Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services (H2017, H0031) provided 
on July 28, 2021, to August 31, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient mental health services. You say that you are appealing with supporting 
records. The Plan denied your request.  The Plan says this provider is not a network provider with the Plan, and the member's primary care physician 
(PCP) confirmed that they did not refer the member to the out-of-network provider. The Plan also says that 
they have also determined that these services are not urgent or emergent, nor were they approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 outpatient mental health services (H2017, H0031) 
provided on July 28, 2021, to August 31, 2021, by an out-of-network (OON) provider.
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 this is medically necessary. The Plan 
denied your request. The Plan says the enrollee can continue receiving care at the current facility. 
 
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 is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where she is 
currently receiving care. 
 
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 rendered on August 17, 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 were not billed correctly. 
 
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 these 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 rendered on August 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an injection(s), anesthetic agent(s) and/or 
steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level 
(64483) provided from March 8, 2021, to October 11, 2021. 
 
You asked the Plan to waive the copayment for an injection(s), anesthetic agent(s) and/or steroid; 
transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level. You say 
that you were not notified about the payment you had to pay, and you do not agree with the charge. You also 
say that you used to pay a $30 copayment for that service. The Plan denied your request. The Plan says you 
were charged the correct cost sharing amount. 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 
copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center, 
including but not limited to hospital or other facility charges and physician or surgical charges.  
 
You have been asked to pay a $295 copayment for each injection(s), anesthetic agent(s) and/or steroid; 
transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level, which is a 
total of $590 ($295 x 2 = $590). Injections, anesthetic agent(s) and/or steroid; transforaminal epidural, with 
imaging guidance (fluoroscopy or CT), lumbar or sacral, single level fall within the outpatient surgery and 
other medical services provided at hospital outpatient facilities and ambulatory surgical centers benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for an injection(s), anesthetic agent(s) and/or 
steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level 
(64483) provided from March 8, 2021, to October 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and an injection (99214, 20553) provided on 
November 11, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit and an injection. You say that you believe in treating your patient's 
medical needs first. You also say that this treatment was medically necessary for the member, and its 
administration was time sensitive. The Plan denied your request. The Plan says they did not authorize any 
services for this provider or facility. The Plan also says that this provider is a non-participating provider and 
there is no referring provider involved in these services. 
 
 
 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 and an injection (99214, 20553) 
provided on November 11, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Entyvio. 
 
You asked the Plan to pre-approve Entyvio. You say that you would like reconsideration because the requested 
Entyvio is medically necessary. The Plan denied your request. The Plan says that the records do not show a 
diagnosis of moderately to severely active Crohn's disease or Ulcerative Colitis. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Entyvio. Our reviewer says that the use 
of Entyvio in patients with Collagenous colitis who have severe symptoms refractory to budesonide is 
supported in the medical literature. Our physician reviewer found the available documentation in the case file 
supports that Entyvio is expected to be safe and effective and otherwise reasonable and necessary for this 
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 Entyvio have been met. Therefore, we decided that the Plan has to pre-approve 
Entyvio.  
 
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 Reblozyl. 
 
You asked the Plan to pre-approve Reblozyl. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the requested use is not medically accepted and therefore coverage of this 
medication has been denied. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Reblozyl. Our reviewer says that 
Reblozyl is not medically reasonable and necessary. Reblozyl is not FDA-approved for your diagnosis. The use 
of Reblozyl is not supported by one of the major drug compendia or by clinical research that appears in a 
Centers for Medicare & Medicaid Services approved medical journal. Our physician reviewer found that your 
condition does not meet criteria for coverage of Reblozyl. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Reblozyl have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Reblozyl.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing (G0483) provided on October 7, 
2021. 
 
You asked the Plan to pay for the definitive drug testing. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says ordering a multi-drug panel of definitive 
(confirmation) urine drug tests that are not used in management of the member is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that definitive drug testing is indicated 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 pay for the definitive drug testing. Our reviewer 
says that Medicare coverage criteria have not been met. Our physician reviewer found records do not document 
results of a screening drug test that are presumptively positive or the results of the screen are negative, and this 
negative finding is inconsistent with the enrollee's medical history or there is no presumptive test available, 
locally and/or commercially, as may be the case for certain synthetic or semi-synthetic opioids. 
 
 
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 definitive drug testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the definitive drug testing (G0483) provided on October 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. 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 Keytruda. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found the review has determined that the 
documentation does not support that Keytruda is medically reasonable and necessary for the enrollee. The 
documentation does not support that Keytruda is safe and effective 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99204) and laboratory services (86803, 
85027, 83036, 82043, 80061, 80053, 36415) provided on September 13, 2021, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for an office visit and laboratory services. You say that by order of the cardiology 
surgeon, you looked for a family doctor to review your medical condition, so you visited this provider on 
September 13, 2021, who sent you do to some blood tests and urine. The Plan denied your request. The Plan 
says emergent/urgent services are covered outside of the service area if necessary to prevent deterioration of 
health due to unforeseen illness while temporarily out of the services area, and the services received were not 
emergent/urgent and were 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 an office visit (99204) and laboratory services 
(86803, 85027, 83036, 82043, 80061, 80053, 36415) provided on September 13, 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 rendered on September 23, 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 procedure code 87798 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 87798 (infectious agent detection, not otherwise specified) 
and 87801 (infectious agent detection, multiple organisms). Code 87798 is a column II code with a modifier 
indicator of 1 when billed with column I code 87801. Code 87798 was not billed with an appropriate modifier 
to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on September 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services (97140, 97810, 97811) provided on 
November 1 to November 17, 2021. 
 
You asked the Plan to pay for acupuncture services. You say that the services at issue were a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for payment for acupuncture services have 
not been met. 
 The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the provider of the services at issue is not a physician, 
nor is there documentation in the case record that indicates the provider is under the supervision of a physician. 
Therefore, we decided that the Plan does not have to pay for acupuncture services (97140, 97810, 97811) 
provided on November 1 to November 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for A Drug Test provided on November 23, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for A Drug Test. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says The denial of authorization for these services is correct. 
 
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 Drug Test provided on November 23, 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 outpatient office visit provided on December 14, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient office visit. You say that you were told that no referral was needed 
to see the specialist. The Plan denied your request. The Plan says they spoke to the enrollee's primary care 
physician, and they did not refer the enrollee to see the out-of-network provider. Also, the service rendered was 
not urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an outpatient office visit provided on December 
14, 2021, 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 an office visit (99214) and psychotherapy (90833) provided 
on November 20, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit and psychotherapy. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says these services were performed on November 
20, 2021, by an out-of-network provider with the member's Plan. The Plan also says that the decision is upheld 
based on Plan rules related to out-of-network services performed 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 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 (99214) and psychotherapy (90833) 
provided on November 20, 2021, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance service (A0428), ground 
mileage (A0425), and supplies (A0382) provided on August 12, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the services should be covered. The Plan 
denied your request. The Plan says The Plan says that the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the ambulance services have not been 
met.  Specifically, there were no medical records provided to substantiate that these services were medically 
necessary. Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance service 
(A0428), ground mileage (A0425), and supplies (A0382) provided on August 12, 2021.