Persius/hicric huggingface dataset:
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 the Plan's requirements are excessive. The Plan denied 
your request. The Plan says step therapy requirements have 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 Prolia. Our reviewer says that the 
requirements for coverage of Prolia have not been met. Our physician reviewer found the Plan requires a trial 
of one intravenous bisphosphonate (such as zoledronic acid) before they will approve the requested drug. The 
records do not indicate that you have tried and failed this drug, or that this drug would likely be less effective 
or have adverse effects for you. 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on May 
02, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you were told not to 
worry about paying for the ambulance rides. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
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 $225 
copayment for ambulance services. 
 
 
 
 
 
 You have been asked to pay a $225 copayment for the ambulance services. This item/service falls within the 
ambulance services 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. Please note that the copayment applies to each one-way trip. Therefore, the total amount of $450 
was applied for two separate ambulance trips. Therefore, we decided that the Plan does not have to waive the 
copayment for the ambulance services provided on May 02, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on June 29, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for office visit. You say that the providers office told you they accepted your plan. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advanced. 
 
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 office visit provided on June 29, 2022, 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 wrist x-rays provided on July 16, 2021. 
 
You asked the Plan to waive the copayment for the wrist x-rays. You say that you cannot afford the 
copayments. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $15 
copayment for outpatient diagnostic tests and therapeutic services and supplies (x-rays). 
 
You have been asked to pay a $15 copayment for the wrist x-rays. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies (x-rays) 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 wrist x-rays provided on July 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care provided on March 9, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the wound care. You say that the service 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 
wound care. We found no exception that would require the Plan to pay for the wound care. The records 
provided for review do not show that the wound care was urgent or emergent. Therefore, we decided that the 
Plan does not have to pay for the wound care provided on March 9, 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 PureWick female catheter (K1006). 
 
You asked the Plan to pre-approve incontinence supplies. You say that the requested catheter is medically 
necessary and vital to the enrollee's health and well-being. The Plan denied your request. The Plan says 
Medicare and the Plan do not cover incontinence supplies because they are disposable, non-reusable hygiene 
items and fall outside the scope of coverage. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve a PureWick female catheter 
(K1006).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pneumatic compression devices (E0650, E0673) provided on 
October 5, 2021. 
 
You asked the Plan to pay for pneumatic compression devices. You say that the items at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The items at issue in this appeal are for use outside of the home. Although these items may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for pneumatic compression devices (E0650, E0673) provided on October 5, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oxygen and oxygen supplies, life sustaining situation 
(code A0422) and ALS specialized service disposable supplies (code A0394) provided on February 6, 2022. 
 
You asked the Plan to pay for oxygen and oxygen supplies, life sustaining situation and ALS specialized 
service disposable supplies. The Plan denied your request. The Plan says the 2022 National Physician Fee 
Schedule lists codes A0422 and A0394 with a status indicator of X, which indicates that this service is not 
valid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that payment for items and services, such as oxygen, 
is included in the fee schedule payment. 
 
We looked at the file and Medicare rules. Medicare says that payment for items and services, such as oxygen, 
is included in the fee schedule payment. Therefore, we decided that the Plan does not have to pay for oxygen 
and oxygen supplies, life sustaining situation (code A0422) and ALS specialized service disposable supplies  
(code A0394) provided on February 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81225, 81227, 81230, 81231, 81232, 81306, 
81328, 81335, 81355, 81291, 0031U, 0032U, 0033U, 81479, 81407, 81238) provided on April 14, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that only the following codes should be billed for 
Cardiovascular Disease Screening: code 80061 (Lipid panel) which includes codes: 82465 (Cholesterol, serum 
or whole blood, total), 83718 (Lipoprotein, direct measurement; high density cholesterol) and/or 84478 
(Triglycerides). 
 
We looked at the file and Medicare rules. The codes billed are not covered for cardiovascular screening. Based 
on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. 
Therefore, we decided that the Plan does not have to pay for genetic testing (81225, 81227, 81230, 81231, 81232, 81306, 81328, 81335, 81355, 81291, 0031U, 0032U, 0033U, 81479, 81407, 81238) provided on April 
14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 77067 and 77063 billed for date of service 
May 9, 2022. 
 You asked the Plan to pay for procedure codes 77067 and 77063. You say that you have provided medical 
records to support payment. The Plan denied your request. The Plan says payment for codes 77067 and 77063 
is bundled into payment for code 77065. 
 
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 codes 
77067 and 77063 are column II codes to column I code 77065. This claim has not been billed with an 
appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 77067 and 77063 billed for 
date of service May 9, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 72192 billed for date of service May 13, 
2022. 
 
You asked the Plan to pay for procedure code 72192. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says payment for code 72192 is bundled into 
payment for code 74176. 
 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 72192 
is a column II code to column I code 74176. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 72192 billed for date of service May 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 22846 and 20936 billed for date of service 
February 23, 2022. 
 
You asked the Plan to pay for procedure codes 22846 and 20936. You say that this service was medically 
necessary. The Plan denied your request. The Plan says payment for code 22846 is bundled into payment for 
code 22853. 
 
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 22846 
is a column II code to column I code 22853. This claim has not been billed with an appropriate modifier to 
bypass the edit. CPT code 20936 has a status indicator of "B" and is not separately 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 codes 22846 and 20936 billed for date of service February 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and the deductible for an ophthalmological 
medical exam (92014) and a determination of a refractive state (92015) provided from January 5, 2022, to 
August 5, 2022. 
 
You asked the Plan to waive the copayment and the deductible for an ophthalmological medical exam (92014) 
and a determination of a refractive state (92015). You say that you had a routine eye exam with services 
covered and only a $35 copayment. You also say that you do not have a deductible. The Plan denied your request. The Plan says the claim was processed correctly, as the member's benefits are specific that he has a 
$100 deductible and a $35 vision specialty care physician copayment. 
 
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 Medicare-covered eye exams by a specialty care physician. You contract with the Plan also says 
that the deductible applies. Your contract with the Plan also says that there is a $100 deductible which applies 
to certain items and services. 
 
You have been asked to pay a $35 copayment for an ophthalmological medical exam (92014) and a 
determination of a refractive state (92015). An ophthalmological medical exam (92014) and a determination of 
a refractive state (92015) fall within the benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $94.23 deductible which applies to an ophthalmological medical exam 
(92014) and a determination of a refractive state (92015). The record shows that as of June 15, 2022, you have 
paid the full amount of your $100 yearly plan deductible. 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 
and the deductible for an ophthalmological medical exam (92014) and a determination of a refractive state 
(92015) provided from January 5, 2022, to August 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for a 
stroke. You do not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. There is not a reasonable expectation that you will 
be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for shoulder injection provided on May 05, 
2022. 
 
You asked the Plan to waive the copayment for shoulder injection. You say that you were seen in the office, 
not in a hospital. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $250 
copayment for outpatient hospital services. 
 
 
 
 
 
 
  
You have been asked to pay a $250 copayment for shoulder injection. This item/service falls within the 
outpatient hospital services 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 shoulder 
injection provided on May 05, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home mechanical ventilator. 
 
You asked the Plan to pre-approve a home mechanical ventilator. You say that this is medically necessary. The 
Plan denied your request. The Plan says that the request for a home mechanical ventilator set in iVAPS mode 
with Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
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 home mechanical ventilator. Our 
reviewer says that a home mechanical ventilator is not medically reasonable and necessary. You have obesity-
hypoventilation syndrome (OHS), obstructive sleep apnea (OSA), valvular heart disease, congestive heart 
failure (CHF), and severe pulmonary hypertension. A diagnosis of COPD is listed in some records and not 
others, and results of pulmonary function testing are not provided. A sleep study and PAP titration showed that BiPAP was successful in treating the sleep disordered breathing, and when used with 15 liters per minute 
oxygen, corrected the hypoxemia. The reason given for needing a ventilator is that oxygen cannot be provided 
at more than 10 liters per minute with BiPAP. This is a limitation of the oxygen concentrators, not the BiPAP, 
and would also apply to a ventilator. Medicare does not cover a ventilator for the treatment of OHS or OSA, or 
when used as BiPAP. Our physician reviewer found that your condition does not meet Medicare criteria for a 
home mechanical ventilator. 
 
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 home mechanical ventilator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home mechanical ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on March 21, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on March 
21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service February 10, 
2022. 
 
You asked the Plan to pay for procedure code 99053. The Plan denied your request. The Plan says procedure 
code 99053 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service February 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on November 5, 
2021. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the supplier is not enrolled in 
the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the durable medical equipment provided 
on November 5, 2021.