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

 
We decided that the Plan does not have to pay for advance care planning including the explanation provided on 
July 01, 2023. 
 
You asked the Plan to pay for advance care planning including the explanation. You say that this service is 
supported in the records proving medical necessity. 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 advance care planning 
including the explanation provided on July 01, 2023.
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 Vabysmo. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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 Vabysmo. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a diagnosis of exudative age-related macular degeneration of the left eye, with active 
choroidal neovascularization. The documentation does not support that the enrollee has tried and failed the 
ophthalmic formulation of bevacizumab. The documentation does not support that the ophthalmic formulation 
of bevacizumab would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the 
enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vabysmo 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 June 29, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the services rendered 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 subsequent nursing 
facility care provided on June 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 30, 2023. 
 
You asked the Plan to pay for an office visit. 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 an office visit provided 
on May 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on April 26, 2023. 
 
You asked the Plan to pay for laboratory services. You say that this service is supported in the records proving 
medical necessity. 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 April 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the lab testing provided on May 17, 2023. 
 
You asked the Plan to waive the copayment for the lab testing. You say that you assumed there were not 
copayment for lab testing. 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 outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $10 copayment for the lab testing. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies 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 $8.57. Therefore, we decided that the Plan does not have to waive the copayment for 
the lab testing provided on May 17, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on June 23, 
2023. 
 
You asked the Plan to waive the copayment for inpatient hospital care. 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 $150 
copayment for inpatient hospital care. 
 
You have been asked to pay a $150 copayment for inpatient hospital care. This item/service falls within the 
inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. you are being asked to pay a $150 copayment for one day. Therefore, we decided that the 
Plan does not have to waive the copayment for inpatient hospital care provided on June 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on July 20, 2023. 
 
You asked the Plan to pay for laboratory services. You say that this service is supported in the records. 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 July 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the cardiovascular monitoring services 
provided on August 21, 2023. 
 
You asked the Plan to waive the copayment for the cardiovascular monitoring services. You say that you were 
unaware of 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 $5 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $5 copayment for the cardiovascular monitoring services. This item/service falls 
within the outpatient diagnostic tests and therapeutic services and supplies 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 cardiovascular monitoring services provided on August 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the walker (E0144) and the trapeze bar 
(E0940) provided on May 27, 2023, by an OON provider.  
 
You asked the Plan to provide reimbursement for the walker and trapeze bar. You say that you were told these 
items were covered, and you would be reimbursed if you provided the necessary documentation. The Plan 
denied your request. The Plan says these items could have been received by an in-network provider. 
 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 provide reimbursement for care from out-of-network providers only in cases 
involving emergencies, out of area urgent care and pre-approved care. 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. 
 
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 
items at issue. We found no exception that would require the Plan to provide reimbursement for these items. A 
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 provide reimbursement for the walker (E0144) 
and the trapeze bar (E0940) provided on May 27, 2023, by an OON provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room services provided on 
June 21, 2023. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that you were not 
examined by a physician an you waited over 5 hours before deciding to leave the hospital. You feel that you 
should not be responsible for the ER copay. 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 $110 
copayment for emergency care. 
 
You have been asked to pay a $110 copayment for the emergency room services. This item/service falls within the emergency care benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room 
services provided on June 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for alcohol and/or other drug treatment program provided from 
November 1, 2022, to March 16, 2023. 
 
You asked the Plan to pay for alcohol and/or other drug treatment program. The Plan denied your request. The 
Plan says these services are not eligible for Medicare coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that a Substance Abuse Facility is not eligible to 
participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Substance Abuse Facility. 
Medicare says that a Substance Abuse Facility is not eligible to participate in the Medicare program. Therefore, 
we decided that the Plan does not have to pay for alcohol and/or other drug treatment program provided from 
November 1, 2022, to March 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urinary tract infection (UTI) molecular test panel 
provided on July 24, 2023. 
 
You asked the Plan to pay for the UTI molecular test panel. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says per Local Coverage Article A58917, this type of testing must be 
billed with a single unit of service with a single code. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the urinary tract infection (UTI) molecular test panel provided on July 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on August 
28, 2023. 
 
You asked the Plan to waive the copayment for a specialist office visit. 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 $50 
copayment for physician/practitioner services/specialist:. 
 
You have been asked to pay a $50 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services/specialist: 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 a specialist office visit provided on August 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99305 billed for date of service November 
23, 2022.  
 
You asked the Plan to pay for procedure code 99305. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 99305 is bundled into payment for code 99306. 
 
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 99305 is a column two code to column one code 99306 with a modifier indicator of 0. The column two 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 99305 billed for date of service November 23, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home or residence visit for the evaluation provided on 
March 23, 2023. 
 
You asked the Plan to pay for a home or residence visit for the evaluation. You say that this service is 
supported in the records proving medical necessity. 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 a home or residence visit 
for the evaluation provided on March 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital inpatient or observation care (99233) 
provided July 13, 2023. 
 
You asked the Plan to pay for the service. You say that you are requesting reconsideration for services advising 
the coding department has reviewed the services and determined that the claim is coded correctly. The Plan 
denied your request. The Plan says the diagnosis codes should not be reported together which is based on the 
Excludes1 Notes instructions in the ICD-10-CM Official Guidelines for Coding and Reporting. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The billed service 99233 was denied because the diagnosis codes associated to I95.9 and R57.9 should not be 
reported together. The billed service has been denied because it was reported with one or more diagnosis code 
pairs that are subject to an Excludes1 note. Based on this information, we decided that Medicare rules for 
coverage of the service have not been met. Therefore, we decided that the Plan does not have to pay for 
subsequent hospital inpatient or observation care (99233) provided July 13, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the endoscopic procedure provided on 
April 26, 2023. 
 
You asked the Plan to reduce the coinsurance for the endoscopic procedure. You say that you should not have 
to pay 20% coinsurance for the allowed 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 20% 
coinsurance for in-network outpatient surgery, including services provided at hospital outpatient facilities. 
 
You have been asked to pay 20% coinsurance for the endoscopic procedure. This item/service falls within the in-network outpatient surgery, including services provided at hospital outpatient facilities 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 reduce the coinsurance for the endoscopic procedure provided on April 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on December 07, 
2022. 
 
You asked the Plan to waive the copayment for an office visit. 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 $10 
copayment for physician/practitioner services/PCPs forMedicare covered services. 
 
You have been asked to pay a $10 copayment for an office visit. This item/service falls within the 
physician/practitioner services/PCPs forMedicare covered 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 copayment for an office visit provided on December 07, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hospital bed and a walker. 
 
You asked the Plan to pre-approve a hospital bed and a walker. You say that the enrollee has amputated toes 
and lost feeling in the left leg and has difficulty walking. The Plan denied your request. The Plan says a 
standard written order (SWO) and office notes are required to meet Medicare guidelines for the requested 
service. 
 The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 a hospital bed and a walker have been 
met. Requests for a hospital bed and a walker require a Standard Written Order (SWO). The records show that 
the Plan made several attempts to obtain the needed notes and an order from your doctor without success. 
Therefore, we decided that the Plan does not have to pre-approve a hospital bed and a walker.