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

 
We decided that the Plan does not have to pay for injections provided on December 06, 2022. 
 
You asked the Plan to pay for injections. You say that the services 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 injections provided on 
December 06, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an above knee prosthesis with custom socket and standard 
fabrication and suspension features (L5321, L5624, L5631, L5649, L5650, L5651, L5671, L5673, L5920, 
L5950), K3-level componentry including microprocessor controlled, hydraulic knee (L5828, L5845, L5848, 
L5856) and flex-walk style foot (L5981), and mutli-ply prosthetic socks (L8430, L8480). 
 
You asked the Plan to pre-approve a prosthesis and additional parts. You say that the services are necessary. 
The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has 
not been met. 
 
The Plan follows Medicare rules. Medicare rules say that lower limb prostheses are covered when specific 
criteria are met. 
 
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 prosthesis and additional parts. Our 
reviewer says that the services are medically necessary. Our physician reviewer found there is no doubt that 
original Medicare would cover the entire requested prosthesis for this K3-level enrollee. Lesser components 
would amount to sub-standard care and would not meet her needs. Therefore, the entirety of the prosthesis and 
all requested knee and foot components are necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of v have been met. Therefore, we decided that the Plan has to pre-approve an 
above knee prosthesis with custom socket and standard fabrication and suspension features (L5321, L5624, 
L5631, L5649, L5650, L5651, L5671, L5673, L5920, L5950), K3-level componentry including microprocessor 
controlled, hydraulic knee (L5828, L5845, L5848, L5856) and flex-walk style foot (L5981), and mutli-ply 
prosthetic socks (L8430, L8480).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 7 units of parenteral nutrition solution (B4185) billed for 
date of service February 10, 2023. 
 
You asked the Plan to pay for parenteral nutrition solution. You say that you have billed the item at issue 
correctly. The Plan denied your request. The Plan says the provided records do not support the item billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
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 parenteral nutrition solution Our reviewer 
says that parenteral nutrition solution does not meet criteria for payment. Our physician reviewer found that the 
provided documentation does not support the number of units billed. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of parenteral nutrition solution have not been met. Therefore, we decided that the 
Plan does not have to pay for 7 units of parenteral nutrition solution (B4185) billed for date of service February 
10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81455) provided on October 28, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says another plan is the primary payer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has requested an 
explanation of benefits from the primary insurer. As the secondary insurer, the Plan cannot be held responsible 
for the lab services until the primary insurer has denied the claim for these services. Therefore, we decided that 
the Plan does not have to pay for lab services (81455) provided on October 28, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (J7030, 80053, 99284, 96360) 
provided on March 7, 2023. 
 
You asked the Plan to pay for the emergency room services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says this provider is not eligible for payment. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for emergency room services (J7030, 80053, 
99284, 96360) provided on March 7, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on November 15, 2022. 
 
You asked the Plan to pay for the physician's services. You say that you were never told about the opt out 
option and that you had the service because you believed you would be covered for half of the total cost. The 
Plan denied your request. The Plan says this provider is a Medicare opt out provider and not eligible to be part 
of the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
physician's services provided on November 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81407, 81408, 81479) provided on February 26, 
2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim for this molecular pathology testing did not include the required 
unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services (81407, 81408, 81479) 
provided on February 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hereditary cardiomyopathy genomic sequence analysis 
panel. 
 
You asked the Plan to pre-approve a hereditary cardiomyopathy genomic sequence analysis panel. You say that 
your doctor felt you needed this test. The Plan denied your request. The Plan says based on the diagnostic 
program, MolDX Technical Assessment, the requested test is not an approved test, 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this 
information, we decided that Medicare rules for coverage of a hereditary cardiomyopathy genomic sequence analysis panel have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
hereditary cardiomyopathy genomic sequence analysis panel.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo. 
 You asked the Plan to pre-approve the drug. The Plan denied your request. The Plan says that the step therapy 
requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that 
Vabysmo is not medically necessary. Our physician reviewer found that the enrollee has exudative age-related 
macular degeneration and the requested medication is a new start. However, there is no indication that the 
enrollee has tried and failed the Plan's step one alternative. Also, there is no indication that the enrollee has a 
contraindication to or would have an adverse effect from the Plan's preferred step one alternative. Therefore, 
the elements of the coverage criteria have not been satisfied. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vabysmo.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on  
January 20, 2022. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
providers have 365 calendar days from the date of service to submit a claim to the Plan for services rendered. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the subsequent nursing facility care was not filed until February 28, 2023. 
This means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care provided on 
January 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on 
February 12, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the claim was filed after time limit 
because there was a credentialing issue for the provider with the Plan. The Plan denied your request. The Plan 
says the claim was untimely, and the submission did not meet the exception criteria guidelines outlined in 42 
CFR Section 424.44. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for subsequent nursing facility care was not filed until March 13, 2023. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care provided on 
February 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99308 billed for date of service March 22, 
2023. 
 You asked the Plan to pay for procedure code 99308. You say that the service at issue was a medical necessity 
for the enrollee. The Plan denied your request. The Plan says payment for code 99308 is included in the 
payment for procedure code 11043. 
 
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, we have confirmed that code 99308 is a column II code to column I code 11043; however, 99308 
was billed with a modifier.  
 
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 99308. Our reviewer says that procedure 
code 99308 does not meet criteria for payment. Our reviewer found that the evaluation and management 
service provided is related to wound care. The service provided does not include documentation to support a 
separate procedure. 
 
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 99308 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99308 billed for date of service March 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 15, 2023. 
 
You asked the Plan to pay for laboratory services. You say that the services 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 laboratory services 
provided on March 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on December 16, 2022, to 
December 26, 2022. 
 
You asked the Plan to pay for physical therapy. You say that you believe the services are 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 physical therapy 
provided on December 16, 2022, to December 26, 2022.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services rendered on September 23, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that the request for anticipated payments (RAP) claim was not received within five 
calendar days from the start of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that the RAP claim was not received within five calendar days 
from the start of care; however, per Medicare rules, the RAP is not required for home health services after 
January 1, 2022. The Plan has not provided a valid denial reason for the services at issue. Therefore, we 
decided that the Plan has to pay for the home health services rendered on September 23, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from February 4, 2023, to 
March 5, 2023. 
 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 NOA was not received timely. As such, this final claim was correctly denied.  
 
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 February 4, 2023. The NOA was not received by the Plan until March 25, 
2023. 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 services 
rendered from February 4, 2023, to March 5, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 11, 2022 to July 
26, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that this service was medically 
necessary. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from July 11, 2022 to July 26, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 8, 2023. 
 
You asked the Plan to pay for the physician's services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says physicians and practitioners who do not wish to enroll in the Medicare 
program may opt-out of Medicare. This means that neither the physician, nor the beneficiary submits the bill to 
Medicare for services rendered. This provider is not under contract with the health Plan and is not certified with 
Medicare 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
physician's services provided on March 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic procedures provided on October 31, 2022. 
 
You asked the Plan to pay for therapeutic procedures. You say that the 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 therapeutic procedures 
provided on October 31, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from January 21, 2022, to 
January 31, 2022. 
 You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the NOA was not received timely. As such, this final claim was correctly denied.  
 
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 21, 2022. The NOA was not received by the Plan until January 26, 
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 services 
rendered from January 21, 2022, to January 31, 2022.