Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics for plantar fascial fibromatosis. 
 
You asked the Plan to pre-approve foot orthotics. You say that orthotics are necessary for heel pain. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
The records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics for plantar fascial 
fibromatosis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98940) rendered by 
the out-of-network (OON) provider on September 13, 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 chiropractic manipulative treatment (98940) rendered by the out-of-network 
(OON) provider on September 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 20, 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 were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an outpatient hospital setting and 
should have been billed with POS code 22. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on July 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient rehabilitation services provided 
from October 12, 2021, to October 20, 2021. 
 
You asked the Plan to waive the copayment for the inpatient rehabilitation services. You say that you have 
already paid for the first 5 days when you were admitted following surgery on October 7, 2021. 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 $325 per 
day for days 1-6 and $0 per day for additional days for each inpatient admission. This applies to each 
admission, including transferring from one facility to another or within the same facility between levels of care.   
The file shows you were admitted as an inpatient from October 7, 2021, to October 11, 2021. You were 
transferred to the inpatient rehabilitation level of care on October 12, 2021. This transfer is considered a new 
admission. Therefore, you have been asked to pay $325 per day for only the first 5 days of inpatient 
rehabilitation services. The total for the rehabilitation stay portion is $1,625 ($325 copayment x 5 days = 
$1,625). The inpatient rehabilitation services fall within the Inpatient Hospital Care 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 inpatient rehabilitation services provided from October 12, 
2021, to October 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
July 2, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network services. 
 
  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must 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 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 out of network physician services provided to the 
enrollee on July 2, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs received from July 4, 2021, to July 5, 
2021. 
 
You asked the Plan to pay for the drugs. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs received 
from July 4, 2021, to July 5, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from September 20, 2021, to October 8, 2021. 
 You asked the Plan to pay for the services. You say that the services which the enrollee required and received 
during the period in question are coverable under the Medicare Act. The Plan denied your request. The Plan 
says there were no skilled therapy or skilled nursing needs. 
 
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 the services. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. There are no identifiable skilled therapy service needs. The enrollee did not require skilled 
nursing or therapy services on a daily basis. The enrollee did not meet severity of illness or intensity of service 
criteria for an inpatient basis in a skilled nursing facility 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) services provided to the enrollee from September 20, 2021, to 
October 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder Detect test provided to the enrollee on July 
12, 2021. 
 
You asked the Plan to pay for the test. You say that this was medically necessary. The Plan denied your 
request. The Plan says screening services, such as pre-symptomatic genetic tests and services used to detect an 
undiagnosed disease or disease predisposition are not a benefit, and are not covered. 
 
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 pay for the test. Our reviewer says that the requested 
services are not considered medically reasonable and necessary in this case. Our physician reviewer found 
CxBladder is considered experimental/investigational as a screening test for urothelial cancer. Cystoscopy, 
ureteroscopy, possible biopsy and upper tract imaging will still be necessary regardless of the results of 
Cxbladder testing. Urinary biomarker tests such as CxBladder give significant false-negative results in patients 
with urothelial cancer and are subject to false-positive results in others. Accuracy is poor for low-stage and 
low-grade tumors. To date, there are multiple urine markers that have improved sensitivity over cytology but 
there is lack of validation of clinical utility. Some of the recently developed markers aim to change the 
paradigm of urothelial diagnosis and follow-up by replacing or reducing the need of invasive investigations. 
Further prospective validations are needed to confirm these findings. 
 
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 test have not been met. Therefore, we decided that the Plan does not have to 
pay for the CxBladder Detect test provided to the enrollee on July 12, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from April 1, 2020, to April 17, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider  has reported skilled services with the incorrect PDPM Health Insurance Prospective 
Payment System (HIPPS) Score. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the skilled nursing facility services were not supported in the medical record, and not reported 
according to the appropriate Patient Driven Payment Model (PDPM construct. Specifically, the completed 
Minimum Data Set (MDS) assessment was done with an Assessment Reference Date of May 19, 2020 with an 
entry date of May 15, 2020. Even though it appears that another completed MDS assessment was submitted 
with an ARD of March 19, 2020, the original submission was outside of the window for submissions. The 
original submission was out of compliance for more days than the stay itself, so the corrected claim cannot be 
used. 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 pay for skilled nursing facility (SNF) services 
provided to the enrollee from April 1, 2020, to April 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical supplies (A4550, A4649) provided to the enrollee on 
September 9, 2021. 
 
You asked the Plan to pay for the supplies. You say that this is medically necessary. The Plan denied your 
request. The Plan says the denied items would be bundled into the payment for the approved surgery. 
 
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, the CPT Code Manual definition of the denied codes is: 
 
A4550: 
 
Surgical trays 
 
A4649: 
 
Surgical supply; miscellaneous  
We find that these denied codes are not supported in the medical record. Specifically, both of these codes have 
a status indicator of "B" which means that payment for covered for services are always bundled into payment 
for other services not specified. Based on this information, we decided that Medicare rules for coverage of the 
supplies have not been met. Therefore, we decided that the Plan does not have to pay for surgical supplies 
(A4550, A4649) provided to the enrollee on September 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and coinsurance for a computed tomography 
(CT) scan of the neck and an iodine injection provided on September 8, 2021. 
 
You asked the Plan to waive the copayment and coinsurance for the CT scan and iodine injection. You say that 
you feel the charges are incorrect. The Plan denied your request. The Plan says the correct copayment and 
coinsurance was applied. 
 
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 $300 
copayment for diagnostic radiology services, not including X-rays. Your contract with the Plan clearly says that you must pay a 20% coinsurance for Part B drugs, including 
injectable drugs.  
 
You have been asked to pay a $300 copayment for the CT scan. The CT scan falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit category. You have also been asked to pay 
$13.32 for the iodine injection, which is 20% of the allowed amount ($66.58 allowed amount x 20% 
coinsurance = $13.32). The iodine injection falls within the Medicare Part B Prescription Drugs 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 and coinsurance for a computed tomography (CT) 
scan of the neck and an iodine injection provided on September 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98940) rendered by 
the out-of-network (OON) provider on September 20, 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 chiropractic manipulative treatment (98940) rendered by the out-of-network 
(OON) provider on September 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Procrit for the enrollee. 
 
You asked the Plan to pre-approve Procrit. You say that this is medically necessary for the enrollee. 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 Procrit. Our reviewer says that Procrit 
is not medically reasonable and necessary. The enrollee has age related osteoporosis without osteoporotic 
fracture. The requested medication is a new start. The provided records do not indicate that the enrollee has 
tried and failed Aranesp or Retacrit. The record does not indicate that the enrollee has a contraindication to or 
would have an adverse effect from the Plan's preferred alternatives. Our physician reviewer found that the 
enrollee's condition does not meet step therapy criteria for Procrit. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Procrit have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Procrit for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee on May 27, 2020, through May 31, 2020.  
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the provider did not bill as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
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 skilled nursing facility (SNF) services 
provided to the enrollee on May 27, 2020, through May 31, 2020. have been met. Despite multiple attempts by 
the plan, medical records were not received from the provider. The provider did not send a valid assessment to 
support their billed Patient Driven Payment Model (PDPM) score of IDIDI x 5 days. Without supporting 
documentation, the plan is right to edit the score down to ZZZZ x 5 days.. Therefore, we decided that the Plan 
does not have to pay for skilled nursing facility (SNF) services provided to the enrollee on May 27, 2020, 
through May 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a K3 level microprocessor knee. 
 
You asked the Plan to pre-approve a microprocessor knee. The Plan denied your request. The Plan says this is 
not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a microprocessor knee is covered for the indications 
established in the applicable LCD. 
 
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 a microprocessor knee. Our reviewer 
says that the requested microprocessor knee is not medically necessary. Our physician reviewer found that as 
the enrollee's physician has not clarified why the K3 level microprocessor knee is medically necessary as 
opposed to a K3 level mechanical knee, Medicare criteria for coverage are not met. 
 
 
 
 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a microprocessor knee have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a K3 level microprocessor knee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drug (A9270) provided on November 
19, 2021. 
 
You asked the Plan to pay for the self-administered drug. You say that you would like reconsideration because 
this drug was part of your emergency room visit. The Plan denied your request. The Plan says this drug is not 
covered under Medicare Part B. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drug 
(A9270) provided on November 19, 2021.  
 
Benefits for the self-administered drug 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $240 copayment charged for ambulance transport 
provided on June 12, 2001. 
 
You asked the Plan to waive this copayment. You say that you do not believe this bill is correct. The Plan 
denied your request. The Plan says this copayment was charged based on the services provided and the Plan 
contract. 
 
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 $240 
copayment for each one-way ambulance transport. The Plan paid its portion of the cost of this service. 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 $240 copayment charged for ambulance transport provided on June 12, 2001.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer (J1439). 
 
You asked the Plan to pre-approve Injectafer. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says step therapy criteria 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 Injectafer. Our reviewer says that this 
drug is not medically reasonable and necessary. Our physician reviewer found the Plan requires a trial of Infed 
and Venofer before they will approve the requested drug. In this case, the patient has not tried and failed the 
required drug(s). There is no documentation provided indicating that the plans 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 Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer (J1439).