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

 
We decided that the Plan does not have to pay for a specialist office visit provided on December 8, 2020 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for a specialist office visit. You say that the services should be paid by the Plan. 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 a specialist office visit provided on December 8, 
2020 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on April 6, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration of this claim. 
The Plan denied your request. The Plan says no prior authorization was 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 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 office visit provided on April 6, 2021, by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 15946 billed for date of service September 
13, 2021. 
 
You asked the Plan to pay for procedure code 15946. You say that this code should be paid. The Plan denied 
your request. The Plan says this code is not supported in the medical record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 15946 is Excision, ischial pressure ulcer, with ostectomy, 
in preparation for muscle or myocutaneous flap or skin graft closure. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 15946. Our reviewer says that billing of this 
code is not supported in the medical record. Our reviewer found the operative report does not include 
documentation to support the description of excision ischial pressure ulcer with ostectomy.  To cite the operative report "The ischial pressure wound was excised and debrided with a 10-blade scalpel and 
electrocautery.  All of the shiny scar-like material was removed.  I then elevated the posterior thigh flap that 
had been elevated once before.  Dissection was carried down to the fascia which was incised.  The posterior 
thigh flap was then elevated and advanced as a fasciocutaneous flap into the wound".  The documentation does 
not support ostectomy, and therefore cannot be verified as performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 15946 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 15946 billed for date of service September 13, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF admission. You say that SNF admission is medically necessary. The 
Plan denied your request. The Plan says you do not meet SNF 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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found you have no identifiable skilled nursing 
needs.  You do have skilled therapy needs, but you do not require skilled therapy on a daily basis on an 
inpatient basis in a SNF. 
 
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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Renflexis. 
 
You asked the Plan to pre-approve Renflexis. You say that this drug is medically reasonable and necessary. 
The Plan denied your request. The Plan says step therapy criteria have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Renflexis. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the enrollee has a 
diagnosis of Rheumatoid arthritis with rheumatoid factor of multiple sites without organ or systems 
involvement. In this case, the Plan requires a trial of two of the following: Remicade, infliximab, Inflectra, or 
Simponi Aria before they will approve the requested drug. The case file does not contain documentation of trial 
and failure of two of the plan's required drugs. The documentation does not support that two of the plan's 
required drugs would likely be less effective, and/or would likely have adverse effects 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 Renflexis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Renflexis.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the requested Prolia is medically necessary. The Plan 
denied your request. The Plan says the enrollee must EITHER have a history of osteoporsis-related fracture; 
OR the enrollee has failed or has a contraindication to Zoledronic acid. 
 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 Prolia. Our reviewer says that the Plan's 
step therapy criteria have not been met. Our physician reviewer found the enrollee has a diagnosis of age-
related osteoporosis without current pathological fracture. The documentation does not show that the enrollee 
has tried and failed Zoledronic acid. The documentation does not support that the Plan's required drug would 
likely be less effective, and/or would likely have adverse effects 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fitness classes. 
 
You asked the Plan to pre-approve fitness classes. You say that this provider has many different programs to 
help you to stay active and delay progression of the Parkinsons disease. The Plan denied your request. The 
Plan says fitness classes are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover gym benefits.  
 
The services at issue in this appeal are gym benefits. Therefore, we decided that the Plan does not have to pre-
approve fitness classes.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789-59 billed for date of service June 29, 
2021. 
 
You asked the Plan to pay for procedure code 83789-59. You say that this service was billed correctly and 
should be paid. The Plan denied your request. The Plan says payment for code 83789-59 should be included in 
payment for code G0480. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for procedure code 83789-59 Our reviewer says 
that the -59 modifier is not supported in the medical records. Our physician reviewer found you 
reported Current Procedural Terminology (CPT) 83789:  Mass spectrometry and tandem mass spectrometry, 
non-drug analyte(s) not elsewhere specified, qualitative or quantitative, each specimen.  Validity testing is an 
internal quality process to affirm that the reported results are accurate and valid, and thus is not a separately billable Medicare service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 83789-59 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 83789-59 billed for date of service June 29, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF admission. You say that you need to be admitted to the SNF after knee 
surgery.  You said that you need to have access to a cooling machine to help you heal and you need physical 
therapy to help rehabilitate your knee.  You said that you need someone to manage your healing process 
because you are pre-diabetic and healing can be difficult. The Plan denied your request. The Plan says SNF 
admission is not medically necessary.  
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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing 
services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and 
effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not reveal 
evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. Your high 
functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of 
a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. 
You do not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily 
basis" in a SNF.  As a practical matter  you do not require the necessary services on an inpatient basis, in a 
skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 92937 and 93461 billed for date of service 
September 22, 2021. 
 
You asked the Plan to pay for procedure codes 92937 and 93461. You say that these services should be paid. 
The Plan denied your request. The Plan says these services cannot be separately reimbursed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure codes 92937 and 93461. Our reviewer says that 
payment for these codes is not supported. Our reviewer found when billing and coding percutaneous coronary 
intervention (PCI), the claim must include the appropriate modifiers to identify which vessel is undergoing a 
specific procedure. The modifiers are LD (left anterior descending coronary artery), LC (left circumflex 
coronary artery), RC (right coronary artery), LM (left main artery) and RI (rasmus intermedius artery). Without 
the correct modifier appended, these two codes would be inclusive to code 92941, which was approved for 
reimbursement.  
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 92937 and 93461 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 92937 and 93461 billed for date of service September 
22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the over-the-counter (OTC) Hempvana with Lidocaine 
provided on September 19, 2021. 
 
You asked the Plan to pay for the OTC Hempvana with Lidocaine. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says items with hemp are not 
covered under the OTC items supplemental benefit as hemp is considered to be an alternative medicine. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the OTC 
Hempvana with Lidocaine is an OTC item. However, the Plan offers a supplemental benefit for over-the-
counter items that Medicare does not cover. Items must be included on the Plan's allowed items list in order to 
be covered under the Plan's supplemental benefit. Items with hemp are not covered under the Plan's OTC items 
supplemental benefit as hemp is considered to be an alternative medicine. Therefore, we decided that the Plan 
does not have to pay for the over-the-counter (OTC) Hempvana with Lidocaine provided on September 19, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for non-urgent transportation. 
 
You asked the Plan to provide coverage for non-urgent transportation. You say that you need transportation to 
and from Syracuse, New York for cataract surgery and you do not have anyone who can take you. You say that 
you slipped on the ice on February 17th and broke your leg. The Plan denied your request. The Plan says non-
urgent transportation is listed as not a covered benefit in your Evidence of Coverage. 
 
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. 
The Plan follows the same rule.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Medicare rules for coverage of non-urgent transportation have not been met. Therefore, we decided 
that the Plan does not have to provide coverage for non-urgent transportation.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve continued SNF services. You say that you do not believe you are ready for 
discharge.  You said that you are a fall risk and have mobility struggles. The Plan denied your request. The 
Plan says continued SNF care is not medically necessary. 
 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 continued SNF services. Our reviewer 
says that daily skilled services are not necessary. Our physician reviewer found you no longer have any 
identifiable skilled nursing or skilled therapy needs and do not require SNF 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 continued SNF services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on October 30, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the wound care supplies. You say that it was medically necessary to treat the 
enrollees and it is a covered benefit. The Plan denied your request. The Plan says the rendering provider is an 
out-of-network provider and there is 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 wound care supplies provided on October 30, 
2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound exam of the head and neck 
(76536) provided on December 13, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 
$160.00 copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a 
physicians office or at a free-standing facility (such as a radiology center or medical clinic).   
 
You have been asked to pay $117.60 for the Medicare-covered radiological diagnostic service provided. This is 
the Plans allowed amount for this service which is less than the applicable copayment. 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 ultrasound exam of the head and neck (76536) provided on 
December 13, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the psychiatric diagnostic evaluation and 
psychotherapy visits provided on September 21, 2021, October 1, 2021, October 7, 2021, October 20, 2021, 
November 4, 2021, November 11, 2021, and November 18, 2021. 
 
You asked the Plan to waive the copayments for the psychiatric diagnostic evaluation and psychotherapy visits. 
You say that you had a bad experience with this provider and would like all the funds that were paid to be 
reversed. The Plan denied your request. The Plan says the proper copayments were applied for the service that 
was rendered. 
 
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 $25 
copayment for each Medicare-covered individual therapy session. The total copayment amount for all the visits 
was $175 ($25 copayment per visit x 7 visits). You have been asked to pay a $175 copayment for the psychiatric diagnostic evaluation and psychotherapy 
visits. The psychiatric diagnostic evaluation and psychotherapy visits falls within the Outpatient Mental Health 
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 copayments for the psychiatric diagnostic 
evaluation and psychotherapy visits provided on September 21, 2021, October 1, 2021, October 7, 2021, 
October 20, 2021, November 4, 2021, November 11, 2021, and November 18, 2021.  
 
Your complaint about your experience with this 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.