Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID testing provided on December 27, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON COVID testing. You say that you feel that this should be covered as it 
was medically necessary. The Plan denied your request. The Plan says this service was provided OON in a 
non-emergency situation and was not authorized. 
 
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 the COVID testing 
provided on December 27, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc injections. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee reports significant relief 
after the last injections. The Plan denied your request. The Plan says six months have not elapsed as required. 
 
The Plan must follow Medicare rules. Medicare rules say that knee injections of Hyaluronan are only covered 
under certain medical indications.  
 
We looked at the file, and Medicare rules. The records show that the enrollee received bilateral injections in 
April 2022. Based on this information, we decided that Medicare rules for coverage of the requested services 
have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc injections.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the outpatient clinic visit, and lab services provided on October 19, 
2021. 
 
You asked the Plan to pay for the services provided. You say that the enrollee had 2 different visits by 2 
different doctors. The Plan denied your request. The Plan says that the claim is a duplicate. 
 
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 the services at issue were billed correctly. The 2 visits the enrollee received were provided by 
physicians in different specialties. Based on this information, we decided that Medicare rules for coverage of 
the services provided have been met. Therefore, we decided that the Plan has to pay for the outpatient clinic 
visit, and lab services provided on October 19, 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: 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 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 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. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
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 drug testing provided on February 22, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the drug testing. You say that the services were medically necessary. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
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 
drug testing. We found no exception that would require the Plan to pay for the drug testing. The records 
provided for review do not show that the drug testing at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for drug testing provided on February 22, 2022, by an 
out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services you received from a 
Licensed Professional Counselor (LPC) on March 11, 2022. 
 
You asked the Plan to pay for the LPC services. You say that you were told these services were covered. The 
Plan denied your request. The Plan says the provider from whom you received these services is not a valid 
provider type. 
 
The Plan must follow Medicare rules. Medicare rules say that the only provider types who are eligible to 
furnish outpatient mental health services to Medicare patients are as follows: physicians, clinical psychologists, 
clinical social workers, clinical nurse specialists, nurse practitioners, physician assistants, certified nurse-
midwives, independently practicing psychologists, and certified registered nurse anesthetists. You received the 
services in dispute from a LPC. LPCs are not valid provider types eligible for Medicare coverage. Therefore, 
we decided that the Plan does not have to pay for outpatient mental health services you received from a 
Licensed Professional Counselor (LPC) on March 11, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve Injectafer. 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. 
 
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 Injectafer. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found in this case, the enrollee has not tried and 
failed the required drug(s). There is no documentation provided indicating that the plans required drug(s) 
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 Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for an office visit provided by an opted-out physician on September 9, 
2021. 
 
You asked the Plan to pay for office visit. You say that your medical need was urgent and the Evidence of 
Coverage states that the Plan may cover a provider that does not participate with Medicare. The Plan denied 
your request. The Plan says that the denial of payment for this service is correct, because this provider does not 
participate in the Medicare program and is not payable. 
 
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. Medicare rules say that Medicare plans may not pay for services given by a physician or other 
practitioner who has opted out of Medicare. The rules also say that a Medicare plan must pay for emergency or 
urgently needed services given by a physician or practitioner who has not signed a private contract with the 
enrollee. 
 
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 did not submit any medical records for review, nor did the Plan submit 
documentation of any attempts to obtain medical records. You say that your medical needs were urgent in 
nature. This provider has opted out of Medicare. Medicare does not typically cover services furnished by an 
opted-out physician; however, this rule does not apply to emergency or urgent care services. Without medical 
records, we cannot determine whether your medical needs constituted urgent care in accordance with your 
appeal request. Therefore, the Plan has not shown that its decision to deny payment for this service is medically justified or correct according to Medicare rules and your contract with the Plan. Therefore, we decided that the 
Plan has to pay for an office visit provided by an opted-out physician on September 9, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation with medical services 
provided on December 16, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation with medical services. You say that the 
nursing facility failed to obtain the prior authorization which should have covered the medical treatments. You 
say the treatment was medically necessary. The Plan denied your request. The Plan says no prior authorization 
was obtained. 
 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 
psychiatric diagnostic evaluation with medical services. We found no exception that would require the Plan to 
pay for the psychiatric diagnostic evaluation with medical services. The records provided for review do not 
show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay 
for the psychiatric diagnostic evaluation with medical services provided on December 16, 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, arthrocentesis, and Part B drug provided on 
February 23, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit, arthrocentesis, and the Part B drug. You say that the provider is 
in-network and prior authorization is not necessary. The Plan denied your request. The Plan says no prior 
authorization was obtained. 
 
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 
office visit, arthrocentesis, and the Part B drug. We found no exception that would require the Plan to pay for 
the office visit, arthrocentesis, and the Part B drug. The record shows the rendering provider was out-of-
network. Therefore, we decided that the Plan does not have to pay for the office visit, arthrocentesis, and Part B 
drug provided on February 23, 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 periodic oral evaluation - established patient (D0120) and 
prophylaxis - adult (D1110) provided February 15, 2022, and the extraction, erupted tooth or exposed root 
(elevation and/or forceps removal) (D7140) provided March 1, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the periodic oral exam, dental cleaning and tooth extraction. You say that this 
provider was in-network in 2021. The Plan denied your request. The Plan says these services processed 
correctly according to your OON benefits. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the periodic 
oral exam and dental cleaning with a $15 copayment and the tooth extraction with 55% coinsurance when 
provided out-of-network. Additionally, you are responsible for the difference between the Plans allowed 
amount and the dentists total charge. 
 
We looked at the file and Medicare rules. In this case you have been asked to pay a $15 copayment plus the 
difference between the allowed amount and the dentists total charge for the periodic oral exam and dental 
cleaning. You have also been asked to pay 55% of the allowed amount plus the difference between the allowed 
amount and the dentists total charge for the extraction. This means you have been asked to pay the correct 
amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to pay for the 
periodic oral evaluation - established patient (D0120) and prophylaxis - adult (D1110) provided February 15, 
2022, and the extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) provided 
March 1, 2022, 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 portable ventilator (Life2000 System). 
 
You asked the Plan to pre-approve a portable ventilator. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 documentation does not support that the requested item is medically reasonable or necessary. Our 
physician reviewer found the enrollee has chronic obstructive pulmonary disease (COPD). The requested 
system is not a true ventilator, because it is not capable of providing full ventilatory support. It is designed to 
provide positive pressure oxygen during activity. There is insufficient evidence that it is beneficial in the 
treatment of any lung disease. Therefore, the enrollee does not meet criteria for the requested item.  
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 (Life2000 System).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 30, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed and 
approved for paymetn. The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the claim. 
 
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 lab 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 lab services provided on September 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on August 16, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the genetic testing. You say that the services were performed at the request of an 
in-network provider. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 
genetic testing. We found no exception that would require the Plan to pay for the genetic testing. The record 
shows that the referring provider was out-of-network. Therefore, we decided that the Plan does not have to pay 
for genetic testing provided on August 16, 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 an office visit provided on February 1, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are appealing this denial. 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 authorization was not obtained. 
 
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 February 1, 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 an EGD with anesthesia. 
 
You asked the Plan to pre-approve an EGD with anesthesia. The Plan denied your request. The Plan says an 
EGD does not meet the Plan's Medical Policy coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an EGD with anesthesia. Our reviewer 
says that the requested EGD with anesthesia is not considered medically reasonable and necessary in this case. 
Our physician reviewer found that the EGD report from March 7, 2022 describes erosive gastritis associated 
with H. Pylori. The enrollees "ulcers" were noted to be superficial and diminutive with no documentation of 
high-risk appearance. Biopsies proved benign. The risk to the enrollee of a repeat EGD under deep sedation 
(anesthesia) is unjustified given the March of 2022 endoscopic and histologic findings as described. No data 
was presented that the enrollees erosive disease has proved refractory to medical management. No undue 
high risk features were present in March of 2022 to warrant the attendant risks not only of anesthesia but of the 
repeat endoscopic procedure itself.  
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an EGD with anesthesia have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an EGD with anesthesia.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vision care services provided on March 5, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the OON vision care services. You say that you went to the same doctor you had 
used for years when you had different insurance. You said that because you have diabetes, your vision care has 
always been covered under your medical insurance. The Plan denied your request. The Plan says unauthorized, 
non-plan care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider 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 vision care services provided on March 5, 2021 by 
an out-of-network (OON) provider.