Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99213, 1111F, 3078F, 3074F) provided on 
October 7, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says this provider is not a network provider with the Plan and the services were 
not referred by a network provider or rendered in an in-network facility. The Plan also says that they have also 
determined that these 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 (99213, 1111F, 3078F, 3074F) 
provided on October 7, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies (A6196, A6252, A6446, A4450) 
provided on July 30, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for wound care supplies. You say that this provider provided medically necessary 
surgical dressings for the treatment of the beneficiary's wounds on theses dates of service. You also say that 
you have an exclusive wound care supply agreement with this facility, wherein you are the exclusive supplier 
of surgical wound dressings to their residents. The Plan denied your request. The Plan says this provider is not 
a network provider, and the services were not referred by a network provider or rendered in an in-network 
facility. The Plan also says that they have also determined that these services are 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 wound care supplies (A6196, A6252, A6446, 
A4450) provided on July 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 lab services provided on September 24, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. 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 September 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the programming device evaluation (93284) rendered by the 
out-of-network (OON) provider on September 10, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the programming device evaluation (93284) rendered by the out-of-network (OON) 
provider on September 10, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says the requested continued SNF care does not 
meet criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found you do not have a need for 
intravenous medications, new tube feeding, ostomy care or daily complex wound care. You do not appear to be 
making consistent progress with daily skilled therapy; despite about two weeks of daily skilled treatment, you 
remain moderate to maximum assist with mobility, transfers and activities of daily living. Provided records do 
not document a need for ongoing daily inpatient skilled therapy services as opposed to part time services. You 
do not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in the home 
with home health care or in a long-term care facility on a part time basis appear appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services provided on October 27, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the ophthalmological services. You say that it is up to the facility to get a prior 
approval and the authorization should fall under the facilities authorization. The Plan denied your request. The 
Plan says the rendering provider is an out-of-network provider 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 ophthalmological services provided on October 
27, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit (99336) provided on August 
18, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the services performed by this non-participating provider 
on August 18, 2021, were not authorized by the Plan. The provider that performed these services is not in the 
Plan. 
 
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 a domiciliary or rest home visit (99336) provided 
on August 18, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) scan of the head for the 
enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says the notes from the doctor do not show a detailed history of symptoms, a detailed 
physical exam, or results or other tests or treatments. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found the enrollee was noted 
to have a non-specific complaint of dizziness. There was limited evidence of a neurological exam that would 
generally prompt a need for imaging. Even then - if imaging were to be performed, a CT is not the primary 
modality for such an evaluation to be performed. Magnetic resonance imaging (MRI) is otherwise generally 
preferred for the performance of neuro-imaging studies. For these reasons the requested study cannot be 
determined to have been reasonable and necessary at the time it was provided. This would not have met 
Medicare criteria for coverage. 
 
 
 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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve computed tomography (CT) scan of the head for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services (90833, 90834) and the office 
visits (99214) rendered by the out-of-network (OON) providers from September 26, 2020, through October 1, 
2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by out of network 
providers, 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 providers in this case are not network providers with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the psychotherapy services (90833, 90834) and the office visits (99214) rendered 
by the out-of-network (OON) providers from September 26, 2020, through October 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 22, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the in-network provider referred the 
enrollee to receive services from you. The Plan denied your request. The Plan says the rendering provider is an 
out-of-network 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 laboratory services provided on November 22, 
2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a diagnostic colonoscopy provided on 
December 17, 2021. 
 
You asked the Plan to waive the deductible for a diagnostic colonoscopy. You say that you were told by your 
insurance that the procedure would be covered in full. You also say that you would have waited to have the 
procedure done if you had known the deductible applied. 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. Your 
contract with the Plan says that there is a $9,000 deductible which applies to outpatient surgery.  
 
The diagnostic colonoscopy you asked the Plan to waive the deductible for falls within the Outpatient Surgery, 
Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $9,000 
deductible which applies to outpatient surgery. This cost sharing is a contractual obligation that had not been 
met at the time a diagnostic colonoscopy was received on December 17, 2021. Therefore, we decided that the 
Plan does not have to waive the deductible for a diagnostic colonoscopy provided on December 17, 2021.  
 Your complaint about receiving incorrect information from your insurance company is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 23, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the services were rendered to the enrollee 
out of medical necessity. The Plan denied your request. The Plan says the rendering provider and referring 
provider are both out-of-network providers and there was no prior 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 June 23, 2021, 
by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. The Plan denied your request. The Plan says this medication does 
falls under Part D coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Botox.  
 
Benefits for Botox may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the office visit (99214) provided on  
October 19, 2021. 
 
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by a provider that 
does not participate in the Medicare program.   
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of this service has not been met. Specifically, this service was rendered by a provider that does not 
participate in the Medicare program. Therefore, we decided that the Plan does not have to issue reimbursement 
for the office visit (99214) provided on October 19, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that you are currently receiving afternoon assistance. 
 
 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found the documentation 
does not support that you require in-home skilled physician, nursing, or rehab services to provide treatment that 
is medically necessary. The documentation does not support that the enrollee is homebound. You have been 
medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The 
requested home health services are not medically necessary and can be received on an outpatient basis. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home health services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90792) rendered by the 
out-of-network (OON) provider on October 28, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was 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 service provided in this case was a telehealth visit rendered by an out-of-network provider. The Plan 
contract states that an enrollee has the option of getting covered services through an in-person visit or by 
telehealth. If the enrollee chooses to get one of these services by telehealth, they must use a network provider. 
The Plan had network providers available who could have provided the service at issue in this appeal. The Plan 
did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this 
service. Therefore, we decided that the Plan does not have to pay for the psychiatric diagnostic evaluation 
(90792) rendered by the out-of-network (OON) provider on October 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xgeva. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of iron-
deficiency anemia and neuroendocrine carcinoma. She has not tried and failed the Plan's required drugs, 
intravenous (IV) bisphosphonate therapy with pamidronate or zoledronic acid. The records do not show that the 
required drugs would be contraindicated or less effective; therefore, Xgeva is not reasonable or medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve Xgeva.