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

 
We decided that the Plan does not have to pre-approve Ilumya. 
 
You asked the Plan to pre-approve Ilumya. You say that this drug is medically necessary. The Plan denied your 
request. The Plan says its step therapy criteria have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Ilumya. Our reviewer says that this 
request does not meet the Plan's step therapy requirements. Our physician reviewer found the record indicates 
that the enrollee has psoriasis vulgaris.  The record indicates that the enrollee has failed topical steroids.  The 
requested medication is a new start.  The provided records do not indicate that the enrollee has tried and failed 
all of the plan's preferred step one alternative. The record does not indicate that the enrollee has a 
contraindication to, or would have an adverse effect from the plan's preferred step one alternative.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Ilumya.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a magnetic resonance imaging (MRI) scan of the lumbar 
spine (72148) provided on December 16, 2021. 
 You asked the Plan to pay for an MRI scan of the lumbar spine. You say that you have provided records to 
support the service at issue. The Plan denied your request. The Plan says rules for payment have not been met 
because the CPT code at issue is inclusive to another billed code. 
 
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 72148 
is a column II code to column I code 72159. 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 a magnetic resonance imaging (MRI) scan of the lumbar spine 
(72148) provided on December 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulatory infusion pump (E0781) provided November 
12, 2021. 
 
You asked the Plan to pay for the infusion pump. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says the Medicare LCD criteria has 
not been met. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. An infusion pump was not necessary to safely administer normal 
saline in the home to a member who has a PICC line, is tolerating oral feed, and feeds via the PEG. Based on 
this information, we decided that Medicare rules for coverage of the infusion pump have not been met. 
Therefore, we decided that the Plan does not have to pay for the ambulatory infusion pump (E0781) provided 
November 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 12, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to appeal the denial of the claim. The 
Plan denied your request. The Plan says the provider is out-of-network and authorization is required prior to an 
out-of-network visit. 
 
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 provided on October 12, 2021 by an 
out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiologic examination of the ankle provided on January 10, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for radiologic examination of the ankle. You say that your records show that the 
above mentioned provider with participating with the member's plan. The Plan denied your request. The Plan 
says the rendering provider is a non-participating provider, and there is no referring provider involved in these 
services. The Plan also says that they did not authorize any services for this provider or the facility. 
 
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 radiologic examination of the ankle provided on 
January 10, 2022, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
October 19, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you were admitted and should not 
have the ER copayment. 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 $90 
copayment for each emergency room visit. The cost sharing is waived if you are admitted within 24 hours for 
the same condition.  
 The file shows that you were kept under observation status only. There is no evidence of a written provider 
order for inpatient care. Therefore, you have been asked to pay a $90 copayment for the ER visit. The ER visit 
falls within the Emergency Care 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 emergency room (ER) visit provided on October 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
November 30, 2021, to December 9, 2021. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you should not have been 
discharged from your previous stay. 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 $225 per 
day for days 1-8 and $0 per day after day 8 for each inpatient admission.  
 
The file shows that you were in the hospital from November 30, 2021, to December 9, 2021. Therefore, you have been asked to pay $225 per day for the first 8 days of inpatient care. The total for your stay is $1,800 
($225 copayment x 8 days = $1,800). The inpatient care falls within the Inpatient Hospital Care 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 inpatient hospital care provided from 
November 30, 2021, to December 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Manual Wheelchair to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve Manual Wheelchair. You say that you would like to appeal the denial of the 
claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is required 
prior to an out-of-network visit. 
 
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 
Manual Wheelchair to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Laboratory Services provided on May 11, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Laboratory Services. You say that you are providing the authorization, now, after 
the services have been received. The Plan denied your request. The Plan says the provider is out-of-network 
and authorization is required prior to an out-of-network visit. 
 
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 May 11, 2021 by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for urine PCR panel testing (87798, 87511 and 87481) provided 
September 14, 2021 
 
You asked the Plan to pay for the PCR testing. You say that this denial was made in error and you ask that this 
decision be reversed and reimbursement made for the services provided. The Plan denied your request. The 
Plan says PCR testing is considered unproven and not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.   
We looked at this the file, and Medicare rules. The standard of care for the evaluation of urinary incontinence is 
urinalysis with urine culture and sensitivity. Based on this information, we decided that Medicare rules for 
coverage of the PCR testing have not been met. Therefore, we decided that the Plan does not have to pay for 
urine PCR panel testing (87798, 87511 and 87481) provided September 14, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and copayment for podiatry services provided 
on September 15, 2021. 
 
You asked the Plan to waive the deductible and copayment for the podiatry services. You say that you did not 
have to pay for these services before. The Plan denied your request. The Plan says the correct deductible 
amount and copayment were applied. 
 
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 $150 deductible which applies to certain items and services. 
 
Your contract with the Plan also clearly says that you must pay a $15 copayment for each podiatry visit. 
 
 The item or service you asked the Plan to waive the deductible and copayment for falls within the Podiatry 
Services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is $150 deductible which applies to certain items and services. This cost sharing is a contractual obligation that 
had not been met at the time the podiatry services were received on September 15, 2021.  
 
The file shows that you enrolled in the Plan on September 1, 2021. For the podiatry services received on 
September 15, 2021, the $150 deductible was applied first. Of the remaining charges, the copayment amount of 
$15 was applied. The total for the visit is $165. Therefore, we decided that the Plan does not have to waive the 
deductible and copayment for podiatry services provided on September 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Dual-energy X-ray absorptiometry (DXA) (77080) 
provided on December 17, 2021 (claim number 3500987700/KLC). 
 
You asked the Plan to pay for the DXA (77080). You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must confirm that Medicare 
coverage criteria have been met.  
 
We looked at the file and Medicare rules. In this case, there were no medical records provided confirming that two or three separate DXA services (77080) were provided December 17, 2021, by this provider. The file 
shows that the Plan paid for one claim submitted with code 77080 by this provider. Therefore, we decided that 
the Plan does not have to pay for the Dual-energy X-ray absorptiometry (DXA) (77080) provided on December 
17, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the patient is not safe at home due to their fall risk.  
You said that the patient needs to regain strength. The Plan denied your request. The Plan says SNF care is not 
medically necessary and the patient can be managed at a lower level of care. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there is no documentation that the patient 
requires skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional 
nurse are not required to safely and effectively provide medically necessary and reasonable treatment. Records 
do not document the need for intravenous medications, new tube feeding or ostomy care or daily complex 
wound care.  While the patient does require therapy, there is no documentation that the patient requires the 
services on an inpatient basis, only in a skilled nursing facility setting. Records do not document that services 
in the home with home health care or in a long-term care facility on a part time basis are not appropriate in this 
case. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist visit provided on October 5, 
2021. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you would like the charges 
covered. The Plan denied your request. The Plan says the copayment was applied 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 $35 
copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse 
practitioner or physicians assistant or other non-physician health care professionals in a specialists office (as 
permitted under Medicare rules).  
 
 
  You have been asked to pay $35 for the specialist visit. A specialist visit falls within the Consultation, 
diagnosis, and treatment by a specialist benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for the specialist visit provided on October 5, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the left hip for the enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is no evidence of conservative therapy, such activity modification, physical 
therapy, or home exercises. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
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 the MRI. Our reviewer says that the 
requested MRI is medically reasonable and necessary. Our physician reviewer found the enrollee is being 
considered for stem cell therapy, and assessment of the remaining if any cartilage of the hip is necessary in 
order to determine if that therapy is feasible. The only way to do this is via the requested MRI of the left hip. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
magnetic resonance imaging (MRI) of the left hip for the enrollee.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ultrasound provided on December 29, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an ultrasound. 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 authorization is 
required prior to an out-of-network visit. 
 
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 ultrasound provided on December 29, 2021 by 
an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation services (A0425, 
A0427) provided on December 10, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation services. You say that the 
services should be covered as you disagree with the charges and were not made aware of the copayment 
beforehand. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the 
services provided. 
 
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 $290 
copayment for Ambulance services.  
 
 You have been asked to pay a $290 copayment for the ambulance transportation services. 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 ambulance transportation services (A0425, A0427) provided on 
December 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for podiatry services provided on October 25, 
2021. 
 
You asked the Plan to waive the copayment for podiatry services. You say that you never had any procedure 
done to either of your feet. The Plan denied your request. The Plan says the copayment was applied 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, when 
in-network, a $45 copayment for each Medicare-covered visit in an office or home setting.  
 
 
  You have been asked to pay $45 for podiatry services. Podiatry services falls within the Podiatry Services 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for podiatry services provided on 
October 25, 2021.