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

 
We decided that the Plan does not have to pay for drug testing provided on February 17, 2022, to March 23, 
2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for drug testing. You say that you would like to request reconsideration of the denied 
claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was determined these 
services can be received in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for drug testing provided on February 17, 2022, to 
March 23, 2022 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 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 Prolia. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has age related osteoporosis without osteoporotic fracture.  The requested medication is a 
new start. The provided records do not indicate that the enrollee has had a a history of osteoporosis-related 
fracture or has tried and failed zoledronic acid. The documentation does not support that the enrollee has a 
contraindication to, or would have an adverse effect to zoledronic acid. 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation provided on February 24, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a psychiatric diagnostic evaluation. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-
network, and it was determined these services can be received in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a psychiatric diagnostic evaluation provided on 
February 24, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dermatology evaluation and management service 
services to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve dermatology evaluation and management service services. You say that you 
would like to request reconsideration of the denied claim. The Plan denied your request. The Plan says the 
provider is out-of-network, and it was determined these services can be received in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. 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 pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
dermatology evaluation and management service services to be provided by an out-of-network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gastrointestinal tract imaging (wireless capsule 
endoscopy). 
 
You asked the Plan to pre-approve gastrointestinal tract imaging. You say that you really need this test done so 
they can see where the rupture is coming from and treat it accordingly. The Plan denied your request. The Plan 
says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that wireless capsule endoscopy is only covered for 
certain indications.  
 
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 gastrointestinal tract imaging. Our 
reviewer says that the documentation does not support that the requested services are medically reasonable or 
necessary. Our physician reviewer found the documentation supports gastrointestinal (GI) bleeding in October 
2021 and recurrent anemia in June 2022. The evaluation has been limited to esophagogastroduodenoscopy 
(EGD) and sigmoidoscopy in October 2021. No recent colonoscopy has been performed nor documented. This 
is required per LCD prior to coverage of a wireless capsule endoscopy for your indication of "GI bleeding." 
Therefore, you do not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of gastrointestinal tract imaging have not been met. Therefore, we decided that the 
Plan does not have to pre-approve gastrointestinal tract imaging (wireless capsule endoscopy).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient eye surgery provided on 
February 9, 2022. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you should not have a 
copayment for this service. The Plan denied your request. The Plan says the copayment applied was correct. 
 
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 $375 
copayment for outpatient surgery.  
 
You have been asked to pay a $375 copayment for an outpatient surgery at an outpatient hospital facility. An 
outpatient surgery at an outpatient hospital facility falls 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 outpatient eye surgery provided on February 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve the total electric hospital bed. You say that the hospital bed is medically 
necessary. The Plan denied your request. The Plan says this type of bed is not covered under Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0265).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital outpatient visit provided on March 21, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for a hospital outpatient visit. You say that you would like to request reconsideration 
of the denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a hospital outpatient visit provided on March 21, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient office visit provided on March 9, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for an outpatient office visit. You say that you would like to request reconsideration 
for payment. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services were not urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an outpatient office visit provided on March 9, 
2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
January 23, 2022, to January 26, 2022. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you were there for a bowel 
blockage which was resolved. 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 $280 per 
day for days 1-5 and $0 per day for days 6-90 for each inpatient admission.  
 
The file shows that you were in the hospital from January 23, 2022, to January 26, 2022, but there is no 
copayment for the discharge date. Therefore, you have been asked to pay $280 per day for the first 3 days of 
inpatient care. The total for your stay is $840 ($280 copayment x 3 days = $840). The inpatient care falls within 
the Inpatient Hospital Care 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 inpatient 
hospital care provided from January 23, 2022, to January 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 31, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services were not urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on January 31, 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 the eye refraction provided on February 10, 2022. 
 
You asked the Plan to pay for the eye refraction. You say that you need a refund for the refraction that is 
covered under your insurance plan. The Plan denied your request. The Plan says this service is not a covered 
benefit since it was performed with a medical diagnosis.  
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 covers eye refractions during a routine exam. 
 
We looked at the file and the Plan's rules. Specifically, the record shows that during this appointment, you were 
seen for the diagnosis of Age-related nuclear cataract, bilateral. Based on this information, we decided that the 
Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not 
have to pay for the eye refraction provided on February 10, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transportation services (A0427, A0425) provided 
on January 6, 2022. 
 
You asked the Plan to pay for ambulance services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says the enrollee had another insurance plan as their primary insurer at the 
time of services. An explanation of benefits must be received from the primary insurer before the Plan will 
make payment. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to bill the primary insurer. As the secondary insurer, the Plan cannot be held responsible for 
ambulance services until the primary insurer has denied the claim for these services. Therefore, we decided that 
the Plan does not have to pay for ambulance transportation services (A0427, A0425) provided on January 6, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vertebroplasty (22514). 
 
You asked the Plan to pre-approve the vertebroplasty. You say that this procedure is medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Percutaneous Vertebral Augmentation is covered for 
Acute (less than 6 weeks) or subacute (6 to 12 weeks) osteoporotic vertebral compression fracture (T1  L5), 
confirmed by recent (within 30 days) advanced imaging (bone marrow edema on MRI or bone scan/SPECT/CT 
uptake). 
 
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 vertebroplasty. Our reviewer says 
that this procedure is not medically necessary. Our physician reviewer found there is limited published, large-
scale, long-term peer-reviewed literature that shows this request to be an effective or safe treatment for the 
noted pathology. There are no detailed records of trial and failure of conservative treatments. 
 
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 vertebroplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a vertebroplasty (22514).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient visit provided on August 25, 2021. 
 
You asked the Plan to pay for an outpatient visit. The Plan denied your request. The Plan says 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 Plan says that the Plan has 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 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 an outpatient visit provided on August 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional office visits (99203, 99213) to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve additional office visits. You say that the enrollee has been seeing the 
requested provider under a previous insurance. The enrollee was told she could still be able to see the provider. 
The Plan denied your request. The Plan says the enrollee must use network providers to get medical care and 
services when there are network providers available. The Plan also says the in-network providers were 
contacted and can provide the requested service. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. 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 pre-approve these items/services. Please note, the records show the Plan approved 3 office visits 
with the OON provider to give you time to obtain a provider that is in-network. Therefore, we decided that the 
Plan does not have to pre-approve additional office visits (99203, 99213) to be provided by an out-of-network 
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair accessory, pneumatic propulsion 
tire (E2211). 
 
You asked the Plan to pre-approve a pneumatic propulsion tire. You say that you are in need of the requested 
power wheelchair with multiple power options. The Plan denied your request. The Plan says the requested 
wheelchair accessory is part of all manual wheelchair bases which you have been approved for. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a pneumatic propulsion tire have not been met. Specifically, the requested item is not covered by 
the plan separately. Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair 
accessory, pneumatic propulsion tire (E2211).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 92134 billed for date of service February 14, 2022. 
 
You asked the Plan to pay for procedure code 92134. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says payment for code 92134 is bundled into 
payment for code 92133. 
 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 92134 
is a column II code to column I code 92133 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 procedure code 92134 billed for date of service February 14, 2022.