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

 
We decided that the Plan does not have to pay for the office visit (99204) and the acupuncture treatments 
(97810, 97811) provided on October 7, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services are not payable as they were 
rendered by an ineligible provider.  
 
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. 
 
 
  
 
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 pay for the office visit (99204) and the 
acupuncture treatments (97810, 97811) provided on October 7, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from September 18, 2022, 
to September 20, 2022. 
 
You asked the Plan to pay for the home health services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and the rules. The claim was billed with a type of bill 324. Based on this information, we 
decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided 
that the Plan does not have to pay for the home health services provided from September 18, 2022, to 
September 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the primary care office visit provided on 
January 4, 2023. 
 
You asked the Plan to waive the deductible for the primary care office visit. You say that you would like to 
appeal these charges, as they are greater than the listed 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. Your 
contract with the Plan says that there is a $650 deductible which applies to out-of-network primary care office 
visits. The Plan contract also says that you must pay 30% coinsurance after meeting the deductible for out-of-
network primary care office visits. 
 
The item or service you asked the Plan to waive the deductible for falls within the physician/practitioner services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is a $650 deductible which applies to out-of-network primary care office visits. This cost sharing is a 
contractual obligation that had not been met at the time the primary care office visit was received on January 4, 
2023. Therefore, we decided that the Plan does not have to waive the deductible for the primary care office 
visit provided on January 4, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of lumbar spine (72131), CT 
scan of thoracic spine (72128), and CT scan of cervical spine (72125). 
 
You asked the Plan to pre-approve a CT scan of lumbar spine (72131), CT scan of thoracic spine (72128), and 
CT scan of cervical spine. You say that this is medically necessary. The Plan denied your request. The Plan 
says that records do not say why magnetic resonance imaging cannot be done. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a CT scan of lumbar spine (72131), CT 
scan of thoracic spine (72128), and CT scan of cervical spine. Our reviewer says that the service is medically 
necessary. Our physician reviewer found the enrollee has clinical and historical findings which require 
evaluation of the spinal cord. The request for CT is appropriate as the imaging will follow intrathecal contrast 
injection (CT myelogram of the cervical, thoracic and lumbar spine). Magnetic resonance imaging (MRI) is not 
possible due to the presence of a spinal cord stimulator and as such provides a contraindication to MRI. 
 
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 CT scan of lumbar spine (72131), CT scan of thoracic spine (72128), and CT 
scan of cervical spine have been met. Therefore, we decided that the Plan has to pre-approve a computed 
tomography (CT) scan of lumbar spine (72131), CT scan of thoracic spine (72128), and CT scan of cervical 
spine (72125).  
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane. 
 
You asked the Plan to pre-approve Durolane. You say that the requested Durolane is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Monovisc, Orthovisc, or Synvisc/Synvisc 
One first.  
 
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 Durolane. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee has not trialed one 
preferred viscosupplemental treatment such as Monovisc, Orthovisc, or Synvisc/Synvisc-One.  Step therapy, as 
outlined by the plan, requires that one of these be trialed first. The documentation does not outline 
contraindications or reasons these medications were not considered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durolane.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatments (97810, 97811) and the infrared 
therapy (97026) provided on September 8, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services are not payable as they were 
rendered by an ineligible provider.  
 
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. 
 
 
  
 
A review of the file and Medicare records indicates that you are not enrolled in the Medicare program. 
Therefore, we decided that the Plan does not have to pay for the acupuncture treatments (97810, 97811) and the 
infrared therapy (97026) provided on September 8, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport, and ground mileage provided on August 23, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that the submitted medical records support the 
necessity for the ambulance services. The Plan denied your request. The Plan says the member was registered 
as an inpatient of a hospital therefore transportation services are not separately payable from the payment to the 
inpatient institution. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that Medicare rules say that once a beneficiary is 
admitted to a hospital it may be necessary to transport the beneficiary to another hospital or other site 
temporarily for specialized care while the beneficiary maintains inpatient status with the original provider.  
 
We looked at the file and Medicare rules. The records provided demonstrate that the enrollee was receiving 
inpatient hospital care at the time of the transport. This means that the transportation service furnished to the 
enrollee while they were admitted as inpatient would be covered as an inpatient hospital and not paid for 
separately under Part B. Based on this information, we decided that Medicare rules for coverage of the 
ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for ambulance 
service, basic life support, non-emergency transport, and ground mileage provided on August 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an in-network injection provided on 
October 19, 2022. 
 
You asked the Plan to waive the deductible for an in-network injection . You say that you were never told that 
you were going to be knocked out for this procedure, if you had known, you would have declined the 
procedure. The staff also told you that you only had a $150 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. Your 
contract with the Plan says that there is a $1000 deductible which applies to Medicare Part B drugs.  
At the time of this service, you had not met the $1000 deductible, which is why you are being asked to pay the 
$907.89. 
 
The item or service you asked the Plan to waive the deductible for falls within the Medicare Part B drugs 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 
$1000 deductible which applies to Medicare Part B drugs.  This cost sharing is a contractual obligation that had not been met at the time an in-network injection was 
received on October 19, 2022. Therefore, we decided that the Plan does not have to waive the deductible for an 
in-network injection provided on October 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and related services provided on February 06, 
2023. 
 
You asked the Plan to pay for an office visit and related 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 an office visit and 
related services provided on February 06, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the echocardiogram provided on March 14, 
2023. 
 
You asked the Plan to waive the deductible for the echocardiogram. You say that you were unaware you had a 
deductible. 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 $750 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies. Your contract with the Plan also says that there is a $20 copayment after the 
deductible is met for each basic imaging service. 
 
 
 You have been asked to pay $454.29 towards your deductible for the echocardiogram. The item or service you 
asked the Plan to waive the deductible for falls within the outpatient diagnostic tests and therapeutic services 
and supplies benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that 
there is a $750 deductible which applies to outpatient diagnostic tests and therapeutic services and supplies. 
This cost sharing is a contractual obligation that had not been met at the time the echocardiogram was received 
on March 14, 2023. Therefore, we decided that the Plan does not have to waive the deductible for the 
echocardiogram provided on March 14, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for outpatient diagnostic service provided on 
November 18, 2022. 
 
You asked the Plan to waive the cost share for outpatient diagnostic service . 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 $400 deductible which applies to outpatient diagnostic tests.  
 
The item or service you asked the Plan to waive the cost share for falls within the outpatient diagnostic tests 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $400 
deductible which applies to outpatient diagnostic tests. The total amount you are being asked to pay is $103.82 
towards your deductible. This cost sharing is a contractual obligation that had not been met at the time 
outpatient diagnostic service was received on November 18, 2022. Therefore, we decided that the Plan does not 
have to waive the cost share for outpatient diagnostic service provided on November 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gloves (A4927) and waterproof tape (A4452). 
 
You asked the Plan to pre-approve gloves and waterproof tape. You say that you have eczema, and your fingers 
get dry very fast. The Plan denied your request. The Plan says these items are not covered, as the gloves and 
tape are not medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve gloves (A4927) and waterproof tape (A4452).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (PCD) (E0651) and 
garment sleeve (E0667).  
 
You asked the Plan to pre-approve a PCD and sleeve. You say that the items are medically necessary. The Plan 
denied your request. The Plan says the items are not medically necessary. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
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 PCD and sleeve. Our reviewer says 
that the enrollee does not need these items. Our physician reviewer found provided records in this case do not 
document a definitive diagnosis of lymphedema; records report a possible arthritic or other etiology. Provided 
records in this case do not document detailed measurements, obtained in the same manner and with reference to 
the same anatomic landmarks, prior to and at the conclusion of the various trials and therapy, with bilateral 
comparisons where appropriate. 
 
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 PCD and sleeve have not been met.  Therefore, we decided that the Plan does 
not have to pre-approve a pneumatic compression device (PCD) (E0651) and garment sleeve (E0667).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after June 
5, 2023. 
 You asked the Plan to pre-approve SNF care after June 5, 2023. You say that the continued admission to a SNF 
is medically necessary. The Plan denied your request. The Plan says the continued admission to a SNF is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care after June 5, 2023. Our 
reviewer says that the requested SNF care is not considered medically reasonable and necessary based on 
Medicare guidelines. Our physician reviewer found you do not have daily skilled nursing needs that require the 
specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled 
therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. 
You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility 
(SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care after June 5, 2023, have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continued skilled nursing facility (SNF) care after June 5, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF services are medically necessary. The Plan 
denied your request. The Plan says you do not meet the Medicare criteria for SNF care. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bifocal lens, the polycarbonate lens, the anti-
reflective coating, and the miscellaneous vision item or service provided on January 20, 2023. 
 
You asked the Plan to pre-approve the bifocal lens, the polycarbonate lens, the anti-reflective coating, and the 
miscellaneous vision item or service. You say that you were told the provider was in-network and you should 
be reimbursed. The Plan denied your request. The Plan says the provider was not contracted for the eyeglass 
materials. 
 
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 the services when received by a network provider. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the bifocal lens, the polycarbonate lens, the anti-
reflective coating, and the miscellaneous vision item or service have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the bifocal lens, the polycarbonate lens, the anti-reflective coating, and 
the miscellaneous vision item or service provided on January 20, 2023.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for the take-home supply of methadone (G2078) provided on January 23, 
2023. 
 
You asked the Plan to pay for procedure code G2078. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
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 rationale incorrectly states that this claim was submitted by a physician 
rather than the OTP facility. The claim shows that the billing provider is the OTP facility. This was submitted 
on a professional claim which is allowed according to the rules. As such, we find that the Plan has not 
substantiated this denial of payment. Therefore, we decided that the Plan has to pay for the take-home supply 
of methadone (G2078) provided on January 23, 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.