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

 
We decided that the Plan does not have to pre-approve Palonosetron. 
 
You asked the Plan to pre-approve Palonosetron. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Palonosetron. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found Palonosetron is indicated for 
chemotherapy regimens with moderate to high emetogenic potential. This enrollee is going to receive 
gemcitabine/abraxane, which has a low emetogenic potential. The service is not reasonable or 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 Palonosetron have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Palonosetron.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit (ER) (99281) 
provided on December 6, 2021. 
 
You asked the Plan to waive the copayment for the ER 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 $90 
copayment for Emergency care.  
 
 
  You have been asked to pay a $90 copayment for the ER visit. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for an emergency room visit (ER) (99281) provided on December 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 15, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided 
that the Plan does not have to pay for the laboratory services rendered on June 15, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99212) rendered by the out-of-network 
(OON) provider on December 15, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this 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 pay for the office visit (99212) rendered by the out-of-network (OON) provider on  
December 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on June 24, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for drug testing. You say that you are appealing this denial and submitted supporting 
documents that support the medical necessity of the services billed in the claim. The Plan denied your request. 
The Plan says the services performed by the non-participating laboratory were not authorized by the Plan. The 
Plan also says that the member was referred by a non-participating provider for services. The provider that 
performed these services is not within the Plan 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 June 24, 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 office visit rendered on January 6, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that evaluation and management services provided on 
the same day as a surgical procedure must be billed with modifier -57. 
 
We looked at the file and Medicare rules. The file shows that the services were performed on the same day as a 
surgical procedure and were not billed with the required modifier -57. Therefore, we decided that the Plan does 
not have to pay for the office visit rendered on January 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 15, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the testing is not covered. 
 
The Plan must follow Medicare rules. The rules say that MolDX will reimburse approved tests covered for 
dates of service consistent with the effective date of the coverage determination. 
 
We looked at the file and Medicare rules. The file shows that the testing at issue was not approved through the 
MolDx program for the date of service at issue. Therefore, we decided that the Plan does not have to pay for 
the laboratory services rendered on July 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network oncologist. 
 
You asked the Plan to pre-approve these services. You say that you do not want to change doctors. The Plan 
denied your request. The Plan says the services are available from network providers. 
 
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 
a referral to an out-of-network oncologist.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit, and chronic care 
management services provided on November 15, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit, and chronic care management services. You say 
that this provider was not responsible to obtain authorization, and the assisted living facility is responsible to 
obtain prior authorization for all of their patients. The Plan denied your request. The Plan says this provider is 
out-of-network with the Plan, and authorization was not obtained prior to the services being rendered. 
 
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, and chronic care 
management services provided on November 15, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (88305, 88312) rendered by the out-
of-network (OON) provider on December 14, 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 laboratory services (88305, 88312) rendered by the out-of-network (OON) 
provider on December 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services provided on December 10, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for ophthalmological services. You say that this provider does not know which 
patients he will be seeing since he is assigned to a facility and given a chart of patients in need of his services. 
You also say that a provider  performing services in a nursing home facility is not responsible to obtain 
authorization, and their visit should fall under the authorization that the nursing home has for the stay of the 
patient. The Plan denied your request. The Plan says this provider is out-of-network with the Plan, and 
authorization was not obtained prior to services being rendered. 
 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 ophthalmological services provided on December 
10, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the x-ray provided by a participating 
specialist on December 8, 2021. 
 
You asked the Plan to waive the copayment for the x-ray. You say that this was a follow-up visit for a broken 
collarbone to check its healing. You say the Plan should pay this portion of the bill. The Plan denied your 
request. The Plan says you have been asked to pay 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 $35 
copayment for x-rays at an in-network specialist's office. For this date of service, you have been asked to pay 
the allowed amount of the claim because this amount is less than the standard $35 copayment for the x-ray. 
 
 You have been asked to pay a $29.58 copayment for the x-ray. The x-ray falls within the Outpatient 
diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for the x-ray provided by a participating specialist on December 8, 2021.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that the Centers for Medicare & Medicaid Services 
(CMS) National Coverage Determinations Manual (CMS Pub. 100-03) in Chapter 1, Part 4, Section 280.1 
stipulates that ventilators (E0465, E0466, and E0467) are covered when specific criteria are met. 
 
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 a portable ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. This enrollee has a diagnosis of chronic obstructive pulmonary disease (COPD) (no pulmonary 
function test results), admitted with exacerbation and pneumonia. Improved with bilevel positive airway 
pressure (bipap) with average volume-assured pressure support (AVAPS) in hospital, although apparently 
bipap was stopped in hospital prior to discharge. Partial pressure of carbon dioxide (PaCO2) remained elevated 
prior to discharge. The enrollee is on chronic opioids, and this is likely contributing to chronic hypoventilation. 
The enrollee may benefit from bipap during sleep in the AVAPS mode. But Medicare does not cover a home 
ventilator when used as bipap. There is no documentation of bipap failure in the home setting while the 
enrollee is stable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for arthrodesis procedure (28750) provided on 
January 10, 2022. 
 
You asked the Plan to waive the deductible for the arthrodesis procedure. 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. Your 
contract with the Plan says that there is a $750 deductible which applies to Outpatient hospital services.  
 
 
  The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
hospital services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 
deductible which applies to Outpatient hospital services. This cost sharing is a contractual obligation that had 
not been met at the time the arthrodesis procedure was received on January 10, 2022. Therefore, we decided 
that the Plan does not have to waive the deductible for arthrodesis procedure (28750) provided on January 10, 
2022.  
 
Since the deductible was met, you have also been asked to pay a $125 copayment for the surgery. 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 cost share for the surgery provided on January 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the destruction by neurolytic agent, of the paravertebral facet 
joint nerve(s), with imaging guidance; lumbar or sacral, single facet joint (64635), the destruction by neurolytic 
agent, of the paravertebral facet joint nerve(s), with imaging guidance; lumbar or sacral, each additional facet 
joint (64636), the propofol injection (J2704), surgical supplies (A4649), and the surgical trays (A4649) 
rendered by the out-of-network (OON) provider on October 26, 2021. 
 
You asked the Plan to pay for these items/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 items/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 items/services at issue in this appeal. The Plan did not pre-approve the 
items/services 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 destruction by neurolytic agent, of the 
paravertebral facet joint nerve(s), with imaging guidance; lumbar or sacral, single facet joint (64635), the 
destruction by neurolytic agent, of the paravertebral facet joint nerve(s), with imaging guidance; lumbar or 
sacral, each additional facet joint (64636), the propofol injection (J2704), surgical supplies (A4649), and the 
surgical trays (A4649) rendered by the out-of-network (OON) provider on October 26, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 5 home health physical therapy and 5 home health 
skilled nursing visit. 
 
You asked the Plan to pre-approve 5 home health physical therapy and 5 home health skilled nursing visit. You 
say that the services are necessary. The Plan denied your request. The Plan says based on the documentation 
provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 
 
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 5 home health physical therapy and 5 
home health skilled nursing visit. Our reviewer says that the services are not medically necessary. Our 
physician reviewer found the documentation does not support the need for home health nursing, or physical 
therapy and the additional visits are not medically necessary for coverage. The enrollee has improved with 
skilled therapy. At this point, the enrollee does not need home health nursing or skilled therapist's intervention 
with additional visits. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 5 home health physical therapy and 5 home health skilled nursing visit have not 
been met. Therefore, we decided that the Plan does not have to pre-approve 5 home health physical therapy and 
5 home health skilled nursing visit.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a podiatry visit provided on December 31, 
2021. 
 
You asked the Plan to waive the copayment for the podiatry 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 $50 
copayment for Podiatry services.  
 
 
  You have been asked to pay a $50 copayment for a podiatry visit. This means that you have been asked to pay 
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for a podiatry visit provided on December 31, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 6, 2021 by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for lab services. You say that these services were referred 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 lab services provided on July 6, 2021 by an out-of-
network (OON) provider.