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

 
We decided that the Plan does not have to pre-approve the Apidra Solostar Insulin Pen. 
 
You asked the Plan to pre-approve the Apidra Solostar Insulin Pen. You say that you would like 
reconsideration because the Apidra Solostar Insulin Pen is medically necessary. The Plan denied your request. 
The Plan says the Apidra Solostar Insulin Pen 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 pre-approve the Apidra Solostar Insulin 
Pen.  
 Benefits for the Apidra Solostar Insulin Pen 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 1, 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 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cane, quad or three prong, includes canes of all materials, 
adjustable or fixed, with tips (E0105) purchased on July 4, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the cane. You say that you paid this on your QVC account. You paid in full in 
the month of August. The Plan denied your request. The Plan says enrollees must receive their medical 
services from an in-network provider with the exception being urgent or emergent services. Non-emergent 
services with non-contracted providers require prior authorization before services being rendered. 
 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 cane, quad or three prong, includes canes of all 
materials, adjustable or fixed, with tips (E0105) purchased on July 4, 2021 by an out-of-network (OON) 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis, sagittal-coronal control, back brace 
(L0650) provided on September 3, 2021. 
 You asked the Plan to pay for a back brace. You say that the brace is medically necessary due to the enrollee's 
function and condition. The Plan denied your request. The Plan says the records submitted do not show a visit, 
face to face or otherwise within 6 months of the written order and were 10 months prior to the written order. 
 
The Plan must follow Medicare rules. Medicare rules say that back braces may be covered for enrollees and a 
WOPD must be completed within six (6) months after the required face-to-face encounter. 
 
We looked at the file and Medicare rules. The records show that the last face-to-face visit with the enrollee was 
on December 9, 2020. The written order for the back brace was submitted on September 3, 2021. There is no 
evidence of a face-to-face visit within 6 months of the written order. Therefore, we decided that the Plan does 
not have to pay for a lumbar-sacral orthosis, sagittal-coronal control, back brace (L0650) provided on 
September 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Genetic Testing provided on October 26, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Genetic Testing. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says prior authorization is required for an out-of-network 
visit. 
 
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 Genetic Testing provided on October 26, 2021 by 
an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames (V2020) and sphere, trifocal, plano to plus or 
minus 4.00d, per lens (V2300) provided December 1, 2021, by an out-of-network (OON) provider. You asked the Plan to pay for the frames and lenses. You say that you purchased glasses OON because of the 
pandemic. The Plan denied your request. The Plan says this service is not covered because it was provided 
OON without prior authorization. 
 
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 out-of-network when you receive prior authorization. 
 
We looked at the file and the Plan's rules. In this case the frames and lenses were provided OON without 
receiving authorization. Based on this information, we decided that the Plan's rules for coverage of the frames 
and lenses have not been met. Therefore, we decided that the Plan does not have to pay for the frames (V2020) 
and sphere, trifocal, plano to plus or minus 4.00d, per lens (V2300) provided December 1, 2021, by an out-of-
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro power arm brace. 
 
You asked the Plan to pre-approve a MyoPro power arm brace. You say that the requested MyoPro power arm 
brace is medically necessary. The Plan denied your request. The Plan says the requested MyoPro power arm 
brace 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 MyoPro power arm brace. Our 
reviewer says that the requested MyoPro power arm brace is not medically necessary. Our physician reviewer 
found at this time the requested robotic orthosis is not proven to be more beneficial for treatment of the 
enrollee's medical condition/function of hemiparesis after stroke than any available standard therapy such as 
conventional treatments for post stroke hemiparesis therapy including constraint induced movement therapy, 
conventional muscle strengthening, and Botox for spasticity if needed. The requested device is not reasonable 
and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a 
malformed body member. The MyoPro is not known to be effective, based on scientific evidence, professional 
standards and expert opinion, in improving health outcomes in stroke patients.  The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the 
literature that the MyoPro Orthosis will improve the long-term outcomes for this enrollee, improve hemiparetic 
arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will 
increase participation in bi-manual activities. 
 
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 MyoPro power arm brace have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro power arm brace.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services rendered on September 8, 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 are not payable. 
 
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 imaging services rendered 
on September 8, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
September 7, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that they were not able to treat you. 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 $75 
copayment for each emergency room visit.  
 
The record shows that you were evaluated and stabilized by the ER staff. Therefore, you have been asked to 
pay a $75 copayment for the ER visit. The ER visit 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 an emergency room (ER) visit provided on 
September 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says these laboratory services are included in 
the dialysis services. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on November 30, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the physician services. You say that it was medically necessary to treat the 
enrollee and would like the claim reprocessed for payment. The Plan denied your request. The Plan says the 
rendering provider is an out-of-network provider and there was no referral from an in-network provider or an 
approved authorization. Also, the service rendered was not urgent or emergent. 
 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 physician services provided on November 30, 
2021, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation services provided 
on November 22, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that it is your 
understanding that transportation should not be your responsibility. 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 $250 
copayment for each one-way ambulance transport.  
 
You have been asked to pay a $250 copayment for the ambulance transportation. The ambulance transportation 
falls within the Ambulance Services benefit category.  This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for ambulance transportation services provided on November 
22, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transthoracic echocardiogram (TTE) with Doppler 
rendered on September 23, 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 procedure code 93306 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 93306 (TTE with Doppler, complete) and 93351 (stress 
TTE, complete). Code 93306 is a column II code with a modifier indicator of 1 when billed with column I code 
93351. Code 93306 was not billed with an appropriate modifier to allow for separate payment. Therefore, we 
decided that the Plan does not have to pay for the transthoracic echocardiogram (TTE) with Doppler rendered 
on September 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the foot orthotics rendered on November 22, 2021. 
 
You asked the Plan to pay for foot orthotics. You say that you need the orthotics to stay active. 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.   
 
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 pay for the foot orthotics rendered on 
November 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a volara airway clearance system device, durable 
medical equipment (DME) miscellaneous (E1399, A9999). 
 
You asked the Plan to pre-approve a volara airway clearance system device. You say that the requested 
procedure is medically necessary for the enrollee. The Plan denied your request. The Plan says there are not 
enough studies to show the volara device will help in the enrollee's care. 
 
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 volara airway clearance system. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found it was reported that she uses a High Frequency Chest Wall Oscillation 
(HFCWO) device externally at home but with limited results. A request for a Volara System (Oscillation and 
Lung Expansion therapy) was made. However, the current studies have not yet shown an overall improvement 
in symptoms for those with CF using Volara compared to using separate standard treatments such as 
bronchodilators and oscillation, and lung expansion, which the Volara utilizes. 
 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 volara airway clearance system device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a volara airway clearance system device, durable medical 
equipment (DME) miscellaneous (E1399, A9999).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit provided on October 20, 
2021, by an OON provider. 
 
You asked the Plan to pay for the domiciliary or rest home visit. You say that it is the rest home's responsibility 
to obtain prior authorization. The Plan denied your request. The Plan says the services were provided out-of-
network and were not approved in advance. 
 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 domiciliary or rest home visit provided on 
October 20, 2021, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for An injection provided on November 15, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for An injection. You say that you would like to appeal the denial of the claim. The 
Plan denied your request. The Plan says the rendering provider is an out-of-network provider and there was no 
approved authorization, and it was determined that the services rendered were not urgent or emergent. Also, the 
services rendered could have been provided by an in-network provider. 
 
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 injection provided on November 15, 2021 by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on October 25, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that this provider was not responsible to 
obtain authorization, and the assisted living facility is responsible to obtain prior authorization for all of their 
patients. The Plan denied your request. The Plan says this provider is out-of-network with the Plan, and 
authorization was not obtained prior to the services being rendered. 
 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 a domiciliary or rest home visit provided on 
October 25, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a specialist office visit on August 17, 2021 
and August 31, 2021. 
 
You asked the Plan to waive the copayments for a specialist office visit. You say that you were told the 
copayment would be waived. The Plan denied your request. The Plan says the copayment applied was correct. 
 
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 $45 
copayment for a specialist office visit. The total cost share is $90. 
 
You have been asked to pay a $45 copayment for a specialist office visit. a specialist office visit falls within the 
Physician/Practitioner Services, Including Doctors Office Visits 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 copayments for a specialist office visit on August 17, 2021 and August 31, 2021.