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

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on August 18, 
2023. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that you are requesting 
reconsideration of the denied claim. 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). Therefore, we decided that the Plan does not have to pay for the subsequent nursing 
facility care provided on August 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services provided on April 22, 2023. 
 
You asked the Plan to pay for the chiropractic services. You say that you are requesting reconsideration of the 
denied claim. 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). Therefore, we decided that the Plan does not have to pay for the chiropractic services 
provided on April 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 25, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was medically necessary. 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). Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on June 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home or residence visit (99347) on March 27, 2023. 
 
You asked the Plan to pay for a home or residence visit. You say that the service at issue was a medical 
necessity for the enrollee. The Plan denied your request. The Plan says you have reported an inappropriate POS 
code. 
 
The Plan must follow Medicare rules. Medicare rules say that for all services (with two (2) exceptions), the 
POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. The two exceptions are for enrollees who are registered hospital 
inpatients or outpatients, in which case, the inpatient or outpatient hospital POS code would be reported 
regardless of where the face-to-face service takes place. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a home or residence visit have not been met. Specifically, the case record shows that the services at 
issue were reported with POS 02, indicating a telehealth visit. The record also shows that the services at issue 
were delivered in person, not via a telecommunications system. In this case, POS 02 is not appropriate. 
Therefore, we decided that the Plan does not have to pay for a home or residence visit (99347) on March 27, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ankle foot orthosis (L1970) and soft interface for 
molded plastic, below knee section (L2820) to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the orthoses. You say that please approve and cover the requested services 
from the preferred provider. 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 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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an ankle foot orthosis (L1970) and soft interface for molded plastic, below knee section (L2820) 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 pay for the shoulder orthosis (L3670) provided July 25, 2023. 
 
You asked the Plan to pay for the shoulder orthosis. You say that the item was necessary. The Plan denied your 
request. The Plan says the enrollee received a shoulder orthosis on April 16, 2021. 
 
The Plan must follow Medicare rules. Medicare rules say that, in no case can the RUL of equipment be less 
than 5 years. The rules also say that replacement due to wear is not covered during the RUL of the equipment.  
 
The item being requested shows to be for replacement of an identical or nearly identical item, due to wear. The case file shows that the existing equipment is less than 5 years old. This means that replacement of this 
equipment due to wear is not covered at this time. Therefore, we decided that the Plan does not have to pay for 
the shoulder orthosis (L3670) provided July 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on July 30, 
2023. 
 
You asked the Plan to waive the copayment for laboratory services. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for outpatient diagnostic tests/laboratory outpatient hospital. 
 
You have been asked to pay a $40 copayment for laboratory services. This item/service falls within the 
outpatient diagnostic tests/laboratory outpatient hospital 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 laboratory services provided on July 30, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the use of Evenity. 
 
You asked the Plan to pre-approve the medication. You say that the requested drug is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the enrollee does not meet all the criteria for the use 
of Evenity. 
 
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 the medication. Our reviewer says that 
Evenity is not medically necessary.  Our physician reviewer found the documentation does not support that 
Evenity is medically reasonable and necessary for the enrollee. Also, the documentation does not support that 
the Evenity is safe and effective 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the use of Evenity.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair lift (E1399).  
 
You asked the Plan to pre-approve a stair lift. You say that you are appealing the denial of authorization for a 
stair lift. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair lift (E1399).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing (0315U) provided on June 9, 2023. 
 
You asked the Plan to pay for the lab testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that MolDX will only cover and reimburse tests that 
demonstrate analytical and clinical validity, and clinical utility at a level that meets the Medicare reasonable 
and necessary requirement. 
 
We looked at the file and Medicare rules. The DecisionDX-SCC test is not listed as a covered test by MolDX. 
Based on this information, we decided that Medicare rules for coverage of the lab testing have not been met. 
Therefore, we decided that the Plan does not have to pay for lab testing (0315U) provided on June 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a protective outer covering for an approved prosthesis 
(L5962). 
 
You asked the Plan to pre-approve the protective outer covering. You say that this feature is medically 
necessary. The Plan denied your request. The Plan says this type of cover exceeds the enrollee's needs. 
 
The Plan follows Medicare rules. Medicare rules say that protective outer surface covering systems (L5962, 
L5964, and L5966) are specialized covers intended to be worn over an existing prosthesis. They are used by a 
beneficiary who has special needs for protection against unusually harsh environmental situations where it is 
necessary to protect the lower limb prosthesis beyond the level of protection that is afforded by L5704, L5705, 
L5706, and L5707. They are not for cosmetic or convenience reasons, or for everyday usage in a typical 
environment. 
 
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 protective outer covering. Our 
reviewer says that this cover is not medically necessary. Our physician reviewer found the documentation available for review does not support that the member requires a protective outer coating that is specialized due 
to exposure of harsh environments. 
 
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 protective outer covering have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a protective outer covering for an approved prosthesis (L5962).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ondansetron. 
 
You asked the Plan to pre-approve the drug. The Plan denied your request. The Plan says that self-administered 
drugs do not fall under Medicare Part B coverage. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve ondansetron.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 18, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that these services were medically necessary. 
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). Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on August 18, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient surgery provided on June 01, 
2023, to June 15, 2023. 
 
You asked the Plan to waive the copayment for the outpatient surgery. You say that you were not told of any 
out-of-pocket cost prior to your surgery. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
You have been asked to pay a $350 copayment for the outpatient surgery. This item/service 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. 
However, since the allowed amount is less than the standard copayment, you only owe $297.52. Therefore, we 
decided that the Plan does not have to waive the copayment for the outpatient surgery provided on June 01, 
2023, to June 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99204) radiologic examination, 
foot (73620) injection(s); tendon sheath, ligament (20550) injection, dihydroergotamine mesylate (J1110) 
strapping of ankle/foot (29540) provided on January 23, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the outpatient visit. You say that for review and reconsideration, you are 
including copy of the medical records to support medical necessity of the service rendered. 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 outpatient office visit (99204) radiologic 
examination, foot (73620) injection(s); tendon sheath, ligament (20550) injection, dihydroergotamine mesylate 
(J1110) strapping of ankle/foot (29540) provided on January 23, 2023, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service January 5, 
2022, to February 1, 2022. 
 You asked the Plan to pay for the billed services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the NOA was not received timely.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 5, 2022. The NOA was not received by the Plan until April 27, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health care billed for 
dates of service January 5, 2022, to February 1, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
August 15, 2023, to August 21, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you are requesting 
reconsideration because the enrollee had to be transferred by ambulance due to medical necessity. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $345 copayment per day, for days 1 to 5, for each Medicare-covered inpatient hospital stay. There 
is a $0 copayment per day, days 6 to 90. 
 
The enrollee has been asked to pay $1,725, which is a $345 copayment per day for days one to five of the 
inpatient hospital stay ($345 copayment x 5 days = $1,725). You have not been charged after day five. This 
item/service falls within the inpatient hospital care benefit category. This means that the enrollee has been 
asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for the inpatient hospital stay provided from August 15, 2023, to August 21, 
2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retacrit injections. 
 
You asked the Plan to pre-approve the medication. You say that the records provided support medical 
necessity. The Plan denied your request. The Plan says the records show that the medication will be dispensed 
by the pharmacy on the patient's behalf. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve retacrit injections.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 77065, 76642, and G0279 for date of service February 
21, 2023. 
 
You asked the Plan to pay for codes 77065, 76642, and G0279. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says 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. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on February 28, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for codes 77065, 76642, and G0279 have not 
been met. Therefore, we decided that the Plan does not have to pay for codes 77065, 76642, and G0279 for 
date of service February 21, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the outpatient surgery provided on April 
24, 2023. 
 
You asked the Plan to reduce the coinsurance for the outpatient surgery. You say that you were told your cost 
would be $111.75, so you are not paying anymore. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
You have been asked to pay 20% coinsurance for the outpatient surgery. This item/service 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. The 
total you owe is $1,329.90 ($6,649.49 allowed amount x 20% = $$1,329.90) Therefore, we decided that the 
Plan does not have to reduce the coinsurance for the outpatient surgery provided on April 24, 2023.