Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 84480, 80051, 82435, 84132 and 84295 
billed for date of service December 9, 2021. 
 
You asked the Plan to pay for procedure codes 84480, 80051, 82435, 84132 and 84295. The Plan denied your 
request. The Plan says the billed codes are bundled.  
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 84480 
is a column II code to column I code 84481. We have also confirmed that code 80051 is a column II code to 
column I code 80053. We have also confirmed that codes 82453, 84132, and 84295, are column II codes to 
column I code 80051. 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 84480, 80051, 82435, 84132 and 84295 billed for date of service December 9, 
2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for outpatient rehabilitation services provided 
from March 8, 2022, to April 21, 2022.  
 
You asked the Plan to waive the copayments for therapy services. You say that you should not be responsible 
for these bills. The Plan denied your request. The Plan says you have been 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 $40 
copayment for each outpatient rehabilitation service.  
 The record shows these services were approved, and you have a cost sharing amount. You have been asked to 
pay up to a $40 copayment for each therapy service provided from March 8, 2022, to April 21, 2022. Therapy 
services fall within the Outpatient Rehabilitation 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 copayments for outpatient rehabilitation services provided from March 8, 2022, to April 21, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve therapy services. You say that you had surgery last September and that you 
cannot make it back home. The Plan denied your request. The Plan says these services can be provided in-
network. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 therapy services. Our reviewer says that the coverage criteria has not been 
met. Our physician reviewer found that the provided records do not document a medical reason that you cannot 
return to your service area and receive the physical therapy treatment with an in-network provider. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapy services have not been met.  
 
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 therapy services. Therefore, we decided that the Plan 
does not have to pre-approve physical therapy services to be provided 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 home COVID-19 tests provided on December 22, 2021. 
 
You asked the Plan to pay for the home COVID-19 tests. You say that this home covid-19 test should be paid 
for by the Plan. The Plan denied your request. The Plan says contract addendum coverage sent to all enrollees 
indicated coverage for home tests would be provided beginning on February 1, 2022. This purchase does not 
qualify for that benefit. 
 
The Plan follows Medicare rules. The rules say that Plans were given the option to cover home testing kits as a 
supplemental benefit but were not required to do so by Medicare. The Plan communicated to enrollees that this 
testing would be covered supplementally free of charge after February 1, 2022.  Therefore, we decided that the 
Plan does not have to pay for a home COVID-19 test purchased on December 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for safety eyeglass frames provided on March 30, 2022. 
 
You asked the Plan to pay for safety eyeglass frames. The Plan denied your request. The Plan says safety 
eyeglass frames are not covered under your contract under any normal circumstances. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  We looked at the file and the Plan's rules. The file shows that the Plans routine eyewear benefit does not cover 
safety eyeglass frames. Therefore, we decided that the Plan does not have to pay for safety eyeglass frames 
provided on March 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an assisted living facility (ALF) placement. 
 
You asked the Plan to pre-approve the ALF placement. You say that you need to be placed into an AFL due to 
issues at home. The Plan denied your request. The Plan says the enrollee is able to live safely in the 
community. 
 
The Plan must follow Medicare rules. Medicare rules say that PACE plans must cover all services determined 
necessary by the IDT to improve and maintain the enrollee's overall health status. 
 
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 ALF placement. Our reviewer says that the requested ALF placement is not medically necessary. Our physician reviewer found 
the provided documentation does not support that the requested services is necessary and reasonable to meet 
the enrollees needs and to improve and maintain the enrollee's overall health status. The reviewer found that 
the requested services are not experimental. The reviewer also found that the requested services are not 
cosmetic. Therefore, the reviewer found that the requested ALF placement is not medically reasonable or 
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 the ALF placement have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an assisted living facility (ALF) placement.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the new patient eye exam and the eye exam with photos 
provided on February 2, 2022, to February 14, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the new patient eye exam and the eye exam with photos. You say that the 
enrollee does not have a primary care physician so it would be impossible to obtain a prior authorization. You 
say 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 
new patient eye exam and the eye exam with photos. We found no exception that would require the Plan to pay 
for the new patient eye exam and the eye exam with photos. The records provided for review do not show that 
the new patient eye exam and the eye exam with photos were urgent or emergent. Therefore, we decided that 
the Plan does not have to pay for the new patient eye exam and the eye exam with photos provided on February 
2, 2022, to February 14, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 21, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 70496.  
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service January 21, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ferumoxytol. 
 
You asked the Plan to pre-approve Ferumoxytol. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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 Ferumoxytol. Our reviewer says that 
the documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has iron deficiency anemia. The documentation does not support that the enrollee has tried 
and failed Infed (iron dextran) and Venofer (iron sucrose). The documentation does not support that Infed (iron 
dextran) and Venofer (iron sucrose) 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 Ferumoxytol have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Ferumoxytol.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested device is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 oxygen concentrator Our 
reviewer says that the documentation does not support that the requested item is medically reasonable or 
necessary. Our physician reviewer found you have a diagnosis of chronic obstructive pulmonary disease 
(COPD)/emphysema. The documentation shows that you continue to have fatigue/shortness of breath when 
going to higher altitude. Oxygen level, however, stays above 90%. The documentation does not support that 
you would benefit from the use of portable oxygen in the home. Coverage of portable oxygen to allow physical 
activity at high altitude is not medically reasonable and necessary. Therefore, you do not meet criteria for the 
requested device. 
 
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 oxygen concentrator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment (DME) provided on May 30, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for DME. You say that you want to appeal the amount being charged. The Plan 
denied your request. The Plan says Your plan does not pay for non-prescription drugs and other over the 
counter items. 
 
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 durable medical equipment (DME) provided on 
May 30, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and 
services provided on March 27, 2022, to April 5, 2022. 
 
You asked the Plan to pay for IRF care. You say that these services were medically necessary. The Plan denied 
your request. The Plan says the medical criteria for an IRF admission has not been met. 
 
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 pay for 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 enrollee was admitted for surgical repair of a hip fracture and a wrist fracture. Medical problems are stable and there are no complex nursing or rehabilitation needs. 
 
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 pay for acute inpatient rehabilitation facility (IRF) admission and services provided on March 27, 2022, to 
April 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cataract surgery and vision services (V2788) you had on 
August 6, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim processed 
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 10% 
coinsurance for outpatient surgery. The rules also say that Medicare does not cover routine vision services and 
eyewear. 
 
Review of the file shows that you had cataract surgery with presbyopia correcting function of intraocular lens 
on August 6, 2021. You have been asked to pay a 10% coinsurance for the cataract surgery. The surgery falls 
within the outpatient surgery 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. Additionally, the presbyopia correcting function of intraocular lens is not covered by 
Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the cataract surgery and 
vision services (V2788) you had on August 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit, x-rays and physical therapy services provided 
by a chiropractor from December 10, 2021, to December 31, 2021. 
 
You asked the Plan to pay for an office visit, x-rays and, physical therapy services and to waive the copayment 
for chiropractic manipulative treatment. You say that the provider never asked if it was okay for you to pay out 
of pocket should insurance not cover the services. The Plan denied your request. The Plan says services other 
than manual manipulation of the spine are not covered when performed by a chiropractor. The Plan also says 
the copayment was applied correctly to the chiropractic manipulative treatment. 
 The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
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 $10 
copayment for Medicare-covered chiropractic services.  
 
You have been asked to pay $80 ($10 copay X 8 visits) for the chiropractic manipulative treatment. 
Chiropractic manipulative treatment falls within the Chiropractic 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. 
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for an office visit, x-rays and physical therapy services provided by a 
chiropractor and the Plan does not have to waive the copayment for chiropractic manipulative treatment from 
December 10, 2021, to December 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for compression stockings provided on February 9, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for compression stockings. You say that you were told to get these by your primary 
care provider. The Plan denied your request. The Plan says these items were not purchased from an in-network 
provider. 
 
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 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 compression stockings provided on February 9, 
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 out-of-network orthopedic referral. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested services are available in the plan's network. 
 
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 
an out-of-network orthopedic referral.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOne Liquid CDx test (0239U) provided June 18, 2021. 
 
You asked the Plan to pay for the FoundationOne Liquid CDx. You say that this test is a medically necessary 
covered benefit. The Plan denied your request. The Plan says that there is insufficient documentation to 
approve this testing. 
 
The Plan must follow Medicare rules. Medicare rules say that [insert custom text from glossary].  
 
We looked at the file and Medicare rules. In this case the documentation shows that the FoundationOne Liquid 
CDx test was performed for the enrollees diagnosis of non-small cell lung cancer. Non-small cell lung cancer 
is a covered indication for FoundationOne Liquid CDx. Based on this information, we decided that Medicare 
rules for coverage of the FoundationOne Liquid CDx have been met. Therefore, we decided that the Plan has to 
pay for the FoundationOne Liquid CDx test (0239U) provided June 18, 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.