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

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on July 27, 
2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that you disagree with the 
copayment 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 $35 
copayment for in-network physician/practitioner services/specialist.  
 
You have been asked to pay a $35 copayment for specialist office visit. However, you are only being asked to 
pay $22.50 which is less than the required amount. This item/service falls within the in-network 
physician/practitioner services/specialist 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 specialist office visit provided on July 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services rendered on March 26, 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 covered. 
 
The Plan must follow Medicare rules. The rules say that the PC and TC for diagnostic services are separately 
payable when furnished in different payment localities. 
 
We looked at the file and Medicare rules. The file shows that the PC and TC were not performed in different 
payment localities. 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 pay for the pathology services 
rendered on March 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) provided on July 25, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and prior authorization was not obtained. 
 
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 (99214) provided on July 25, 2022, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medication assisted treatment (G2067) provided on 
December 27, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the medication assisted treatment. You say that the services should be covered as 
you disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they 
were non-emergent and prior authorization was not obtained. 
 
  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 medication assisted treatment (G2067) provided 
on December 27, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vision care services to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve vision care services. You say that you have been under this provider's care 
since 1990 for your detached retinas and cataract surgeries. The Plan denied your request. The Plan says the member's needs can be met in-network, therefore going out of network is not medically necessary at this time. 
The Plan also says that there are 44 in-network providers within a 20 mile radius of the member's zip code. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when the services are received by a participating provider. 
 
We looked at the file and the Plan's rules. The Plan rules say that services are only covered when received by a 
participating provider. Based on this information, we decided that the Plan's rules for coverage of vision care 
services have not been met. Therefore, we decided that the Plan does not have to pre-approve vision care 
services to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies, 2 lead, per month (A4595) 
provided on June 9, 2022. 
 
You asked the Plan to pay for the supplies. You say that the supplies should be covered. The Plan denied your 
request. The Plan says the supplies are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that for DMEPOS items and supplies provided on a 
recurring basis, billing must be based on prospective, not retrospective use. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the supplies have not been met. The provided documentation does not support that the enrollee 
requires or uses the device. As such, the necessity of the periodic electrode delivery is not supported. Therefore, we decided that the Plan does not have to pay for the electrical stimulator supplies, 2 lead, per 
month (A4595) provided on June 9, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Mavenclad. 
 
You asked the Plan to pre-approve Mavenclad. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 pre-approve Mavenclad.  
 
Benefits for Mavenclad 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 73100 billed for date of service July 13, 
2022. 
 
You asked the Plan to pay for procedure code 73100. You say that the enrollee had multiple exams on the same 
date of service. The Plan denied your request. The Plan says payment for code 73100 is bundled into payment 
for code 73110. 
 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 73100 
is a column II code to column I code 73110. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 73100 billed for date of service July 13, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, emergency 
transport (A0429) and ground mileage (A0425) provided on June 20, 2022. 
 
You asked the Plan to pay for the emergency ambulance transport and ground mileage. You say that the 
ambulance transport was medically necessary. The Plan denied your request. The Plan says the services as 
billed are excluded from Medicare coverage. 
 
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 looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the emergency transport are not met. Specifically, the services at issue were billed with a GY 
modifier. The Plan cannot pay for the services as billed by the non-contracted provider. Based on this 
information, we decided that Medicare rules for coverage of the emergency ambulance transport and ground 
mileage have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance service, 
basic life support, emergency transport (A0429) and ground mileage (A0425) provided on June 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography/computed tomography 
(PET/CT) scan. 
 
You asked the Plan to pre-approve a PET/CT scan. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PET scan is covered under certain circumstances. 
 
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 PET/CT scan. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee had a computed 
tomography (CT) of the chest on November 3, 2021, over 1 year ago, that showed abnormal findings in the 
lungs, mediastinum and right hilum. This scan was over 1 year ago and no follow-up CT scan has been done. 
Prior to authorizing PET/CT for follow-up a repeat CT of the chest to determine if those abnormal findings 
have resolved, remained stable or having increased would seem appropriate. Absent such information the 
medical necessity of PET/CT has not yet been established. 
 
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 PET/CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography/computed tomography (PET/CT) scan.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services and home health aide services. 
 
You asked the Plan to pre-approve home health services and home health aide services. You say that home 
health services and home health aide services are medically necessary. The Plan denied your request. The Plan 
says based on your assessment you do not need as many hours of care as you are requesting. Our records show 
you live alone. You are independent for dressing and personal hygiene. You need help with housework and 
meals. You need some help with your medication and once a day insulin. You do not need as many visits for 
these complex skilled nursing needs for services as requested. No documentation to support the need for more 
services. 
 
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. The rules say that HHA services may be covered if it is medically necessary for the 
enrollee to receive skilled nursing or therapy. 
 
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 home health services and home health 
aide services. Our reviewer says that home health services and home health aide services are not medically 
necessary. Our physician reviewer found that there is no documentation to show that the enrollee has functional 
deficits resulting in activities of daily living impairment and no changes in clinical status after first visit thus 
further skilled nursing assessment after 1 visit and the requested home health aide service was not 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 home health services and home health aide services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve home health services and home health aide 
services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5261) purchased on  
June 7, 2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable as 
they were purchased from an out-of-network provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from the Plans select hearing aid provider.  
 
We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract states that hearing aids must be 
purchased from the Plans select hearing aid provider. The hearing aids in this case were purchased from an 
out-of-network provider. Therefore, we decided that the Plan does not have to issue reimbursement for the 
hearing aids (V5261) purchased on June 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve 
branches including imaging guidance, when performed (64624). 
 
You asked the Plan to pre-approve the surgical procedure. You say that please consider this an official request 
for an appeal of the decision to deny CPT code 64624. Enclosed you will find updated information for review. 
The Plan denied your request. The Plan says there is not enough evidence to show that this procedure is safe 
and that it works well for knee pain. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at this the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the surgical procedure have not been met. Therefore, we decided that the Plan does not have to pre-
approve destruction by neurolytic agent, genicular nerve branches including imaging guidance, when 
performed (64624).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for COVID-19 test kits provided on August 4, 2022. 
 
You asked the Plan to pay for COVID-19 test kits. You say that on August 4, 2022, you  had COVID-19 
symptoms, and you immediately purchased the home self-test kid. You also say that you could not receive the 
test kit from the government agent on time after ordering it 7 days prior. The Plan denied your request. The 
Plan says per the Centers for Medicare & Medicaid Services (CMS), plans or issuers may, but are not required 
by federal law to provide such coverage for over-the-counter at-home COVID-19 tests. The Plan also says that 
per the EOC, if the member gets services that are excluded (not covered), the member must pay for the services 
themselves. 
 
The Plan must follow Medicare rules. Medicare rules say that enrollees cannot submit a claim for these tests to 
Medicare or their MA plan (unless covered by a supplemental benefit) for reimbursement under this initiative.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of COVID-19 test kits have not been met. Therefore, we decided that the Plan does not have to pay 
for COVID-19 test kits provided on August 4, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo and Yervoy. 
 
You asked the Plan to pre-approve Opdivo and Yervoy. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested drugs are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 Opdivo and Yervoy. Our reviewer says 
that the documentation does not support that the requested drugs are medically reasonable or necessary. Our 
physician reviewer found the enrollee has a diagnosis of glioblastoma. The Food and Drug Administration has 
not stated that the requested drugs are indicated for the enrollee's condition. The Medicare approved cancer 
drug compendia do not contain a supportive citation for the use of the requested drugs in the enrollee's clinical 
situation. Therefore, the enrollee does not meet criteria for the requested drugs. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Opdivo and Yervoy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Opdivo and Yervoy.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve continued inpatient skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF care. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says that you do not meet criteria for coverage of the 
requested services. 
 
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will 
stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before 
the last covered day. This notice must include a description of the enrollee's right to an appeal. 
 
We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or 
more days before September 20, 2022. The Plan must pay for SNF services until the 100-day SNF care benefit 
is exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the 
Plan has to pre-approve continued inpatient skilled nursing facility (SNF) services.  
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services provided from 
June 21, 2022, to June 22, 2022. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you disagree with the 
copayment. 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 $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for emergency room services. This item/service falls within the 
emergency 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 emergency room services 
provided from June 21, 2022, to June 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance (eg, proton) imaging (MRI), 
spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; 
lumbar (72158). 
 
You asked the Plan to pre-approve an MRI of lumbar spine without and with contrast. You say that the records 
do not support that an MRI is medically necessary. The Plan denied your request. The Plan says the enrollee 
has complex ongoing health concerns. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of lumbar spine without and 
with contrast. Our reviewer says that an MRI of lumbar spine without and with contrast is not medically 
necessary. Our physician reviewer found that the reviewed documentation indicates that the enrollee had an x-
ray of the back that was unchanged since 2016. The member complained of back pain that was relieved with 
steroids and Tylenol. There is no discussion to any issue past or present regarding the member's back. The 
member also is having pain from bouts of gout and possibly arthritis. An MRI does not appear to medically 
necessary 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 an MRI of lumbar spine without and with contrast have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance (eg, proton) imaging 
(MRI), spinal canal and contents, without contrast material, followed by contrast material(s) and further 
sequences; lumbar (72158).