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

 
We decided that the Plan does not have to pay for the lab services provided on January 19, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says these services are 
not payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab 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 lab services provided on January 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services for an eyelid procedure (00103) billed for 
date of service August 5, 2021. 
 
You asked the Plan to pay for anesthesia services. You say that you have provided records to support the 
services at issue. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 00103 is "Anesthesia for reconstructive procedures of 
eyelid (eg, blepharoplasty, ptosis surgery)." 
 
We find that CPT code 00103 is not supported in the medical record. Specifically, no legible medical records 
have been provided to support the services at issue in this case. Based on this information, we decided that Medicare rules for coverage of anesthesia services have not been met. Therefore, we decided that the Plan does 
not have to pay for anesthesia services for an eyelid procedure (00103) billed for date of service August 5, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an injection provided on March 22, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an injection. You say that you would like to request reconsideration of the denied 
claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was determined these 
services can be received 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 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 injection provided on March 22, 2021, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repair of current push wheelchair. 
 
You asked the Plan to pre-approve the wheelchair repair. You say that please overturn the decision and allow 
the repairs to the client owned wheelchair. The Plan denied your request. The Plan says the requested repairs 
do not meet medical necessity criteria based on previous repair history and cost of replacement. 
 
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 the wheelchair repair. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not reveal that the enrollee has a mobility deficit that impairs MRADLs in the home and cannot be overcome with a cane or walker. There are no detailed physician progress 
notes including a detailed gait and neuromuscular/musculoskeletal examination. There is no evidence of a 
home assessment indicating the requested wheelchair will be able to maneuver in the home. 
 
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 wheelchair repair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve repair of current push wheelchair.
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 you would like the plan to reconsider their 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 Prolia. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found you have a history of age-related osteoporosis. The documentation does not support that you have tried 
and failed both oral and intravenous bisphosphonates for one year. The documentation does not support that 
either oral and intravenous bisphosphonates would likely to be ineffective or adversely affect the drug's 
effectiveness or are likely to cause an adverse reaction or other harm to you. Therefore, you do not meet criteria 
for the requested drug. 
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 2, 2021, to 
March 3, 2021 
 
You asked the Plan to pay for the home health services. You say that the Centers for Medicare & Medicaid 
Services (CMS) has implemented an exception to RAP billing deadlines, and this claim falls under those 
exceptions. The Plan denied your request. The Plan says the non-contracted provider did not submit the RAP 
claim for services for dates of service February 2, 2021, to March 3, 2021, until April 5, 2021. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Specifically, the record indicates the RAP was not 
submitted within 5 days of the from the start of care date. Therefore, we decided that the Plan does not have to 
pay for the home health services provided from February 2, 2021, to March 3, 2021
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oncology (prostate), mRNA (81542) microdissection (ie, 
sample preparation of microscopically identified target) (88381) provided January 24, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that Decipher Prostate was ordered by the 
doctor to help guide them through the process of selecting the appropriate treatment for him to achieve the best 
possible outcomes. The Plan denied your request. The Plan says the claim must be submitted to the primary 
payer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the claim must be 
submitted to the primary payer before the Plan can process the claim. As the secondary insurer, the Plan cannot 
be held responsible for the laboratory services until the primary insurer has denied the claim for these services. 
Therefore, we decided that the Plan does not have to pay for oncology (prostate), mRNA (81542) 
microdissection (ie, sample preparation of microscopically identified target) (88381) provided January 24, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services rendered on February 15, 2022. 
 
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 this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on March 18, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for these services have not been met. 
 
 
 
  Therefore, we decided that the Plan does not have to pay for the imaging services rendered on February 15, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for mammogram provided on February 28, 
2022. 
 
You asked the Plan to waive the copayment for mammogram. You say that you never had to pay this before, 
and you dont know why you do now. The Plan denied your request. The Plan says the copayment applied is 
correct. 
 
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 $50 
copayment for diagnostic x-rays provided in an outpatient hospital facility.  
 
You have been asked to pay $50 copayment for mammogram. Mammograms fall 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 mammogram provided on 
February 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on February 7, 2022. 
 
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 are not covered. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 8 identifies professional component of clinical laboratory codes for which separate payment 
may be made only if the physician interprets an abnormal smear for hospital inpatient. 
 
We looked at the file and Medicare rules. The file shows that the services were not performed for a hospital 
inpatient. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on 
February 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an office visit provided on March 1, 2022. 
 
You asked the Plan to waive the cost share for office visit. You say that this is too much for an office visit. The 
Plan denied your request. The Plan says the cost share applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $100 deductible which applies to Physician/Practitioner Services, 
Including Doctors Office Visits. Your contract also says there is a 10% coinsurance for services obtained from 
a primary care provider. 
 
 
 
 
 The item or service you asked the Plan to waive the cost share for falls within the benefit category 
Physician/Practitioner Services, Including Doctors Office Visits. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is $100 deductible which applies to Physician/Practitioner Services, 
Including Doctors Office Visits. This cost sharing is a contractual obligation that had not been met at the time 
office visit was received on March 1, 2022.  Therefore, $70.72 has been applied to meet the deductible. 
 
Since the $100 deductible was met, you have also been asked to pay $2.02 coinsurance for the office visit. 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 the 
Plan does not have to waive the cost for an office visit provided on March 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator. 
 
You asked the Plan to pre-approve a spinal cord stimulator. You say that the clinical information provided 
supports the need for a spinal cord stimulator. The Plan denied your request. The Plan says the request is not 
medically necessary because the records do not show that the enrollee is using it as a late or last resort 
treatment. 
 
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 a spinal cord stimulator. Our reviewer 
says that a spinal cord stimulator is not considered medically reasonable and necessary in this case. Our 
physician reviewer found all other treatments have not been tried. More conservative measures, including 
physical therapy, are needed. 
 
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 spinal cord stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a spinal cord stimulator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on January 
31, 2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that this was a follow up from 
your surgery and should be covered. The Plan denied your request. The Plan says the copayment applied is 
correct. 
 
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 $40 
copayment for each covered visit or consultation in an outpatient location with a specialist.  
 
 
 
 You have been asked to pay $40 copayment for specialist office visit. Specialist office visits fall within the 
Physician/Practitioner Services, Including Doctors Office Visits 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 specialist office visit provided on January 31, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided on March 1, 2022, 
to April 8, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient mental health services. You say that two separate departments from 
the Plan told you as an out-of-network provider, you can continue to see the enrollee for outpatient clinical 
social work, submit claims online and receive remittance for all of your sessions. You also say you and the 
enrollee were both told that these clinical behavioral health sessions would be authorized for you to see her in 
weekly therapy sessions. The Plan denied your request. The Plan says services from non-participating 
providers are not covered unless preauthorized. 
 
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 provided on 
March 1, 2022, to April 8, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on April 6, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received 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 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 laboratory services provided on April 6, 2022, by 
an out-of-network (OON) provider.
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 you would like the plan to reconsider their 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 Prolia. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has postmenopausal osteoporosis and has been on alendronate, risedronate and raloxifene in 
the past. The enrollee has recently developed headaches, chills and fatigue after taking risedronate. The 
documentation does not support that the enrollee has tried and failed zoledronic acid. While the Medicare-
approved major drug compendia shows that influenza-like symptoms have been reported with bisphosphonates, 
the compendia report that the majority of these cases were transient and did not require discontinuation of the 
drug. Therefore, the enrollee does not meet criteria for the requested drug. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic panel testing provided on January 7, 2022. 
 
You asked the Plan to pay for genetic testing. You say that the enrollee meets the Medicare criteria for this 
testing which has been determined to be reasonable and necessary for the enrollee's condition. The Plan denied 
your request. The Plan says the denial of payment for this testing is correct, because this testing included the 
FANCC gene which is excluded from Medicare coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare will deny panels of tests that include 
the FANCC gene.  
 
We looked at the file and Medicare rules. This testing panel included the FANCC gene. Based on this 
information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we 
decided that the Plan does not have to pay for genetic panel testing provided on January 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the specimen validity testing provided on February 15, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing shall not separately bill the validity testing.  
 
We looked at the file and Medicare rules. The requested urine specimen validity testing is not separately 
payable from the drug testing in this case. Based on this information, we decided that Medicare rules for 
coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
specimen validity testing provided on February 15, 2022.