Persius/hicric huggingface dataset:
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 Prolia is medically necessary. The Plan denied your 
request. The Plan says since this drug is being provided by a pharmacy, it is not eligible for Part B coverage. 
 
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 Prolia.  
 
Benefits for Prolia 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on October 4, 2022, to 
October 13, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the psychotherapy services. You say that this was a continuation of care.  The 
Plan denied your request. The Plan says the OON services were not pre-authorized.  
 
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 services at issue in this appeal. The Plan did not pre-approve the service 
at issue. We found no exception that would require the Plan to pay for these OON services. Therefore, we 
decided that the Plan does not have to pay for psychotherapy services provided on October 4, 2022, to October 
13, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the out-of-network cost share for the office visit provided on 
January 30, 2023, by an out-of-network provider. 
 
You asked the Plan to waive the out-of-network cost share for the outpatient service. You say that you did not 
see this provider listed in the provider directory. You say that you called the Plan to see if the doctor was in-
network. You say that you were advised that they were. You say that you received a bill for $58.74 because 
provider was out-of-network. You also say that this should be reprocessed as in-network as a one-time 
exception. 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 $65 
copayment for Physician services by an out-of-network provider.  
 You have been asked to pay a coinsurance of $58.70 for the outpatient service received out-of-network, which 
is less than the $65 copayment. This service falls within the Physician services benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the out-of-network cost share for the office visit provided on January 30, 2023, by an 
out-of-network provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the cost share for the office visit (99212) provided on February 14, 2023. 
 
You asked the Plan to waive the cost share for the physician service. You say that the enrollee has dual 
coverage. You also say that this claim should be fully covered. The Plan denied your request. The Plan says 
that 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 says that enrollees must pay a 
$0 copayment for Physician services.  
 
The Plan says the enrollee must pay a coinsurance for the physician service. Based on the plan contract, 
however, the enrollee cannot be asked to pay more than a $0 copayment for the physician service. Therefore, 
we decided that the Plan has to waive the cost share for the office visit (99212) provided on February 14, 2023.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 8, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the OON office visit. You say that the medical records provided support the 
services in dispute.  The Plan denied your request. The Plan says the OON services were not pre-authorized. 
 
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 services at issue in this appeal. The Plan did not pre-approve the service 
at issue. We found no exception that would require the Plan to pay for these OON services. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on March 8, 2023, by an out-of-network 
(OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for liposuction provided on November 2, 2022. 
 
You asked the Plan to pay for liposuction. You say that this was to remove a lipoma and should be covered. 
The Plan denied your request. The Plan says no records were received by the provider despite multiple 
attempts, to support the need for this surgical procedure. 
 
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 liposuction have been met. There are 
no medical records within the casefile. Without the requested clinical information, we are unable to determine 
if the requested services are medically necessary. Therefore, we decided that the Plan does not have to pay for 
liposuction provided on November 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 continuous glucose monitor and 
supplies. 
 
You asked the Plan to pre-approve the FreeStyle Libre 2 and supplies. You say that this is a medical necessity. 
The Plan denied your request. The Plan says the clinical does not appear that the enrollee takes insulin at all, 
and no hypoglycemia is noted. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
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 FreeStyle Libre 2 and supplies. Our 
reviewer says that the elements of the coverage criteria are not satisfied. Our physician reviewer found the 
record indicates that the enrollee has diabetes. The record provided does not indicate that the enrollee is being 
treated with insulin or has problematic hypoglycemia as defined by the Medicare rules.  
 
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 FreeStyle Libre 2 and supplies. have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a FreeStyle Libre 2 continuous glucose monitor and supplies.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided September 29, 2022 to 
October 28, 2022. 
 You asked the Plan to pay for the home health services. You say that this service was medically necessary. 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, a NOA was not received by the Plan. Without this documentation the claim cannot be paid. 
Therefore, we decided that the Plan does not have to pay for home health services provided September 29, 
2022 to October 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit, foot inserts, and occupational therapy 
provided on February 14, 2023, by a chiropractor. 
 
You asked the Plan to pay for the outpatient services. You say that you have been experiencing a lot of knee 
pain. You say that you absolutely needed this for your quality of life. You also say that you believe this should 
be covered. The Plan denied your request. The Plan says the services in this case are not covered when 
provided by a chiropractor. 
 
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 services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the office visit, foot inserts, and occupational therapy provided on 
February 14, 2023, by a chiropractor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for end-stage renal disease (ESRD) related services provided on 
December 31, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the ESRD related services. You say that authorization would have been the 
responsibility of the facility, and your provider should not be penalized. You say that the records provided 
support the medical necessity of the services in dispute.  The Plan denied your request. The Plan says the 
enrollee was not referred by a participating provider. The OON services were not pre-authorized.  
 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 end-stage renal disease (ESRD) related services 
provided on December 31, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided in the United Mexican States on 
November 16, 2022. 
 
You asked the Plan to pay for dental services. You say that you have used dental coverage outside of the 
country for many years with no questions asked. The Plan denied your request. The Plan says this service is not 
covered by Medicare or the Plan when performed outside of the United States. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services furnished outside of the 
United States and its territories are only covered under limited, specified circumstances. The Plan has a 
worldwide coverage benefit that goes beyond Medicare coverage. For that reason, the Plans rules apply to this 
case. The Plan covers worldwide urgent care services, but only when the services were necessary to treat an 
unforeseen illness or injury. 
 
We looked at the file and Medicare rules. These services do not meet any of the limited circumstances for 
which Medicare covers services furnished outside of the United States. Additionally, these services are not 
covered by the Plans worldwide coverage benefit because the need for these services was foreseeable prior to 
leaving the United States. Based on this information, we decided that the rules for coverage of dental services 
have not been met. Therefore, we decided that the Plan does not have to pay for dental services provided in the 
United Mexican States on November 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the office visit (99205) provided on November 18, 
2022. 
 
You asked the Plan to reimburse you for the outpatient service. You say that this provider does not take 
insurance. You say that you were led to believe that that the provider would be covered for an office visit. You 
say that you have had previous claims paid for providers that do not accept insurance. You also say that this 
should be covered too. The Plan denied your request. The Plan says the provider in this case has opted out of 
Medicare. The Plan also says that payment cannot be made for services that are performed by a provider that 
has opted out of 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 service 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 reimburse you for 
the office visit (99205) provided on November 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the preoperative office visit provided on 
April 13, 2022. 
 
You asked the Plan to waive the copayment for the preoperative office visit. You say that this service should be 
fully covered. 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 $10 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $10 copayment for the preoperative office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for the preoperative office visit provided on April 13, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve MRI of the abdomen. 
 
You asked the Plan to pre-approve the MRI. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says that the request for an MRI is not medically necessary at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
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 MRI. Our reviewer says that the 
request is medically necessary. Our physician reviewer found the enrollee has a history of hepatitis C and 
hepatocellular carcinoma with 2 nodules. The enrollee is on the liver transplant list and must have MRI 
surveillance every 3 months to monitor for tumor recurrence and or metastatic disease since either would 
negate transplant eligibility. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
MRI of the abdomen.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share amount for the specialist office visit provided 
on March 8, 2023.  
 You asked the Plan to waive the cost share amount for the outpatient service. You say that this was a follow-up 
visit from your surgery on March 2, 2023. You also say that you should not have been billed for this as it is 
included in your surgery follow-up. 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 $30 
copayment for Physician services.  
 
You have been asked to pay a $30 copayment for the outpatient service. This service falls within the Physician 
services benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Additionally, there is no evidence presented that the service at issue in this case is related to the procedure 
performed on March 2, 2023. Therefore, we decided that the Plan does not have to waive the cost share amount 
for the specialist office visit provided on March 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the car battery purchased on January 26, 
2023. 
 
  You asked the Plan to provide reimbursement for the car battery. You say that this is a covered benefit. You 
also say that if it is not covered, the Plan would be committing and selling a deceptive product. The Plan denied 
your request. The Plan says the criteria for eligibility have not been met. The Plan also says that this is not 
covered because there is no evidence of benefit coordination with the Plan's Assistance-Supplemental program. 
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the car battery have not been met. Specifically, the car battery replacement falls under the SSBCI 
benefits, which you need to be approved for before you are allowed coverage for specific services under this 
benefit. The documentation does not show that you received approval for coverage for the SSBCI benefit, nor 
that you have an eligible condition that meets all the required criteria. Therefore, we decided that the Plan does 
not have to provide reimbursement for the car battery purchased on January 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 24, 2022. 
 
You asked the Plan to pay for the outpatient service. You say that the provider does not file any insurance. You 
say that you have to submit your receipts. You say that you were not able to send in the necessary information 
until March 2022 due to illness. You also say that it was your understanding that you could submit claims from 
the prior year until the end of March the following year. The Plan denied your request. The Plan says the claim 
for the date of service in this case was filed more than one calendar year after the date of service. 
 
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 outpatient service was not filed until February 27, 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 the office visit provided on January 24, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95908 billed for date of service December 
15, 2022.   

You asked the Plan to pay for procedure code 95908. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 95908 is bundled into payment for code 
95870. 
 
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 95908 
is a column II code to column I code 95870 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 95908 billed for date of service December 15, 2022.