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

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from December 19, 
2022, to January 5, 2023, by an OON provider. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you were advised the nursing center 
stay would be completely covered by the Plan. 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 enrollees contract with the Plan clearly says that enrollees 
must pay 35% coinsurance for OON SNF care.  
 
 
  The enrollee has been asked to pay $2,338.74 for a SNF stay ($6,682.11 allowed x 35% = $2,338.74). This 
item/service falls within the OON SNF 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 a SNF stay provided from December 19, 2022, to January 5, 2023, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
May 12, 2022.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service May 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the singles vaccine provided on November 14, 2022. 
 
You asked the Plan to pay for the singles vaccine. You say that it is medically necessary. The Plan denied your 
request. The Plan says they cover some vaccines under Medicare Part D prescription drug benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the singles vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the singles 
vaccine. Therefore, we decided that the Plan does not have to pay for the singles vaccine provided on 
November 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR) (33285). 
 
You asked the Plan to pre-approve an ILR. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says implantable loop recorders are not needed for 
assessment of enrollees with frequent symptoms. Therefore, it is not considered standard of 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 an ILR. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a history of head symptoms. There is no documentation provided to suggest a 
history of unexplained syncope or any other apparent indication for an ILR. In summary, there is insufficient 
documentation to support the medical necessity for insertion of an ILR in this enrollee's clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an implantable loop recorder (ILR) (33285).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Liqvio. 
 
You asked the Plan to pre-approve Liqvio. You say that the requested drug, Liqvio is medically necessary. The 
Plan denied your request. The Plan says the enrollee did not meet the step therapy requirements. 
 
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 the injections. Our physician reviewer 
found that the Plan requires a trial of Praluent before they will approve Liqvio. Our physician reviewer found 
that based on the medical records provided there is no indication that the enrollee has tried and failed the 
required drug. Our physician reviewer found that there is no indication that the Plans required drug would 
likely be less effective and/or likely 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 Liqvio have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Liqvio.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual exam provided on February 28, 2023. 
 
You asked the Plan to pay for the annual exam. You say that the services provided should be covered. 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 annual exam 
provided on February 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR) (33285). 
 
You asked the Plan to pre-approve an ILR. You say that the enrollee has a history of bradycardia. The device is 
medically necessary. The Plan denied your request. The Plan says an ILR is not needed for routine assessment 
of enrollees with atrial fibrillation. Therefore, it is not considered standard of 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 an ILR. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a history of atrial fibrillation. There is no documentation provided to suggest a 
history of unexplained syncope, cryptogenic stroke or any other apparent indication for an implantable cardiac 
monitor (ICM). In summary, there is insufficient documentation to support the medical necessity for insertion 
of an ICM in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an implantable loop recorder (ILR) (33285).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 10, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that the services were provided in good faith. 
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 April 10, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service December 
27, 2022, to December 31, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that these services were medically necessary and 
were ordered by an in-network provider. The Plan denied your request. The Plan says the billed code is invalid 
for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service December 27, 2022, to December 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant Reveal diagnostic testing provided on January 
29, 2023. 
 
You asked the Plan to pay for the Guardant Reveal diagnostic testing. You say that this testing should be 
covered. The Plan denied your request. The Plan says this testing is considered investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests such as the 
Guardant Reveal are subject to the MolDX application, assessment, and approval process. 
 We looked at the file and Medicare rules. We find that the Guardant Reveal test has not been approved for 
coverage based on information in the DEX Diagnostic Exchange. Based on this information, we decided that 
Medicare rules for coverage of the Guardant Reveal diagnostic testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the Guardant Reveal diagnostic testing provided on January 29, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic services. 
 
You asked the Plan to pre-approve chiropractic services. You say that it is medically necessary. The Plan 
denied your request. The Plan says these services are excluded.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pre-approve chiropractic services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for incontinence supplies received from April 2, 2021, to March 
3, 2023. 
 
You asked the Plan to pay for incontinence supplies. You say that you feel these items should be covered. The 
Plan denied your request. The Plan says the items received are not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pay for incontinence supplies received from 
April 2, 2021, to March 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for annual contact supply (S0500) purchased on December 30, 
2022. 
 
You asked the Plan to pay for annual contact supply (S0500). You say that you have a $200 eyewear 
allowance. You also say you do not feel should have had to pay anything out-of-pocket for your contacts. The 
Plan denied your request. The Plan says the maximum benefit has been exceeded. 
 
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 up to $200 towards supplemental eyewear every year. 
 
We looked at the file and the Plan's rules. The Plan rules say there is a $0 copayment up to the eyewear 
allowance for unlimited contacts up to Plan coverage limit. The Plan rules also say there is a $200 allowance 
for supplemental eyewear every year. Members are responsible for all costs over and above the allowance 
amount. The record shows the benefit was exhausted with this transaction leaving a $74 member liability. 
Based on this information, we decided that the Plan's rules for coverage of annual contact supply (S0500) have 
not been met. Therefore, we decided that the Plan does not have to pay for annual contact supply (S0500) 
purchased on December 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on February 13, 2023. 
 
You asked the Plan to pay for the home visit. You say that the assisted living facility is responsible to obtain 
prior authorization for all of their patients. 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 home visit provided 
on February 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81455) provided on November 1, 
2022. 
 
You asked the Plan to pay for the laboratory services. You say that you are unable to obtain additional medical 
records from the provider. The Plan denied your request. The Plan says detailed procedure notes are needed in 
order to determine the clinical utility of the service performed. 
 
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 laboratory services have been met. 
In this case additional information was required to review the claim. The Plan requested this information, but it 
was not received. Without this information we are unable to verify if the claim was medically necessary. 
Therefore, we decided that the Plan does not have to pay for the laboratory services (81455) provided on 
November 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 22, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that this is a Medicare-covered service. 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 genetic testing 
provided on November 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on March 15, 2023. 
 
You asked the Plan to pay for the office visit. You say that you were told this provider was in-network. 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 office visit provided 
on March 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mastectomy sleeve identified with code L8010. 
 
You asked the Plan to pre-approve a mastectomy sleeve. You say that you have lymphedema in your right arm 
due to lumpectomy surgery that as done many years ago. You also say that you are requested a new sleeve to 
maintain the fluid in your arm. The Plan denied your request. The Plan says the requested item is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a mastectomy sleeve (L8010) is denied as 
noncovered, since it does not meet the definition of a prosthesis. 
 
We looked at the file and Medicare rules. The requested item is specifically not a covered benefit. Based on 
this information, we decided that Medicare rules for coverage of a mastectomy sleeve have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a mastectomy sleeve identified with code 
L8010.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the cardiac catheter procedure provided on 
February 03, 2023. 
 
You asked the Plan to waive the coinsurance for the cardiac catheter procedure. You say that you agree with 
the deductible, but not this coinsurance amount. 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 10% 
coinsurance for outpatient surgery. 
 
You have been asked to pay 10% coinsurance for the cardiac catheter procedure. This item/service falls within 
the outpatient surgery 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 $316.80 ($3,167.99 allowed amount after deductible x 10% 
coinsurance = $316.80). Therefore, we decided that the Plan does not have to waive the coinsurance for the 
cardiac catheter procedure provided on February 03, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an outpatient surgery provided on January 
10, 2023. 
 
You asked the Plan to waive the cost share for an outpatient surgery. You say that you disagree with the cost 
share. 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. Your 
contract with the Plan says that there is a $1000 deductible a $295 copayment which applies to outpatient 
surgery/Medicare-covered surgery.  
 
The item or service you asked the Plan to waive the cost share for falls within the outpatient surgery/Medicare-
covered surgery benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract 
that there is a $1000 deductible a $295 copayment which applies to outpatient surgery/Medicare-covered 
surgery. The total amount you are being asked to pay $789.36 towards your $1,000 deductible. This cost 
sharing is a contractual obligation that had not been met at the time an outpatient surgery was received on January 10, 2023. Therefore, we decided that the Plan does not have to waive the cost share for an outpatient 
surgery provided on January 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left heart catheterization (93458). 
 
You asked the Plan to pre-approve a left heart catheterization. You say that you disagree with the denial and 
request reconsideration. The Plan denied your request. The Plan says the enrollee has no chest pain and has not 
had a stress test. A left heart catheterization 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 left heart catheterization. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has a single episode of chest pain. The enrollee has not had a 
non-invasive workup, such as a stress test. Documentation does not reveal the rationale for this invasive 
imaging study. Guidelines do not support a need for cardiac catheterization in this setting. As a result, at this 
time cardiac catheterization would not be considered medically appropriate and necessary in this enrollees 
clinical management. 
 
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 left heart catheterization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a left heart catheterization (93458).