that the Plan 
paid for one claim submitted with code 99204 by this provider. Therefore, we decided that the Plan does not 
have to pay for the office visit services (99204) provided on April 12, 2021 (claim number 33217811-00).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional routine transportation trips. 
 
You asked the Plan to provide additional transportation. You say that this transportation is necessary, and you 
need more trips this year. The Plan denied your request. The Plan says you have exhausted your supplemental 
benefit, which covers 40 trips per year. Additional trips are not a covered benefit. 
 
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 40 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 provide additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional supplies, materials, and clinical staff time 
(99072) provided on October 21, 2021. 
 
You asked the Plan to pay for the additional supplies, materials, and clinical staff time (99072). You say that 
the Plan has failed to satisfy their payment obligations and 30% payment from the billed charges is expected. 
The Plan denied your request. The Plan says CPT code 99350 has been paid and CPT code 99072 remains 
denied as bundled services are not eligible for separate reimbursement.  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 99072 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99072 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the additional supplies, materials, and clinical staff time (99072) have not been met. Therefore, we decided 
that the Plan does not have to pay for the additional supplies, materials, and clinical staff time (99072) provided 
on October 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH is the most appropriate level 
of care because his needs are too complex for skilled nursing care. The Plan denied your request. The Plan says 
authorization because the LTACH is medically necessary, and the enrollee's needs can be met at a lower level 
of care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The health plan has approved ongoing care 
in the current acute care facility. 
 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that SNF services are medically necessary. The Plan 
denied your request. The Plan says the member does not meet CMS Guidelines, Chapter 8, Section 30 for 
Skilled Nursing. The member's needs can be met at lower level of care. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that 
daily skilled services are not medically necessary. Our physician reviewer found that based on the medical 
records provided there is no documentation that you require skilled nursing services, i.e., the specialized skill, 
knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide 
medically necessary and reasonable treatment. The medical records do not document the need for intravenous 
medications, new tube feeding, or ostomy care or daily complex wound care. You do require skilled therapy 
services. There is no documentation that daily skilled services are required. You are walking household 
distances with a single point cane with contact guard assistance and is contact guard assist for transfers. The 
provided records do not document a significant decline in your functional status to necessitate daily inpatient 
skilled therapy services. As a practical matter, there is no documentation that you require the services on an 
inpatient basis, only in a skilled nursing facility setting. The medical records do not document that the services 
in the home with home health care or in a long-term care facility on a part time basis are not appropriate in this 
case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SNF services.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport (A0428) and ground mileage (A0425) provided on January 11, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the enrollee keeps receiving a bill. You 
also say that the enrollee should not have to pay this bill. The Plan denied your request. The Plan says the 
enrollees claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits 
starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it 
is the providers responsibility to verify the enrollees coverage before rendering services and to know proper 
billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport (A0428) and ground mileage (A0425) provided on January 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services (99212, 93000, and 93308) provided 
on January 13, 2022, by a provider who has opted out of the Medicare program. 
 
You asked the Plan to pay for the outpatient services provided by a provider who has opted out of the Medicare 
program. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your 
request. The Plan says services are not covered when provided by a provider who has opted out of the 
Medicare program. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
outpatient services (99212, 93000, and 93308) provided on January 13, 2022, by a provider who has opted out 
of the Medicare program.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Computed tomography (CT) scan (70450) provided on 
October 12, 2021. 
 
You asked the Plan to pay for code 70450. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered 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. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the Computed tomography (CT) scan (70450) provided on 
October 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous image-guided lumbar decompression 
(PILD or the MILD procedure). 
 
You asked the Plan to pre-approve MILD procedure. You say that this is covered by Medicare through 
Coverage with Evidence Development (CED) and the enrollee is an excellent candidate. The Plan denied your 
request. The Plan says the denial of authorization for this service is correct, because studies have not proven 
that this is helpful for the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare covers the MILD procedure through 
CED for beneficiaries with lumbar spinal stenosis who are enrolled in an approved clinical study.  
 
We looked at the file and Medicare rules. You have requested enrollment in trial NCT03072927, which is a 
Medicare-approved CED study; however, this study is not currently recruiting new participants. Therefore, the 
enrollee cannot receive coverage for the MILD procedure through this CED study at this time. Based on this 
information, we decided that Medicare rules for coverage of MILD procedure have not been met. Therefore, 
we decided that the Plan does not have to pre-approve percutaneous image-guided lumbar decompression 
(PILD or the MILD procedure).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the psychotherapy (90832) provided on 
November 4, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service 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 $60 
copayment for each out-of-network Medicare-covered individual or group therapy visit for outpatient mental 
health care.   
 You have been asked to pay a $60 copayment for the Medicare-covered individual therapy visit rendered by an 
out-of-network provider. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for the psychotherapy (90832) 
provided on November 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sales tax charged for the COVID-19 home test you 
purchased on January 1, 2022. 
 
You asked the Plan to pay for the sales tax. You say that you were told this would be covered. The Plan denied 
your request. The Plan says it has paid for the COVID-19 test itself, but the sales tax is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that no payment is ever made for sales tax. Therefore, 
we decided that the Plan does not have to pay for the sales tax charged for the COVID-19 home test you 
purchased on January 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the criteria for coverage are not met. 
 
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 you do not treat with insulin three 
or more times per day or use an insulin pump. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a Freestyle Libre 2 continuous glucose monitor (CGM).