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

 
We decided that the Plan does not have to pay for the laboratory services provided on February 24, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the referring provider is a contracted 
provider, and you would like the claim reprocessed for payment. The Plan denied your request. The Plan says 
the rendering and referring providers are both OON providers and there was no approved authorization. Also, 
the service rendered was not urgent or emergent. 
 
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 the laboratory services provided on February 24, 
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 therapeutic drugs (D9610) 
 
You asked the Plan to pre-approve the therapeutic drugs. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your dental benefits. 
 
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 pre-approve 
therapeutic drugs (D9610)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair for the enrollee. 
 You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says the clinical documentation does not show a mobility limitation due to a 
neurological condition, myopathy, or congenital skeletal deformity. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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. Our reviewer says that 
the requsted Our physician reviewer found that there is no documentation that the enrollee's mobility deficit 
cannot be helped by the use of a walker, cane, or manual wheelchair. There is no documentation that the 
enrollee would be able to safely operate the power mobility device. There is no documentation that the patient 
has a qualifying diagnosis for a group 3 power wheelchair. The provided records do not document that her 
mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity.  
 
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 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 3 standard power wheelchair for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiac risk assessment genetic screening test (CPT 
code(s): 81407, 81408) provided on November 5, 2020. 
 You asked the Plan to pay for the cardiac risk assessment genetic screening test. You say that the claim should 
be paid. The Plan denied your request. The Plan says they contacted the enrollee's provider, and the office 
stated the services were not ordered by the enrollee's provider 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the cardiac risk assessment genetic screening test have not been 
met. The cardiac risk assessment genetic screening panel was initiated by the laboratory and not by the 
enrollee's treating physician nor following a consultation or evaluation by the enrollee's treating physician. 
Therefore, we decided that the Plan does not have to pay for the cardiac risk assessment genetic screening test 
(CPT code(s): 81407, 81408) provided on November 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for COVID-19 vaccine administration (0001A) provided 
October 18, 2021. 
 
You asked the Plan to pay for the vaccination administration. You say that this is an appeal to request payment 
on this account. You have not been paid anything and the EOB explanation is vague. The Plan denied your 
request. The Plan says this service is not covered by this payer/contractor. You must send the claim to the 
correct payer. The Plan must follow Medicare rules. Medicare payment for COVID vaccinations administered during 
calendar years 2020 and 2021 to MA beneficiaries will be made through the Medicare FFS program. You must 
submit your claim for administration of the COVID-19 vaccine to the CMS Medicare Administrative 
Contractor (MAC) for payment. Therefore, we decided that the Plan does not have to pay for COVID-19 
vaccine administration (0001A) provided October 18, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $83.75 copayment for an ultrasound performed on March 
22, 2022. 
 
You asked the Plan to waive the $83.75 copayment for an ultrasound. You say that you should not be 
responsible for this because you were told this test was now required by your insurance. The Plan denied your 
request. The Plan says you pay a $125 copayment for radiological diagnostic services, not including x-rays, 
performed in a physicians office. 
 
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 $125 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.   
You have been asked to pay a $83.75 copayment for an ultrasound. An ultrasound falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit category. Your contract with the Plan clearly 
says that you must pay a $125 copayment for Outpatient Diagnostic Tests and Therapeutic Services and 
Supplies. However, you have only been asked to pay $83.75, which is less than the $125 copayment amount. 
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 $83.75 copayment for an ultrasound performed on March 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extra heavy duty, extra wide, hospital bed with 
weight capacity greater than 600 pounds (E0304). 
 
You asked the Plan to pre-approve a hospital bed. You say that this is the first time you are requesting a 
hospital bed and is needing durable medical equipment due to your medical conditions. The Plan denied your 
request. The Plan says the records do not show that the enrollee meets the criteria for the requested extra heavy 
duty extra wide hospital bed. 
 
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. The criteria for the requested hospital bed are that your weight must 
exceeds 600 pounds. The records show that the enrollee's current weight is 268 pounds. Therefore, the criteria 
have not been met. Based on this information, we decided that Medicare rules for coverage of a hospital bed 
have not been met. Therefore, we decided that the Plan does not have to pre-approve an extra heavy duty, extra 
wide, hospital bed with weight capacity greater than 600 pounds (E0304).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Prolia (CPT code J0897). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says they did not receive records to verify if the medication meets Medicare criteria. 
 
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 corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the Prolia (CPT code J0897). have 
been met. We did not receive records (office visit notes, test results or treatment) to determine if the medication 
is necessary. Therefore, we decided that the Plan does not have to pre-approve the Prolia (CPT code J0897).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are unable to walk and need rehabilitation in 
order to be able to go home. The Plan denied your request. The Plan says that criteria for admission to the IRF 
setting have not been met. Your ongoing skilled therapy and nursing needs can be provided at a lower level of 
care 
 
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 in this 
case the requested IRF care is found to be medically reasonable and necessary. Our physician reviewer found 
clinical documentation shows that you are quite functionally complex and would benefit from 3 face to face 
visits by physical medicine and rehabilitation physician on an inpatient basis in addition to monitoring active 
comorbidities. Therapy evaluations and physical medicine and rehabilitation evaluation state that you would 
significantly benefit from and tolerate intense therapy thus IRF criteria have been met. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dupixent 300/2ml injection for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says this self-administered drug is excluded from coverage under Part B. 
 
 
 
 
 
 
 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dupixent 300/2ml injection 
for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CGM (CPT code K0554). 
 
You asked the Plan to pre-approve the CGM. You say that the CGM is necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The enrollee is injecting insulin 1 time per day; therefore, the 
enrollee is not insulin three or more times per day. Based on this information, we decided that Medicare rules 
for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve 
the CGM (CPT code K0554).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital admission provided 
from March 30, 2020, to April 3, 2020. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you were told you would 
not have a copayment because this hospitalization was related to COVID-19. The Plan denied your request. 
The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your 
contract. Medicare covers all medically necessary hospitalizations. This includes if you're diagnosed with 
COVID-19 and might otherwise have been discharged from the hospital after an inpatient stay, but instead need 
to remain in the hospital under quarantine. Please note you are still responsible for any hospital deductibles, 
copayments, or coinsurance that apply. 
 
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 $492 
copayment for each of the first four days of a Medicare-covered inpatient hospital stay. Copayments begin to 
apply on the date you are admitted and do not apply to the date you are discharged. 
 You have been asked to pay a $1,968 copayment for four days of inpatient hospital care ($492 x 4 = $1,968). 
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 inpatient hospital admission provided from March 30, 
2020, to April 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74176 billed for date of service March 30, 
2022. 
 
You asked the Plan to pay for procedure code 74176. You say that the enrollee had multiple exams on this date, 
and this service is supported as billed. The Plan denied your request. The Plan says payment for code 74176 is 
bundled into payment for code 74174. 
 
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 74176 
is a column II code to column I code 74174. 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 74176 billed for date of service 
March 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture provided from December 13, 2021, to 
December 27, 2021. 
 
You asked the Plan to pay for acupuncture. You say that acupuncture is a covered benefit under the enrollee's 
health plan. The Plan denied your request. The Plan says a licensed acupuncturist is a non-covered provider 
type and the provider is not supervised by any physician, physician assistant, nurse practitioner or a clinical 
nurse specialist. 
 
  The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, a licensed acupuncturist is a non-covered provider 
type and the provider is not supervised by any physician, physician assistant, nurse practitioner or a clinical 
nurse specialist. Therefore, we decided that the Plan does not have to pay for acupuncture provided from 
December 13, 2021, to December 27, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound (76770) provided on February 27, 2022. 
 
You asked the Plan to pay for the ultrasound (76770). You say that the procedure was rendered in the 
appropriate place of service and the claim should be reconsidered for payment. The Plan denied your request. 
The Plan says the claim was billed with an incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules say that services furnished to a 
patient who is a registered inpatient, shall, at a minimum, report the inpatient hospital POS code 21. 
 
In this case, the CPT Code Manual definition of code 76770 is ultrasound, retroperitoneal (eg, renal, aorta, 
nodes), real time with image documentation; complete. 
  We find that CPT code 76770 is not supported in the medical record. Specifically, the outpatient POS code was 
billed but the enrollee was an inpatient at the time the service was received. Based on this information, we 
decided that Medicare rules for coverage of the ultrasound (76770) have not been met. Therefore, we decided 
that the Plan does not have to pay for the ultrasound (76770) provided on February 27, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio (CPT code J3380). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says the enrollee has not tried and failed the preferred step therapy drug(s): 
Remicade, Inflectra, or infliximab; and Stelara. The Plan states there is no indication our preferred drug(s) 
would likely be: less effective, and/or cause adverse effects for the enrollee. 
 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 the medication. Our physician reviewer 
found the enrollee has not tried and failed the required drug(s). The documentation does not support that 
Remicade, Inflectra, or Infliximab, and Stelara would likely be less effective, and/or would likely have adverse 
effects for the enrollee 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Entyvio (CPT code J3380).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided by a chiropractor on April 25, 2022. 
 
You asked the Plan to pay for the office visit. You say that you needed immediate attention to your back. The 
Plan denied your request. The Plan says the office visit is not a covered chiropractic service. 
 
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 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 provided by a chiropractor on April 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the coronavirus test kits purchased on January 28, 
2022. 
 
You asked the Plan to reimburse you for the coronavirus test kits. You say that your spouse was advised by a 
plan representative that their test kits would be covered. The Plan denied your request. The Plan says coverage 
applies to eligible tests that are purchased on or after February 1, 2022, through the end of the federal public 
health emergency or December 31, 2022, whichever is earlier. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the coronavirus test kits have not been met. Specifically, the test kits were purchased prior to 
February 1, 2022. Therefore, we decided that the Plan does not have to reimburse you for the coronavirus test 
kits purchased on January 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wig. 
 
You asked the Plan to pre-approve a wig. You say that the wig is necessary. The Plan denied your request. The 
Plan says the requested service is not covered by Medicare or the health plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. 
This item is available to the general public and would be helpful even to those who are not sick or injured. 
Therefore, we decided that the Plan does not have to pre-approve a wig.