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

 
We decided that the Plan does not have to pre-approve a neurology visit (99213) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the neurology visit. You say that the services are medically necessary. The 
Plan denied your request. The Plan says there are network providers available. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a 
neurology visit (99213) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oncology visit (99205) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the oncology visit. You say that this service is medically necessary. The 
Plan denied your request. The Plan says there are network providers available. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an 
oncology visit (99205) 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 coinsurance for continuous positive airway pressure 
(CPAP) machine replacement parts provided on November 11, 2021. 
 
You asked the Plan to waive the coinsurance for CPAP replacement parts. You say that you returned the 
replacement parts a few months ago. You say that you are being taken advantage of since you are being billed 
for parts that you sent back. 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 20% 
coinsurance for durable medical equipment.  
 
 The Plan confirmed with the provider that there is no record of the replacement parts being returned. The Plan 
also confirmed the provider does not accept returns per their company policy. You have been asked to pay a 
total of $52.04, which is 20% coinsurance for CPAP replacement parts.  
 
Code Allowed Amount 20% Coinsurance 
A7034 $72.70 $14.54 
A4604 $47.10 $9.42 
A7038 $17.76 $3.55 
A7032 $122.65 $24.53 
Total  $52.04 
 
CPAP replacement parts falls within the Durable Medical Equipment (DME) and Related Supplies benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the coinsurance for continuous positive airway pressure (CPAP) 
machine replacement parts provided on November 11, 2021.  
 
Your complaint about the providers return policy 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not have a need for 
intravenous medications, new tube feeding, ostomy care or daily complex wound care. The enrollee is walking 
greater than household distances with no device with contact guard/stand-by assistance and is independent for 
transfers. Provided records do not document a significant decline in the enrollees functional status to 
necessitate daily inpatient skilled therapy services. The enrollee does 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for an oxygen concentrator provided on 
November 4, 2021. 
 
You asked the Plan to reduce the coinsurance for an oxygen concentrator. You say that you have had the same 
oxygen concentrator for five years. You also say that the cost for the same machine keeps increasing. 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 20% 
coinsurance for in-network durable medical equipment.  
 
 You have been asked to pay $21.94, which is 20% of the allowed amount for an oxygen concentrator ($109.69 
allowed amount x 20% coinsurance = $21.94). An oxygen concentrator falls within the Durable Medical 
Equipment (DME) and Related Supplies benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the coinsurance 
for an oxygen concentrator provided on November 4, 2021.  
 
Your complaint about the cost increasing for your oxygen concentrator and the customer service of the 
provider 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Methotrexate. 
 
You asked the Plan to pre-approve Methotrexate. The Plan denied your request. The Plan says this drug is only 
covered under the medical benefit if it is being used to treat cancer. 
 
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 Methotrexate.  
 
 
 Benefits for Methotrexate 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 pay for bilateral Avastin injections provided on July 26, 2021. 
 
You asked the Plan to pay for the bilateral Avastin injections. You say that you billed these services correctly. 
The Plan denied your request. The Plan says you billed an incorrect diagnosis code on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this 
case, you billed for bilateral Avastin injections.  For these injections, you indicated two diagnoses on the claim: 
H35.3211 (exudative age-related macular degeneration, right eye, with active choroidal neovascularization), 
and H35.3221 (exudative age-related macular degeneration, left eye, with active choroidal neovascularization).  
The records show that you billed the Avastin injection procedures with a -50 modifier, indicating that the 
injections were performed bilaterally.  However, you billed with single laterality diagnoses.  There is a more 
appropriate diagnosis for bilateral exudative age-related macular degeneration with active choroidal 
neovascularization, which is H35.3231. So, you have billed the procedure codes correctly with the correct 
bilateral modifier, but you have billed an incorrect diagnosis code to indicate the bilateral condition.  Therefore, we decided that the Plan does not have to pay for bilateral Avastin injections provided on July 26, 
2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not have any parental medication; 
complex wound care or nutrition given via a feeding tube. You are medically stable without any acute 
exacerbations of chronic medical problems. Your physical function is at or near your baseline and you can 
receive services at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires IRF care. The Plan denied your 
request. The Plan says criteria for admission to the IRF setting have not been met. The enrollee's ongoing 
skilled therapy and nursing needs can be provided at a lower level of care. 
 
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 enrollees nursing, medical and rehabilitation needs 
does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation 
does support a need for physical and/or occupational therapy, there is no documented need for an intensive, 
multi-disciplinary rehabilitation program. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a nerve block injection provided on July 
30, 2021. 
 
You asked the Plan to waive the copayment for a nerve block injection. You say that you had to pay out of 
pocket for the last procedure you had. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 
copayment for each outpatient surgery at an outpatient hospital.  
 
 The record shows the nerve block injection you received is considered a surgical procedure. You have been 
asked to pay a $275 copayment for a nerve block injection. A nerve block injection falls within the Outpatient 
Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for a nerve block injection provided on July 30, 
2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy 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 the records do not show that additional home physical therapy visits are needed. 
 
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 there are no 
documented ongoing skilled physical therapy needs. You have made little progress with therapy and remain 
dependent for mobility. You have available caregivers. Skilled physical therapy is not required to establish a 
maintenance program, or to prevent deterioration of your condition. As such, the requested ongoing home 
health physical therapy services are not medically reasonable or 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home health physical therapy services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 14, 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 June 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cala-Trio arm band. 
 
You asked the Plan to pre-approve a Cala-Trio arm band. You say that the requested Cala-Trio arm band is 
medically necessary. The Plan denied your request. The Plan says the requested Cala-Trio arm band is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Cala-Trio arm band. Our reviewer 
says that the requested Cala-Trio arm band is not medically necessary. Our physician reviewer found there is 
insufficient support in the medical literature regarding the use of the Cala-Trio arm band for the treatment of 
refractory essential tremor. Professional neurology associations do not endorse the arm band in this setting. The 
documentation does not support that the Cala-Trio arm band is medically reasonable and necessary for the 
enrollee 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 a Cala-Trio arm band have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Cala-Trio arm band.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not have a need for 
intravenous medications, new tube feeding, ostomy care or daily complex wound care. Daily skilled services 
are not required. Provided records do not document a significant decline in the enrollees functional status 
compared to her recent baseline to necessitate daily inpatient skilled therapy services. The enrollee does 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve a repeat Zilretta injection. 
 
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 that the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has knee osteoarthritis. Zilretta 
is being requested for its current Food and Drug Administration (FDA) labelled indication. The FDA has not 
restricted its use to a single time. The services are therefore reasonable and 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 been met. Therefore, we decided that the Plan has to pre-
approve a repeat Zilretta injection.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit (99213) provided on 
November 15, 2021. 
 
You asked the Plan to waive the copayment for the office visit. You say that you had already met your 
maximum out-of-pocket amount before this office visit. The Plan denied your request. The Plan says a previous 
claim from June 2021 had been reprocessed to reduce your copayment at that time by $300. You are 
responsible for a $30 copayment for an office visit with a specialist, and you met your out-of-pocket maximum 
on November 5, 2021. 
 
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 $30 
copayment for an office visit with a specialist.  
 
You have been asked to pay a $30 copayment for the office visit with a specialist. Documentation shows that 
you had not met your out-of-pocket maximum at the time.  
 
 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 the office visit (99213) provided on November 15, 2021.