Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit (99336) provided on 
November 18, 2021, by an out-of-network provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the medically necessary services at 
issue were provided to the enrollee in good faith. The Plan denied your request. The Plan says rules for 
payment for out-of-network care have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a domiciliary or rest home visit (99336) provided 
on November 18, 2021, by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 21, 2021. 
 
You asked the Plan to pay for the laboratory services. 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 lab services, the POS code must reflect the 
location in which the sample was taken. 
 
We looked at the file and Medicare rules. Review of the file shows the claim was billed with an inappropriate 
place of service 11. According to claims history, the specimen was obtained in a Community Mental Health 
Center. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on 
September 21, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says you do not meet Medicare criteria for coverage of SNF 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there is no documentation that you require the 
services in an inpatient skilled nursing facility setting. A lower level of care appears to be appropriate for your 
condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs, Prolia, provided 
on September 23, 2021. 
 
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that the cost of Prolia is too 
expensive. The Plan denied your request. The Plan says the coinsurance amount charged is 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 20% 
coinsurance for drugs covered under Medicare Part B. 
 
 
 
 You have been asked to pay $363.86, which is 20% of the Plans allowed amount ($1,819.31), for Medicare 
Part B drugs. Medicare Part B drugs 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 Medicare Part B drugs, Prolia, provided on September 23, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99202) provided February 15, 2021. 
 You asked the Plan to pay for an office visit. You say that the services provided were medically necessary. The 
Plan denied your request. The Plan says there is no established relationship between the ordering physician and 
the enrollee. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare rules for explanation of decision: 
unless provided otherwise, other services included on the Medicare telehealth services list must be furnished 
using, at a minimum, audio and video equipment permitting two-way, real-time interactive communication 
between the patient and distant site physician or practitioner. 
 
We looked at the file and Medicare rules. Specifically, the documentation does not clearly indicate that the 
service was furnished using audio and video equipment permitting two-way, real-time interactive 
communication between the patient and distant site physician or practitioner. CPT code 99202 is not included 
on the list of codes which are appropriate for audio-only telehealth services. The documentation does not 
clearly show if this service was furnished using audio-only or audio-video communication. Therefore, we 
decided that the Plan does not have to pay for an office visit (99202) provided February 15, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on July 7, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has provided insufficient information to determine if the denial of 
payment meets Medicare criteria. The case file does not contain any valid reason for the denial of payment of 
these services. It is the Plan's responsibility to provide evidence to support their reasons to deny payment. 
Therefore, we decided that the Plan has to pay for the laboratory services provided on July 7, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 10, 2021. 
 
You asked the Plan to pay for the laboratory services. 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 lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on June 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a total knee arthroplasty performed from 
November 2, 2021, to November 3, 2021. 
 
You asked the Plan to waive the coinsurance for the knee arthroplasty. You say that you feel you should have 
the inpatient copayment instead of the coinsurance. The Plan denied your request. The Plan says the correct 
coinsurance was applied. 
 
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 20% 
coinsurance per visit for outpatient surgery.  
 
You have been asked to pay $2,291.97, which is 20% of the allowed amount for the knee arthroplasty 
($11,459.87 allowed amount x 20% coinsurance = $2,291.97). Please note that in order to be considered an inpatient, your doctor must have a written order. The file does not show that this order was made, therefore you 
are still considered an outpatient. The knee arthroplasty 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 coinsurance for a total knee arthroplasty performed from November 2, 2021, to 
November 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99202) provided February 2, 2021. 
 You asked the Plan to pay for an office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says there is no established relationship with the ordering provider. 
 
The Plan must follow Medicare rules. Medicare rules say that unless provided otherwise, other services 
included on the Medicare telehealth services list must be furnished using, at a minimum, audio and video 
equipment permitting two-way, real-time interactive communication between the patient and distant site 
physician or practitioner. 
 
Specifically, the documentation does not clearly indicate that the service was furnished using audio and video 
equipment permitting two-way, real-time interactive communication between the patient and distant site 
physician or practitioner. CPT code 99202 is not included on the list of codes which are appropriate for audio-
only telehealth services. The documentation does not clearly show if this service was furnished using audio-
only or audio-video communication. Therefore, we decided that the Plan does not have to pay for an office visit 
(99202) provided February 2, 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 services are medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for 
coverage of the LTACH services. 
 
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 the enrollee continues to receive acute care services and these have not been 
denied. The medical record does not indicate that the enrollee requires services that he is not currently 
receiving but that would be available at the LTACH 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 15, 2021. 
 
You asked the Plan to pay for the laboratory services. 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. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services provided on January 15, 2021.
Appeal type: Step-Therapy
Decision: Favorable

 
We decided that the Plan has to pre-approve Eyelea. 
 
You asked the Plan to pre-approve Eyelea. You say that Eyelea is medically necessary. The Plan denied your 
request. The Plan says that there is a Plan preferred drug that must be tried first. 
 
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 Eyelea. Our reviewer says that the 
enrollee was treated with Avastin (Bevacizumab) in 2018. Our physician reviewer found the enrollee tried and 
failed the Plan preferred 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 Eyelea have been met. Therefore, we decided that the Plan has to pre-approve 
Eyelea.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Skyrizi. 
 
You asked the Plan to pre-approve Skyrizi. You say that Skyrizi is medically necessary. The Plan denied your 
request. The Plan says Skyrizi is not covered by the Plan. 
 
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 Skyrizi.  
 
Benefits for Skyrizi 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the DME provided on June 16, 2021. 
 
You asked the Plan to waive the coinsurance for the durable medical equipment. You say that it is not fair to 
you that you must pay for this when it is needed. The Plan denied your request. The Plan says the coinsurance 
applied is 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 20% 
coinsurance for all other Medicare-covered prosthetic devices and supplies.  
 
 
 You have been asked to pay 20% coinsurance for the breast prosthesis and mastectomy brassiere. The breast 
prosthesis and mastectomy brassiere fall within the Prosthetic devices and related 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 coinsurance for the DME provided on June 16, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from May 16, 2020 to June 
14, 2020. 
 You asked the Plan to pay for home health services. You say that the services were 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 pay for home health services. Our reviewer says that 
the services were not medically necessary. Our physician reviewer found the documentation does not support 
that skilled nursing or skilled therapy services were required during the time frame in question. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pay for home health services provided from May 16, 2020 to June 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for hospital outpatient surgery provided on 
October 7, 2021. 
 
You asked the Plan to waive the copayment for hospital outpatient surgery. You say that the Plan should pay 
your bill. The Plan denied your request. The Plan says the copayment amount charged is 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 $325 
copayment for surgical services provided in an outpatient hospital facility.  
 
You have been asked to pay a $325 copayment for hospital outpatient surgery. Hospital outpatient surgery 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 hospital outpatient 
surgery provided on October 7, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on 
December 1, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that the services should be covered in full 
since you left the emergency room. The Plan denied your request. The Plan says the cost-sharing applied 
correctly and the records indicate that you were triaged by a nurse practitioner and x-rays were ordered before 
you eloped from the ER. 
 
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 $120 
copayment for Emergency care.  
 
 
  You have been asked to pay a $120 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 provided on December 1, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Gelsyn-3 injection provided on July 1, 2021. 
 
You asked the Plan to pay for the Gelsyn-3 injection. You say that the attached documentation supports the 
denied J7328 charge. You say that the documents should be reviewed, and the claim reprocessed for payment. 
The Plan denied your request. The Plan says OrthoVisc, SynVisc, and/or SynVisc-One are the preferred drugs 
of choice for this condition. The Plan also says the use of Genvisc-3 would be appropriate only if OrthoVisc, 
SynVisc, and/or SynVisc-One specifically has been tried and failed or if he was unable to tolerate the preferred 
drugs. 
 
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 the Gelsyn-3 injection. Our reviewer 
says that the enrollee has not tried and failed the required drugs. Our physician reviewer found that the medical 
records provided do not indicate that the Plan's required drugs would likely be less effective and/or likely have 
adverse effects for the enrollee. 
 
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 Gelsyn-3 injection have not been met. Therefore, we decided that the Plan 
does not have to pay for the Gelsyn-3 injection provided on July 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro orthotic device(L8702) 
 
You asked the Plan to pre-approve the orthotic device. You say that the enrollee has been referred by his family 
practice physician for myoelectric orthotic restoration. The Plan denied your request. The Plan says MyoPro is 
considered investigational due to lack of clinical evidence demonstrating an impact on improved health 
outcomes. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the MyoPro orthotic device(L8702)