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

 
We decided that the Plan does not have to pay for the transitional care management services provided on 
August 3, 2022, by an OON provider.  
 
You asked the Plan to pay for the transitional care management services. You say that the service was 
medically necessary. The Plan denied your request. The Plan says the service was not 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 the transitional care management services 
provided on August 3, 2022, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 07, 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 March 07, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on March 24, 2023. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration for the services 
provided. 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 office visit provided on 
March 24, 2023.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit for evaluation provided on March 30, 2023. 
 
You asked the Plan to pay for home visit for evaluation. You say that the assisted living facility is responsible 
to obtain prior authorization for all patients. The Plan denied your request. The Plan says that unauthorized, 
out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for home visit for 
evaluation provided on March 30, 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 February 28, 
2023. 
 
You asked the Plan to waive the copayment for an office visit. You say that you think that you were billed 
incorrectly for this service. 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 $35 
copayment for each specialist office visit for Medicare-covered services. 
 
You have been asked to pay a $35 copayment for an office visit. This item/service falls within the each 
specialist office visit for Medicare-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 February 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on February 16, 2023. 
 
You asked the Plan to pay for lab testing. You say that you are requesting the submitted documentation be 
reviewed. 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 lab testing provided on 
February 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for anesthesia on January 03, 2023.  
 
You asked the Plan to waive the cost share for anesthesia. You say that you should not have a 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 10% 
coinsurance of the approved amount. The annual deductible applies for inpatient hospital care. Hospital care 
includes the care you get in acute care hospitals, critical access hospitals, inpatient rehabilitation facilities, and 
long-term care hospitals. Inpatient hospital care starts the day you are formally admitted to the hospital with a 
doctors order. The day before you are discharged is your last inpatient day. The provider billed in the amount 
of $2,040 and the allowed amount is $172.4. There was a $155.21 deductible and a $17.25 coinsurance for the 
service. $155.21 + $17.25 = $172.46. Therefore, results in the total cost shairng amount of $172.46. 
 
You have been asked to pay a 10% coinsurance and a $155.21 deductible for anesthesia. 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. Therefore, we decided that the Plan does not have to waive the cost share for 
anesthesia on January 03, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit for evaluation provided on April 05, 2023. 
 
You asked the Plan to pay for home visit for evaluation. You say that the assisted living facility is responsible 
to obtain prior authorization for all patients. The Plan denied your request. The Plan says that unauthorized, 
out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for home visit for 
evaluation provided on April 05, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 3, 2023, by an OON 
provider.  
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says this service was not 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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
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 an office visit provided on May 3, 2023, by an 
OON provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiac rehab services provided on October 19, 2022, to 
October 26, 2022. 
 
You asked the Plan to pay for cardiac rehab services. You say that this was medically necessary and 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 cardiac rehab services 
provided on October 19, 2022, to October 26, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for audiologic function test on April 11, 2023. 
 
You asked the Plan to waive the copayment for audiologic function test. You say that this should be covered 
because you thought a $45 copayment would cover everything. 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 $45 
copayment for a Medicare-covered diagnostic hearing exam. Diagnostic hearing and balance evaluations 
performed by your provider to determine if you need medical treatment are covered as outpatient care when 
furnished by a physician, audiologist, or other qualified provider. Diagnostic hearing exams. The provider 
billed in the amount of $175 and the allowed amount is $38.59. This is less than the copayment amount. 
Therefore, results in the total cost shairng amount of $38.59. You have been asked to pay a $38.59 copayment, which is less than the copayment for audiologic function test. 
This item/service falls within the hearing 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 audiologic function test on April 11, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for eye surgery provided on March 29, 2023. 
 
You asked the Plan to waive the copayment for eye surgery. You say that you say that you already paid for one 
surgery and should not be responsible for the other eye 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 $245 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. 
 
You have been asked to pay a $245 copayment for eye surgery. This item/service falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 eye surgery provided on March 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on March 20, 2023. 
 
You asked the Plan to pay for office visit. You say that you are requesting the submitted documentation be 
reviewed. 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 office visit provided on 
March 20, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy services. 
 
You asked the Plan to pre-approve massage therapy services. You say that you need these services for your 
condition. You say that you have water retention and swelling. You also say that you have tried compression 
socks, elevating your legs, and exercise, all of which have not worked. The Plan denied your request. The Plan 
says massage therapy is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare does not cover massage therapy. Therefore, we decided that 
the Plan does not have to pre-approve massage therapy services.
Appeal type: Step-Therapy
Decision: Favorable

 
We decided that the Plan has to pre-approve Cimzia Powder for Recon 400 mg. 
 
You asked the Plan to pre-approve Cimzia Powder for Recon 400 mg. You say that the requested Cimzia 
Powder for Recon 400 mg is medically necessary. The Plan denied your request. The Plan says that the 
enrollee must try and fail two of the following drugs: Humira, Amjevita, Orencia, Enbrel, Actemra, Xeljanz, 
Xeljanz XR, Rinvoq, and Cosentyx. 
 
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 looked at the file and Medicare rules. The Plan says that the enrollee has tried and failed Orencia. The Plan 
then sent additional information that shows the enrollee also tried and failed Enbrel. The Plan's step therapy 
criteria require trial and failure of two preferred drugs. Orencia and Enbrel are on the Plan's list of preferred 
drugs that have been tried and failed. Based on this information, we decided that Medicare rules for coverage 
of Cimzia Powder for Recon 400 mg have been met. Therefore, we decided that the Plan has to pre-approve 
Cimzia Powder for Recon 400 mg.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Darzalex. 
 
You asked the Plan to pre-approve Darzalex. You say that the requested Darzalex is medically necessary. The 
Plan denied your request. The Plan says the requested Darzalex is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Darzalex. Our reviewer says that the 
requested Darzalex is not medically necessary. Our physician reviewer found Darzalex is FDA-approved for 
the treatment of light chain (AL) amyloidosis, but it's use beyond a maximum of two years is not endorsed as 
safe and effective. The use of Darzalex for the treatment of light chain (AL) amyloidosis beyond a maximum of 
two years is not supported by one of the major drug compendia or by clinical research that appears in a CMS-
approved medical journal. The use of Darzalex for the treatment of light chain (AL) amyloidosis beyond a maximum of two years does not meet Medicare criteria as safe and effective and otherwise reasonable and 
necessary for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Darzalex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Darzalex.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on December 07, 2022. 
 
You asked the Plan to pay for a home visit. 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 a home visit provided on 
December 07, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a secure digital (SD) card assembly (K0108). 
 
You asked the Plan to pre-approve an SD card assembly. You say that the power wheelchair repairs were 
denied due to duplicate, but these repairs were previously approved, and the authorization expired. You also 
say that the new request was only an authorization extension, and you would like this reviewed for approval as 
previously approved. The Plan denied your request. The Plan says this does not serve a medical purpose. The 
Plan also says that this cannot be covered as it is not reasonable and necessary per Medicare criteria. 
 
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 a secure digital (SD) card assembly (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on February 20, 2023. 
 
You asked the Plan to pay for a home visit. You say that the provider was not responsible for obtaining 
authorization. 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 visit provided on 
February 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99215 billed with diagnosis codes E83.52 
and E55.9 provided on February 13, 2023. 
 
You asked the Plan to pay for procedure code 99215. 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. The rules say that health plans, physicians, hospitals, and other health 
care providers must comply with the Official International Classification of Disease, 10th Edition, Clinical 
Modification (ICD-10-CM) Coding Guidelines. 
 
We looked at the file and Medicare rules. In this case, coding guidelines state that a type 1 Excludes note is a 
pure excludes note. It means "Not Coded Here!" An Excludes1 note indicates that the code excluded should 
never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two 
conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. 
Diagnosis codes E83.52 and E55.9 should not be reported together. Therefore, we decided that the Plan does 
not have to pay for procedure code 99215 billed with diagnosis codes E83.52 and E55.9 provided on February 
13, 2023.