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

 
We decided that the Plan does not have to pre-approve a surgeon consult and follow up visit to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the consult and follow up visit. You say that you saw the OON provider the 
other year and would like to have the services performed by them again. The Plan denied your request. The 
Plan says the requested provider is an OON provider and there are multiple in-network providers that are 
available and have been approved in the enrollee's service area. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a surgeon consult and follow up visit to be provided by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services. 
 
You asked the Plan to pre-approve home health care. You say that the enrollee has been diagnosed with 
dementia. You say that they need help in the home since their diagnosis. You also say that the enrollee is not 
able to be left alone. The Plan denied your request. The Plan says there have not been any skilled needs 
identified that would require the requested home health care. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health care have not been met. Specifically, there is no documentation to support that the 
enrollee requires any skilled services, thus the requested services would be considered custodial and not 
covered at this time. Therefore, we decided that the Plan does not have to pre-approve home health aide 
services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electroencephalogram (EEG) services coded 95819 
provided on January 22, 2022. 
 
You asked the Plan to pay for the EEG services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services are not payable as billed.  
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 CPT code 95819 is not supported in the medical record. Specifically, this code has a professional 
component/technical component of 1. This service was billed with a place of service of 21 (inpatient hospital). 
The professional interpretation was furnished in the same payment locality from where the technical 
component was furnished. We find that the Medicare rule for payment of this claim has not been met as the 
professional interpretation of a diagnostic test must be separately billed with modifier  26 by the interpreting 
physician. Based on this information, we decided that Medicare rules for coverage of the EEG services have 
not been met. Therefore, we decided that the Plan does not have to pay for the electroencephalogram (EEG) 
services coded 95819 provided on January 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for running shoes and shoe inserts provided on June 2, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to reimburse for the running shoes and shoe inserts. You say that the items should be 
covered as you disagree with the denial.  The Plan denied your request. The Plan says the items denied 
correctly as they were non-emergent and prior 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 reimburse 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 reimburse for these items/services. 
Therefore, we decided that the Plan does not have to reimburse for running shoes and shoe inserts provided on 
June 2, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orencia infusions. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has rheumatoid arthritis. 
She has not tried and failed at least one of the Plan's required drugs, Remicade, Infliximab, Inflectra, or 
Simponi Aria. The records do not show that the required drugs would be contraindicated or less effective; 
therefore, Orencia is not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Orencia infusions.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic procedure coded 97110 provided on 
September 21, 2021. 
 
You asked the Plan to pay for the therapeutic procedure. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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, the CPT Code Manual definition of code 97110 is therapeutic procedure, 1 or more areas, each 15 
minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. 
 
 
 We find that CPT code 97110 is not supported in the medical record. Specifically, the documentation shows 
that the services rendered were performed by a physical therapist assistant in a home health or hospice setting. 
This means there is a more appropriate code to be billed for the services rendered. Based on this information, 
we decided that Medicare rules for coverage of the therapeutic procedure have not been met. Therefore, we 
decided that the Plan does not have to pay for the therapeutic procedure coded 97110 provided on September 
21, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you do not drive and have no 
other way to get to your appointments. The Plan denied your request. The Plan says you have already 
exhausted your routine transportation benefit for the year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year. This limit applies regardless of the necessity of the 
transports. 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit, wrist hand finger orthosis, and x-ray (99203, 
L3807, 73110) provided on May 5, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit, wrist hand finger orthosis, and x-ray. You say that the services 
should be covered as you disagree with the denial. The Plan denied your request. The Plan says the services 
denied correctly as they were non-emergent and prior 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, wrist hand finger orthosis, and x-
ray (99203, L3807, 73110) provided on May 5, 2022, 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 coded 84153, 80048, and 85610 
provided on January 5, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
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 CPT codes 84153, 80048, and 85610 are not supported in the medical record. Specifically, these 
codes are not payable with a -26 modifier. The facility was paid for both the technical component and 
professional component based on the claim history for these services. This means this claim is not payable as 
billed. Based on this information, we decided that Medicare rules for coverage of the laboratory services have 
not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 84153, 
80048, and 85610 provided on January 5, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Cologuard test (81528) provided on January 26, 2022. 
 
You asked the Plan to pay for the Cologuard test. You say that this test is a covered service. The Plan denied 
your request. The Plan says that criteria for coverage could not be reviewed because no clinical notes were 
submitted. 
 
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. In this case the Plan denied coverage due to a lack of medical records. There was 
no documentation in the file indicating that the Plan made attempts to obtain this missing information.  
Therefore, we decided that the Plan has to pay for the Cologuard test (81528) provided on January 26, 2022.  
 
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 blood smear services coded 85060 provided on February 
22, 2022. 
 
You asked the Plan to pay for the blood smear services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
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 CPT code 85060 is not supported in the medical record. Specifically, this code may not be paid if 
furnished to hospital outpatients or non-hospital enrollees. Review of the enrollees claim shows the provider 
billed in a place of service of 22 (outpatient hospital). Based on this information, we decided that Medicare 
rules for coverage of the blood smear services have not been met. Therefore, we decided that the Plan does not 
have to pay for the blood smear services coded 85060 provided on February 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve an office visit. The Plan denied your request. The Plan says the enrollee 
must use network providers to get health care and services when there are network providers available. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an office 
visit to be provided by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit. 
 
You asked the Plan to pre-approve Retacrit. You say that the requested Retacrit is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for Retacrit. 
 
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 Retacrit. Our reviewer says that the 
enrollee does not meet criteria for Retacrit. Our physician reviewer found the record indicates that the enrollee 
has high risk myelodysplastic syndrome with an epogen level of over 700. The coverage criteria do not indicate 
that coverage is available for these conditions. The elements of the coverage criteria are not satisfied. The 
requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Retacrit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that you are requesting a 
reconsideration of the Plan's denial. The Plan denied your request. The Plan says these items are not a covered 
benefit under your contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
 
 Although these items may be appropriate for you, they do not fall into a covered benefit category and cannot be 
paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve 
compression stockings identified with code A6530.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit for a second opinion to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the evaluation and management service. You say that you would like to get 
a second opinion on your glaucoma diagnosis from 4 years ago. The Plan denied your request. The Plan says 
there are in-network providers available to provide a second opinion. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider within your medical group. The Plan has 
confirmed there are network providers available within your medical group who can provide the items/services 
at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an office visit for a second opinion to be 
provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound (76536) provided on June 2, 
2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that the services should be covered as 
you disagree with the denial. 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 $105 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
 
  You have been asked to pay a $96.58 copayment for an ultrasound, which is less than the standard $105. This 
item/service falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for an ultrasound (76536) provided on June 2, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve a repeat ESI. You say that your pain continues in your right thigh along with 
tingling and numbness. You say that you have experienced 60% relief from the first injection. You say that you 
feel that another injection might give you more relief. You also say that you would have to see a surgeon which 
would cost even more money. The Plan denied your request. The Plan says the requested repeat injection is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a repeat epidural steroid injection (ESI) is 
medically necessary when the first injection directly and significantly provided at least 50% pain relief for at 
least three months.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a repeat ESI have not been met. Specifically, the file indicates that you have had 60% pain relief 
from an injection that you received less than 3 months ago. Therefore, we decided that the Plan does not have 
to pre-approve a repeat epidural steroid injection (ESI).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (ESI) (62321). 
 
You asked the Plan to pre-approve repeat ESI. You say that you had a stroke and fell. You say that you are 
trying to get some help with the pain that has resulted. You also say that the injections help in between. The 
Plan denied your request. The Plan says a repeat ESI is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a repeat epidural steroid injection (ESI) is 
medically necessary when the first injection directly and significantly provided at least 50% pain relief for at 
least three months. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of repeat ESI have not been met. Specifically, the file does not support that at least three months have 
passed since your first and second injections. Therefore, we decided that the Plan does not have to pre-approve 
a repeat epidural steroid injection (ESI) (62321).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture treatment (97811). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested service does not meet Medicare criteria for 
coverage. 
 
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 requested acupuncture treatment have not been met.  
 Specifically, the auxiliary personnel furnishing the acupuncture will not be under the appropriate level of 
supervision of a physician, physicians assistant, or nurse practitioner/clinical nurse specialist. Therefore, we 
decided that the Plan does not have to pre-approve acupuncture treatment (97811).