Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on February 16, 2022 by an out-
of-network (OON) licensed clinical social worker (LCSW). 
 
You asked the Plan to pay for the OON LCSW services. You say that you have provided medical records to 
support payment for this service. The Plan denied your request. The Plan says unauthorized, non-plan 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 in this case is not a network provider with the Plan. 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 medical services provided on February 16, 2022 by an out-of-
network (OON) licensed clinical social worker (LCSW).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rituxan injection services. 
 
You asked the Plan to pre-approve Rituxan injection services. You say that the enrollee has autoimmune brain 
disease and the requested injection services are medically necessary. The Plan denied your request. The Plan 
says the requested therapy is unproven for the enrollee's issues. The Plan says that this therapy is 
investigational and experimental. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Rituxan injection services. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found Rituxan is not 
FDA approved for use in the enrollee's diagnosis of limbic encephalitis/autoimmune encephalitis. The proposed 
use is not supported in the Compendia or a supported/approved Journal. The Compendia is silent on the use of 
the proposed drug/diagnosis combination. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Rituxan injection services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Rituxan injection services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and routine venipuncture provided on 
November 30, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit and routine venipuncture. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says the services were billed by/rendered 
by/referred by non-participating providers, The Plan also says that the services were not urgent or emergent, 
nor were they approved in advance. 
 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 and routine venipuncture provided 
on November 30, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on December 14, 2021. 
 
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 separately payable. 
 
The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided 
that the Plan does not have to pay for the laboratory services rendered on December 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3 for the enrollee. 
 
You asked the Plan to pre-approve Gelsyn-3. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the enrollee does not have any stated contraindications to the preferred products. 
 
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 Gelsyn-3. Our reviewer says that 
Gelsyn-3 is not medically reasonable and necessary. The Plan requires a trial of Orthovisc, Synvisc or Synvisc-
One before they will approve the requested drug. In this case, the patient has not tried and failed the required 
drugs. There is no documentation provided indicating that the Plan's required drugs would likely be less 
effective and/or likely have adverse effects for the enrollee. Our physician reviewer found that the enrollee's 
condition does not meet step therapy criteria for Gelsyn-3. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gelsyn-3 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 29, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says there is no 
evidence to support the referring provider was treating the patient. 
 
The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory 
tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary.  
 
 
 
 
 
 We looked at the file and Medicare rules. In this case, the records do not show that the lab services were 
ordered by the enrollee's treating physician. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the 
lab services provided on January 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing services of the prostate (0005U). 
 
You asked the Plan to pre-approve genetic testing services of the prostate. You say that genetic testing of the 
prostate is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not 
been met. 
 
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 genetic testing services of the prostate 
(0005U), have been met. In this case, the medical records that were provided do not include any evidence of 
genetic testing being ordered or why these services are medically necessary. Therefore, we decided that the 
Plan does not have to pre-approve genetic testing services of the prostate (0005U).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lower limb prosthetic components (codes L5312, 
L5705, L5828, L5845, L5848, L5856, L5920, L5984, and L5987). 
 
You asked the Plan to pre-approve lower limb prosthetic components. You say that the enrollee has exceeded 
the functional limits of the current prosthetic knee/foot and wants a knee that keeps up with a K3 lifestyle. The 
Plan denied your request. The Plan says the denial of authorization for these components is correct, because the 
enrollee needs the use of an ambulatory aid which is not consistent with a K3 ambulator and the notes do not 
show why a mechanical knee cannot be used. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve lower limb prosthetic components. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the Willow Wood meta shock foot and a microprocessor knee exceed the 
enrollee's medical needs. The K3 microprocessor knee exceeds the enrollee's medical needs because there are 
no objective physician notes supporting that the enrollee is a K3 ambulator or why the enrollee is unable to use 
the advanced feet. Without objective physician supporting documentation, this request cannot be supported. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lower limb prosthetic components have not been met. Therefore, we decided 
that the Plan does not have to pre-approve lower limb prosthetic components (codes L5312, L5705, L5828, 
L5845, L5848, L5856, L5920, L5984, and L5987).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal paracentesis with imaging guidance provided 
on December 16, 2021 by an out-of-network (OON) provider. 
 
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 were rendered by 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 referring provider 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 abdominal paracentesis with imaging guidance provided on December 16, 2021 by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 10, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
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 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 the lab services provided on August 10, 2021.
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. The Plan denied your request. The Plan says the criteria for 
admission to the Acute Inpatient Rehabilitation setting have not been met. 
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that 
you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational 
therapy, there is no documentation of a need for an intensive rehabilitation program. Our physician reviewer 
also found that there is not a reasonable expectation that you will be able to fully participate in and benefit from 
the intensive rehabilitation therapy program provided in an IRF. 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thirty (30) additional routine transportation trips 
(A0120). 
 
You asked the Plan to pre-approve additional transportation trips. You say that you need additional 
transportation rides for your surgery. The Plan denied your request. The Plan says you have exhausted the 
maximum benefit of 24 one-way trips per year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way trips per year trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve thirty (30) additional routine transportation trips (A0120).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound rendered on February 2, 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 separately payable. 
 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 76700 
is a column II code to column I code 93976. 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 the abdominal ultrasound rendered on February 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
 
We decided that the Plan does not have to waive the coinsurance for colostomy supplies provided on February 
1, 2022. 
 
You asked the Plan to waive the coinsurance for colostomy supplies. You say that you don't understand where 
the different charges are coming from. The Plan denied your request. The Plan says the coinsurance applied is 
correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare-covered medical supplies, which include colostomy bags and supplies directly 
related to colostomy care.  You have been asked to pay a total of $44.21 for colostomy supplies. 
 
Date of Service Item Allowed Amount Coinsurance Member Liability 
February 1, 2022 Barrier Wipes $5.50 20% $1.10 
February 1, 2022 Ostomy Pouch LIQ $36.12 20% $7.22 
February 1, 2022 EXT Wear OST SKN Barrier $130.05 20% $26.01 
February 1, 2022 Drain Ostomy Pouch $49.40 20% $9.88 
TOTAL:    $44.21 
 
Colostomy supplies fall within the Prosthetic devices and related 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 coinsurance for colostomy supplies provided on February 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pneumatic compression devices (E0675, E0673) provided on 
September 8, 2021. 
 
You asked the Plan to pay for pneumatic compression devices. You say that the requested items were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for pneumatic 
compression devices have not been met. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism is a preventive service. The rules also say that a PCD coded 
as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for pneumatic compression devices (E0675, E0673) provided on September 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee currently meets long term 
acute care admission criteria. The Plan denied your request. The Plan says the criteria for admission to the 
LTACH have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the patient does not require services at the LTACH that are not already available at 
the current facility. Our reviewer found that there are no services at the LTACH that the patient requires that 
are not already available and covered at the current facility. Our physician reviewer also found that transfer to a 
LTACH is not medically necessary as it would not be clinically advantageous at this time. 
 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist telehealth visit provided on 
February 14, 2022. 
 
You asked the Plan to waive the copayment for the telehealth visit. You say that you only called to cancel the 
injection appointment. 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 $35 
copayment for each specialist visit, including telehealth services.  
 
The record shows a telehealth visit was provided in order to discuss options for treatment. Therefore, you have 
been asked to pay a $35 copayment for the telehealth visit. The telehealth visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for a specialist telehealth visit provided on February 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office services provided on February 3, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the office services. You say that the service provided to the enrollee was a follow 
up visit and previous claims were paid. The Plan denied your request. The Plan says the rendering provider is 
an OON provider and there was no referral from an in-network provider or an 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 office services provided on February 3, 2022, 
by an out-of-network (OON) provider.