Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames (V2020) and spherocylinder, bifocal lenses 
(V2203) purchased on April 4, 2022, from an out-of-network (OON) provider. 
 
You asked the Plan to pay for the frames and spherocylinder, bifocal lenses. You say that you were not aware 
that the facility you went to was not in-network. The Plan denied your request. The Plan says these services 
were rendered by a provider who is not in the Plan's network. 
 
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 they are rendered by a Plan approved vision care provider. 
 
 
 
 We looked at the file and the Plan's rules. Specifically, the record shows that you received these services from 
an OON provider. Based on this information, we decided that the Plan's rules for coverage of the frames and 
spherocylinder, bifocal lenses have not been met. Therefore, we decided that the Plan does not have to pay for 
the frames (V2020) and spherocylinder, bifocal lenses (V2203) purchased on April 4, 2022, from an out-of-
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies billed with 
code K0553 for October 10, 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 there is no valid proof of delivery. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS 
suppliers are required to maintain proof of delivery. 
 
We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 continuous glucose monitor (CGM) supplies billed with 
code K0553 for October 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (G0483) provided on October 17, 2022. 
 You asked the Plan to pay for drug testing. You say that these services were necessary and are supported in the 
medical record. The Plan denied your request. The Plan says there is insufficient information to support that 
these services were requested and medically necessary. 
 
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 drug testing have been met. 
Specifically, the physician order does not clearly document that the number of drug classes tested was 
requested, and there are no physician notes to indicate that it was medically necessary to test all of these 
classes. Therefore, we decided that the Plan does not have to pay for drug testing services (G0483) provided on 
October 17, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a diagnostic radiology exam provided on December 22, 
2022. 
 
You asked the Plan to pay for a diagnostic radiology exam. You say that you were told you could see anyone 
you wanted while on this plan. 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). There are many other providers available in-network in close proximity to your 
home. Therefore, we decided that the Plan does not have to pay for a diagnostic radiology exam provided on 
December 22, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lenalidomide (Revlimid) 
 
You asked the Plan to pre-approve Revlimid. You say that the enrollee has been taking this regimen for two 
years now. The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B 
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 pre-approve lenalidomide (Revlimid)  
 
Benefits for Revlimid 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 pre-approve computed tomography (CT) coronary calcification. 
 You asked the Plan to pre-approve CT coronary calcification. You say that the enrollee is at risk for heart 
disease. The Plan denied your request. The Plan says the records do not show how the results of this testing 
would change the enrollee's treatment. 
 
The Plan follows Medicare rules. Medicare rules state that CT angiography is only covered for certain 
indications and is never covered for screening. 
 
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 CT coronary calcification. Our reviewer 
says that the enrollee does not meet criteria for this test. Our physician reviewer found the records do not 
document any covered indications for this test. The test appears to be ordered as a screening tool in this case, 
which is not covered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT coronary calcification have not been met. Therefore, we decided that the 
Plan does not have to pre-approve computed tomography (CT) coronary calcification.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 You asked the Plan to pre-approve Feraheme. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy requirements 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 Feraheme. Our reviewer says that the 
requirements for coverage of Feraheme have not been met. Our physician reviewer found the Plan requires a 
trial of Ferrlecit, Sodium Ferric Gluconate, Infed, or Venofer before they will approve the requested drug. In 
this case, the enrollee has not tried and failed the required drugs. There is no documentation provided 
indicating that the required drugs would likely be less effective or 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 Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services billed with code 31591 for October 11, 
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 claim was not billed with an appropriate diagnosis code. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the services were billed with a mismatched diagnosis code that does not match the laterality of the procedure. 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 surgical services billed with code 31591 for October 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) (E0675) and 
appliance (E0673) provided on October 21, 2022. 
 
You asked the Plan to pay for the PCD and appliance. The Plan denied your request. The Plan says this is not 
covered for use outside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device (PCD) (E0675) and appliance (E0673) provided on October 
21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel (81455) 
provided October 12, 2022.  
You asked the Plan to pay for the genetic testing. You say that this letter and attached documents support the 
medical necessity of the tests requested, to assist in the treatment, prognosis, and diagnosis for this type of 
cancer. The Plan denied your request. The Plan says this test is not a covered benefit as the Tempus xT 648 
Solid Tumor Assay does not have FDA approval or clearance as a companion in vitro diagnostic test. 
 
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 the genetic testing have been met. the 
records provided from the provider was not legible. The records show that the Plan made multiple attempts to 
obtain legible records from the servicing provider without success. Therefore, we decided that the Plan does 
not have to pay for the targeted genomic sequence analysis panel (81455) provided October 12, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme (Q0138). 
 You asked the Plan to pre-approve Feraheme. The Plan denied your request. The Plan says this request does 
not meet the Plan's Part B step therapy criteria for the requested drug. 
 
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 Feraheme. Our reviewer says that the 
enrollee does not meet the coverage criteria for Feraheme. Our physician reviewer found the provided records 
do not indicate that the enrollee has tried and failed the Plan's preferred step one alternative. The record does 
not indicate that the enrollee has a contraindication to, or would have an adverse effect from the Plan's 
preferred step one alternative. Our reviewer found that the elements of the coverage criteria are not satisfied. 
Our physician reviewer also found that the requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme (Q0138).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (72070) provided on May 25, 2022. 
 
You asked the Plan to pay for the radiology services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the primary payer is responsible for payment for this service. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has requested an 
Explanation of Benefits from the primary insurer. As the secondary insurer, the Plan cannot be held responsible 
for the radiology services until the primary insurer has denied the claim for these services. Therefore, we 
decided that the Plan does not have to pay for radiology services (72070) provided on May 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for a motorized scooter provided on August 
22, 2022. 
 
You asked the Plan to provide reimbursement for a scooter. You say that the motorized scooter was medically 
necessary due to your chronic illness. The Plan denied your request. The Plan says that items/services received 
from a provider who does not participate in Medicare are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made for items/services 
received from a provider that is not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to provide reimbursement for a motorized scooter 
provided on August 22, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for observation care services (99225) billed for date of service June 1, 
2022. 
 
You asked the Plan to pay for observation care services. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says that this claim is a duplicate of a previously paid claim 
and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. We find that the file does not include sufficient evidence to support 
the Plans argument that the claim at issue is a duplicate. The case record does not contain a copy of the paid 
prior claim. Based on this information, we decided that Medicare rules for coverage of observation care 
services have been met. Therefore, we decided that the Plan has to pay for observation care services (99225) 
billed for date of service June 1, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 4, 2021. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says more than 
one calendar year from the date of service had passed before the claim was filed. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the physician's services was not filed until April 20, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on March 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on November 3, 
2022. 
 
You asked the Plan to pay for the durable medical equipment. 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. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for the durable medical equipment 
provided on November 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) (E0675) and 
appliance (E0673) provided on September 27, 2022. 
 
You asked the Plan to pay for the PCD and appliance. The Plan denied your request. The Plan says this is not 
covered for use outside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device (PCD) (E0675) and appliance (E0673) provided on 
September 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (82607, 82306, 80053, 80061, 85025, 83036, 
84443, 84436, 84439, 84480, 84481) provided on November 16, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that the provided is in-network with the commercial 
plan. The Plan denied your request. The Plan says these services are not covered because they were provided 
OON. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the lab services (82607, 82306, 80053, 80061, 
85025, 83036, 84443, 84436, 84439, 84480, 84481) provided on November 16, 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 anesthesia services (01940) provided on March 4, 2022. 
 
You asked the Plan to pay for the anesthesia services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
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 CPT code 01940 is not supported in the medical record. Specifically, the claim was not billed with 
a valid primary diagnosis code for this service per Local Coverage Article: Billing and Coding: Monitored 
Anesthesia Care (A57361). Based on this information, we decided that Medicare rules for coverage of the 
anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia 
services (01940) provided on March 4, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the insertion tray with drainage bag with indwelling catheter, foley 
type, two-way latex with coating (teflon, silicone, silicone elastomer or hydrophilic, etc.) identified with code 
A4314 provided on October 14, 2022. 
 
You asked the Plan to pay for the insertion tray. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says that this code has a medical unlikely edit (MUE) of zero. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Review of the file shows that the Plan states that this code has a MUE value of 
zero. However, for a durable medical equipment, this code has a MUE of three (3). No other denial rationale 
was provided. Therefore, the Plan did not substantiate their denial. Therefore, we decided that the Plan has to 
pay for the insertion tray with drainage bag with indwelling catheter, foley type, two-way latex with coating 
(teflon, silicone, silicone elastomer or hydrophilic, etc.) identified with code A4314 provided on October 14, 
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.