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

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from . 
 
You asked the Plan to pay for SNF care. You say that the member walked 75 feet with therapy and had to take 
several breaks. You also say that you are worried that the member is not safe at home alone. The Plan denied 
your request. The Plan says based on the medical documentation provided with the appeal, the member exceeds 
mobility and activities of daily living criteria for skilled nursing admission. 
 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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
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 pay for skilled nursing facility (SNF) care provided from .
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a mammogram provided on May 11, 2022. 
 
You asked the Plan to waive the copayment for a mammogram. You say that you are disputing the share cost. 
The Plan denied your request. The Plan says this cost sharing was charged 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 $25 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $25 copayment for a mammogram. This item/service falls 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 a mammogram provided on May 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an oral appliance provided on March 2, 
2021. 
 
You asked the Plan to waive the cost share for an oral appliance. You say that you received approval for the 
oral appliance and the Plan should pay the remaining balance. The Plan denied your request. The Plan says this 
cost sharing was charged 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 10% 
coinsurance for durable medical equipment and supplies. 
 
You have been asked to pay $110.04, which is 10% coinsurance of the allowed amount for an oral appliance 
($1,100.40 allowed amount x 10% coinsurance = $110.04). This item/service falls within the durable medical 
equipment 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 cost share for an oral appliance provided 
on March 2, 2021.  
 
Please note that neither you nor the Plan are responsible for paying the balance bill. Please contact the 
provider about a refund for any amount you paid above the Medicare allowable amount for this oral appliance. 
If the provider is billing you for charges beyond any applicable cost-sharing amounts, please contact the Plan 
directly.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an urgent care visit provided on May 22, 2021. 
 
You asked the Plan to pay for the urgent care visit. You say that due to the Covid-19 pandemic, this practice 
has operated with limited staff as well as a high patient volume. The Plan denied your request. The Plan says 
the claim was received past the allowable time frame of 12 months. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the urgent care visit was not filed until September 9, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for an urgent care visit provided on May 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Feraheme. 
 
You asked the Plan to pre-approve Feraheme. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step-therapy rules for the requested drug 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 Feraheme. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of drugs Infed and Venofer before they will approve the requested drug. The case file does 
not contain documentation of trial and failure of Infed and Venofer. The documentation does not support that 
Infed and Venofer 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 Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Feraheme.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step-therapy rules for the requested drug 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 Prolia. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a history of osteoporotic fracture or a trial of zoledronic acid before they will approve the 
requested drug, Prolia. Based on the medical records provided, there is no history of osteoporotic fracture or an 
indication that the enrollee has tried and failed the required drug. Based on the medical records provided and 
the Medicare-approved major drug compendia, there is no indication that intravenous zoledronic acid would 
likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99214 billed for date of service July 25, 
2022. 
 
You asked the Plan to pay for procedure code 99214. You say that you have provided medical records to show 
the medical necessity of this service. The Plan denied your request. The Plan says payment for code 99214 is 
bundled into payment for codes 77263 and 77470-26. 
 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 99214 
is a column II code to column I codes 77263 and 77470-26. 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 99214 billed for date of service 
July 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an annual physical exam provided on August 3, 2022. 
 
You asked the Plan to pay for the annual physical exam. You say that your last annual physical exam took 
place on August 2, 2021, which is more than one year before your exam on August 3, 2022. The Plan denied 
your request. The Plan says that the medical claims the Plan received from your providers attest that you 
previously received an annual physical exam on July 11, 2022, so your annual benefit was exhausted with this 
exam. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. 
Therefore, we decided that the Plan does not have to pay for an annual physical exam provided on  
August 3, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on August 2, 2022. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says the provider must 
attempt to consult the attending or primary care physician about the services furnished and document the 
consent or declination date to consultations and the date of consultations in the patients medical record. If 
consultation with the attending or primary care physician is unsuccessful, document the patients medical chart 
with the date and manner of notification to the physician. There was no documented contact with the 
attending/primary care physician. 
 The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for psychotherapy provided on August 2, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for CT scan provided on September 29, 2022. 
 
You asked the Plan to waive the copayment for CT scan. You say that you are disputing the share cost. The 
Plan denied your request. The Plan says this cost sharing was charged 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 $295 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $138.10, which is less than the $295 copayment for CT scan. This item/service 
falls 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 CT scan provided on September 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (93325, 76536) provided on August 22, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the radiology services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this service was not pre-approved or emergent. There were network 
providers available. 
 
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 radiology services (93325, 76536) provided on 
August 22, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the general health panel (80050) provided on August 8, 
2022. 
 
You asked the Plan to pay for the general health panel. You say that this service should be covered. The Plan 
denied your request. The Plan says this panel is not covered. 
 
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-
covered code. 
 
You have requested payment for services billed under code 80050. Medicare does not cover or pay for services 
billed under this code. Therefore, we decided that the Plan does not have to pay for the general health panel 
(80050) provided on August 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for rest home visit provided on September 02, 2022. 
 
You asked the Plan to pay for rest home visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for rest home visit provided 
on September 02, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on April 29, 2022. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on April 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM) and 
supplies (K0553, K0554). 
 
You asked the Plan to pre-approve a CGM and supplies. You say that you disagree with the denial. The Plan 
denied your request. The Plan says you take fixed dose insulin twice a day and you do not adjust your 
insulin dose based on your blood glucose results. You do not meet criteria for approval. 
 
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 documentation indicates that you do not use insulin with at least 
three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing 
results. Based on this information, we decided that Medicare rules for coverage of a CGM and supplies have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous 
glucose monitor (CGM) and supplies (K0553, K0554).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
July 14, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 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 should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service July 14, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Revefenacin inhalation solution (code J7677) and pharmacy 
dispensing fee for inhalation drug (code Q0514) provided on January 24, 2022. 
 
You asked the Plan to pay for Revefenacin inhalation solution (code J7677) and pharmacy dispensing fee for 
inhalation drug (code Q0514). The Plan denied your request. The Plan says Original Medicare would be 
responsible for payment of all Medicare covered services related or unrelated to the members terminal 
condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the 
effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare 
also covers attending physician services and all care unrelated to the terminal illness until the first day of the 
month following the month in which hospice was revoked or discharged.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for Revefenacin inhalation solution (code J7677) and pharmacy 
dispensing fee for inhalation drug (code Q0514) provided on January 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
August 16, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 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 should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service August 16, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood draw (36415), basic metabolic panel (80048), and 
travel allowance for medically necessary laboratory services (P9603) provided on August 19, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the enrollee was not enrolled in hospice on 
this date. The Plan denied your request. The Plan says the enrollees claim would be covered under Original 
Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of 
the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures for a Medicare Advantage 
member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on August 4, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the blood draw 
(36415), basic metabolic panel (80048), and travel allowance for medically necessary laboratory services 
(P9603) provided on August 19, 2021.