Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the OneTouch Verio test strips. 
 You asked the Plan to pre-approve the OneTouch Verio test strips. You say that this specific brand of test strip 
is medically reasonable and necessary over the Plan's preferred brand. The Plan denied your request. The Plan 
says there is no reason why the enrollee could not use the Plan's preferred brands. 
 
The Plan follows Medicare rules. Medicare rules say that the Plan may limit coverage to specific preferred 
brands as long as the criteria listed in the Medicare rule section are satisfied. 
 
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 OneTouch Verio test strips. Our 
reviewer says that this brand of test strips is not medically reasonable and necessary over the Plan's preferred 
brand of test strip. Our physician reviewer found specifically in this case, there is no reason given why the 
enrollee would need the OneTouch Verio test strips beyond it being liked more than the Plan's preferred brand. 
Therfore, the OneTouch verio meter and strips do not meet medical necessity criteria. 
 
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 OneTouch Verio test strips have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the OneTouch Verio test strips.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 26, 2021 billed with 
codes 81227, 81226, 81241, 81400, 81401, 81230, 81231, 81240, 81232, 81406, 81350, 81479, 81223, 81408, 
and 81291. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the 
services were billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on October 26, 2021 
billed with codes 81227, 81226, 81241, 81400, 81401, 81230, 81231, 81240, 81232, 81406, 81350, 81479, 
81223, 81408, and 81291.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) services 
you are requesting do not meet the requirements for approval. 
 
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 pre-approve 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 complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for right hip pain. Medical problems are stable. 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 pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wigs provided on April 7, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for wigs. You say that the wigs were purchased due to what was advised to you by a 
Plan rep, and you do not feel the claim should be denied. The Plan denied your request. The Plan says you 
purchased a wig, from an out-of-network provider without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for wigs provided on April 7, 2022, by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 15, 2021, by an OON 
provider. 
 
You asked the Plan to pay for an office visit. You say that the treatment was medically necessary for the 
enrollee and its administration was time sensitive. The Plan denied your request. The Plan says the out-of-
network services were not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on October 15, 2021, by 
an OON provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Epogen. 
 
You asked the Plan to pre-approve Epogen. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan requires 
a trial of Procrit or Retacrit before it will approve Epogen. 
 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 Epogen. Our reviewer says that the 
enrollee does not meet the Medicare criteria for a step therapy exception for Epogen. Our physician reviewer 
found the enrollee has not tried and failed the Plan's preferred drugs of Procrit or Retacrit. The record does not 
show that these drugs would likely be less effective and/or 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 Epogen have not been met. Therefore, we decided that the Plan does not have to 
pre-approve use of Epogen.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wheelchair van transportation (A0130) provided on 
November 12, 2021. 
 
You asked the Plan to pay for the wheelchair van transportation. You say that the enrollee required 
safety/monitoring en route due to their psychiatric condition. The Plan denied your request. The Plan says the 
enrollee does not meet the criteria for wheelchair van transportation, as the code is not listed. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided 
that the Plan does not have to pay for the wheelchair van transportation (A0130) provided on November 12, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visits provided on November 4, 2021 and December 
23, 2021, by an OON provider. 
 
You asked the Plan to pay for office visits. You say that you thought this provider was your primary care 
physician (PCP). You did not know you needed a referral to see the PCP.  The Plan denied your request. The 
Plan says the out-of-network services were not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for office visits provided on November 4, 2021 and 
December 23, 2021, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 5, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the service was 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 
office visit. We found no exception that would require the Plan to pay for the office visit. The records provided 
for review do not show that the office visit was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the office visit provided on January 5, 2022, by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay further for the specialist services rendered on March 14, 2022, to 
April 8, 2022. 
 
You asked the Plan to pay further for these services. You say that you were referred to the doctor by the 
Veterans Hospital and he did not request authorization. The Plan denied your request. The Plan says the claim 
was 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $5 copayment for per physician specialist visit in the provider network, including additional 
telehealth services.  
 
The file shows that the enrollee received surgical services on March 14, 2022. The Plan agreed to pay for these 
services at the Medicare allowed amount. Further payment cannot be made beyond the Medicare allowed 
amount. 
 Review of the file shows that the enrollee had an office visit with a specialist April 8, 2022. The Plan agreed to 
pay for these services at the Medicare allowed rate, minus the $5 copayment. These services fall within the 
physician specialist visit in the provider network, including additional telehealth services, benefit category. 
This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This 
cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we 
decided that the Plan does not have to pay further for the specialist services rendered on March 14, 2022, to 
April 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on December 15, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advanced. 
 
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 laboratory services at issue in this appeal. The Plan did not pre-approve 
the laboratory services at issue. We found no exception that would require the Plan to pay for these laboratory 
services. Therefore, we decided that the Plan does not have to pay for laboratory services provided on 
December 15, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services rendered on March 8, 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 the PC and TC for diagnostic services are separately 
payable when furnished in different payment localities. 
 
We looked at the file and Medicare rules. The file shows that the PC and TC were not performed in different 
payment localities. 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 pay for the imaging services rendered 
on March 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the determination of refractive state (92015) provided on 
April 4, 2022 by an ophthalmologist. 
 
You asked the Plan to pay for the determination of refractive state. You say that you would like to know why 
you are being charged for this when you should have no copay. The Plan denied your request. The Plan says 
your contract only provides coverage for a refraction service when performed as part of a routine vision exam 
by optometrist. The Plan also says that a refraction service provided by an ophthalmologist is not covered and 
is excluded from Medicare coverage. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when the refraction is performed as part of a routine vision eye exam 
by an optometrist. 
 
 
 We looked at the file and the Plan's rules. The record shows this refraction you received was rendered by an 
ophthalmologist. Based on this information, we decided that the Plan's rules for coverage of the determination 
of refractive state have not been met. Therefore, we decided that the Plan does not have to pay for the 
determination of refractive state (92015) provided on April 4, 2022 by an ophthalmologist.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 10, 2022. 
 
You asked the Plan to pay for the services provided. You say that no coding change is required. The Plan 
denied your request. The Plan says no separate payment is made. 
 
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 99053 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99053 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
have not been met. Therefore, we decided that the Plan does not have to pay for the medical services provided 
on January 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames (V2020), deluxe lens feature (V2702), and 
photochromatic tint (V2744) provided on July 21, 2020. 
 
You asked the Plan to pay for the glasses. You say that you would like to be reimbursed for an eye 
examination. The Plan denied your request. The Plan says eyeglasses are not covered. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when you have received cataract surgery. 
 
We looked at the file and the Plan's rules. No documentation was provided showing you received cataract 
surgery prior to July 21, 2020. Based on this information, we decided that the Plan's rules for coverage of the 
glasses have not been met. Therefore, we decided that the Plan does not have to pay for the frames (V2020), 
deluxe lens feature (V2702), and photochromatic tint (V2744) provided on July 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture (D5212) and a maxillary 
partial denture (D5213). 
 
You asked the Plan to pre-approve the partial dentures. You say that you believe these dentures should be 
covered. The Plan denied your request. The Plan says your benefit for the requested item or service has already 
been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service August 11, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture (D5212) and a 
maxillary partial denture (D5213).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 12, 2021. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on August 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation (D9310) provided on March 22, 2022. 
 
You asked the Plan to pay for the consultation. You say that you were in severe pain and there was not an in-
network endodontist within at least 50 miles from you that was able to perform the procedure within a 
reasonable timeframe. The Plan denied your request. The Plan says this service is not a covered benefit under 
your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
consultation (D9310) provided on March 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on November 18, 2021, by an OON 
provider. 
 
You asked the Plan to pay for genetic testing. You say to please review the attached documentation to support 
medical necessity of the testing performed and to justify the services in which were processed as non-covered. 
The Plan denied your request. The Plan says the out-of-network services were not authorized.  
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for genetic testing provided on November 18, 2021, 
by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for targeted genomic sequence analysis panel (81455) provided 
on March 22, 2021. 
 
You asked the Plan to pay for targeted genomic sequence analysis panel. You say that you are appealing with 
supporting documentation. The Plan denied your request. The Plan says screening genetic testing is not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that Molecular next generation sequencing (NGS) 
testing alone (for myeloid mutations) or in combination with FISH testing is not reasonable and necessary for 
the diagnosis of MDS, and is not a Medicare benefit.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of targeted genomic sequence analysis panel have not been met. Therefore, we decided that the Plan 
does not have to pay for targeted genomic sequence analysis panel (81455) provided on March 22, 2021.