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

 
We decided that the Plan does not have to pay for x-rays provided on November 07, 2022. 
 
You asked the Plan to pay for x-rays. 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 x-rays provided on 
November 07, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth visit provided on May 31, 2022. 
 
You asked the Plan to pay for a telehealth visit. You say that this was medically necessary and should be 
covered. 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 a telehealth visit 
provided on May 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87798, 87481, 87640, and 87653 
provided on December 8, 2022. 

You asked the Plan to pay for procedure codes 87150, 87798, 87481, 87640, and 87653. You say that you 
would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the 
services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets. 
 
We looked at the file and Medicare rules. In this case, the test panel was billed with multiple codes and 
multiple units of service. The panel cannot be unbundled and must be billed with one unit of service. Based on 
this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 87150, 87798, 87481, 87640, and 87653 
provided on December 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services and a clinic visit provided on September 14, 
2022. 
 
You asked the Plan to pay for lab services and a clinic visit. You say that these services were medically 
necessary. 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 lab services and a clinic 
visit provided on September 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen 
(74170) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a CT scan of the abdomen to be provided by an OON provider. You say that 
the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are 
able to provide these services. Therefore, coverage criteria have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a computed tomography (CT) scan of the abdomen (74170) to be provided by an out-of-network (OON) 
provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the diagnostic mammogram provided on November 
21, 2022. 
 
You asked the Plan to waive the copayment for the diagnostic mammogram. You say that you do not think you 
should have to pay for this service. The Plan denied your request. The Plan says that this cost sharing was 
charged correctly. 
 
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 you pay no coinsurance, copayment, or deductible for Medicare-covered x-ray 
services. 
 
The Plan says you must pay a $79.84 copayment for the diagnostic mammogram. Based on the Plan contract, 
however, you cannot be asked to pay any cost sharing for the diagnostic mammogram. Therefore, we decided 
that the Plan has to waive the copayment for the diagnostic mammogram provided on November 21, 2022.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would have a better chance and quicker 
outcome to return to living his life as a builder/home contractor. The Plan denied your request. The Plan says 
the enrollee's condition does not meet Medicare guidelines for IRF services. 
 
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 that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that 
the enrollee 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 an IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the arthrocentesis and drug injection 
provided on July 29, 2022. 
 
You asked the Plan to waive the cost share for the arthrocentesis and drug injection. You say that this should 
not be considered a surgery. 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 $475 copayment for outpatient surgery provided at an outpatient hospital. The Plan contract also clearly says that 
you must pay 20% coinsurance for Medicare Part B drugs provided at an outpatient hospital. 
 
According to Medicare an arthrocentesis (code 20610) is considered a surgical procedure. You have been asked 
to pay a $475 copayment for the arthrocentesis. This item/service falls within the outpatient surgery benefit 
category.  
 
You have also been asked to pay $195.24, which is 20% coinsurance of the allowed amount for the drug 
injection ($976.18 allowed amount x 20% coinsurance = $195.24). This item/service falls within the Medicare 
Part B drugs benefit category. You have been asked to pay a total of $670.24 ($475 copayment + $195.24 
coinsurance = $670.24). 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 the arthrocentesis and drug 
injection provided on July 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the primary care provider office visit 
provided on November 15, 2022. 
 
You asked the Plan to waive the copayment for the primary care provider office visit. You say that this should 
be considered your annual wellness visit. 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 $10 
copayment for primary care physician/practitioner services. 
 
You have been asked to pay a $10 copayment for the primary care provider office visit. This item/service falls 
within the primary care physician/practitioner services 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. The records show the office visit provided was a new patient 
visit and not an annual wellness visit. Therefore, we decided that the Plan does not have to waive the 
copayment for the primary care provider office visit provided on November 15, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that you would like the Plan to reconsider their denial. The 
Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for a CGM. 
 
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 the enrollee does not use insulin 
with at least three daily injections and does not 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 have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluoroscopic evaluation (92611), x-ray of swallow 
function, with contrast (74230), and x-ray of upper gastrointestinal tract, with contrast, (74240) provided on 
November 9, 2022. 
 
You asked the Plan to pay for the fluoroscopic evaluation and x-rays with contrast. You say that these services 
were performed at the request of the primary care physician at the facility. You say that there are no contract 
providers that could have provided this service in the way to eliminate transporting. You also say that then 
enrollee has a limitation to transport. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that procedures and examinations which are not 
covered under the portable x-ray provision include procedures involving the use of contrast media.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the x-rays with contrast and fluoroscopic evaluation have not been met. Therefore, we decided that 
the Plan does not have to pay for the fluoroscopic evaluation (92611), x-ray of swallow function, with contrast 
(74230), and x-ray of upper gastrointestinal tract, with contrast, (74240) provided on November 9, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the requested Prolia is medically necessary. The Plan 
denied your request. The Plan says the enrollee must try and fail one intravenous bisphosphonate therapy first. 
 
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 Plan's 
step therapy criteria have not been met. Our physician reviewer found based on the medical records provided 
there is no indication that the enrollee has tried and failed the required drug(s). Based on the medical records 
provided and the Medicare-approved major drug compendia there is no indication that the plan's required 
drug(s) 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 Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 18, 2022. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
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 an office visit provided 
on October 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for hand x-rays provided on February 10, 
2022. 
 
You asked the Plan to waive the copayment for hand x-rays. You say that you do not think you should owe 
anything for these services. 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 $40 
copayment for Medicare-covered x-rays. 
 
You have been asked to pay a $40 copayment for hand x-rays. This item/service falls within the Medicare-
covered x-rays 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 hand x-rays provided on 
February 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an office visit to be provided by an OON provider. You say that the services 
are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to 
provide these services. Therefore, coverage criteria have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the mastectomy bra (L8000), and 
mastectomy form (L8020) provided on November 15, 2022. 
 
You asked the Plan to waive the copayment for the prostheses. You say that you are not happy with the 
mastectomy form. You say that it is not heavy enough. You say that you tried to return them. You also say that 
you do not want to pay for something you cannot use. 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 20% 
coinsurance for Prosthetic Devices and Related Supplies.  
 
You have been asked to pay a 20% coinsurance for the prostheses. These items 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. Additionally, the record shows you are eligible for another prosthesis in May. Therefore, 
we decided that the Plan does not have to waive the copayment for the mastectomy bra (L8000), and 
mastectomy form (L8020) provided on November 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit provided on November 02, 
2022, to November 23, 2022. 
 
You asked the Plan to pay for domiciliary or rest home visit. You say that the records attached support the 
services provided. 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 domiciliary or rest home 
visit provided on November 02, 2022, to November 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a subsequent nursing facility care visit provided on August 
31, 2022. 
 
You asked the Plan to pay for a subsequent nursing facility care visit. You say that the records attached support 
the services provided. 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 a subsequent nursing 
facility care visit provided on August 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on July 19, 2022. 
 
You asked the Plan to pay for wound care supplies. You say that these services do not require separate 
authorization. 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 wound care supplies 
provided on July 19, 2022.