Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee lives at home alone and has been in 
extreme pain, is a fall risk and has fell several times. The Plan denied your request. The Plan says the enrollee 
has no skilled nursing needs. The Plan says that services needed are custodial 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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does 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 skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 2 remaining units of code 93010, billed on date of service 
January 24, 2023. 
 
You asked the Plan to pay for 2 units of 93010. You say that the additional units of 93010 should be covered 
because records support the services were performed. The Plan denied your request. The Plan says 5 units of 
93010 were paid, but the remaining 2 units billed were denied because they are not supported in the record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for 2 additional units of 93010. Our reviewer 
says that 2 additional units of 93010 are not supported in the documentation. Our physician reviewer found 
documentation provided does not support any additional units of code 93010 were performed above 5 units. 
 
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 additional 2 units of 93010 have not been met. Therefore, we decided that 
the Plan does not have to pay for the 2 units of code 93010 billed for date of service January 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the smoking and tobacco use cessation counseling visit 
(99406) provided September 8, 2022. 
 
You asked the Plan to pay for the cardiology visit. You say that that the medical records provided will show 
proof of medical necessity. The Plan denied your request. The Plan says the service does not meet Medicare 
NCD criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The clinical information does not document that the enrollee uses 
tobacco. Based on this information, we decided that Medicare rules for coverage of the cardiology visit have 
not been met. Therefore, we decided that the Plan does not have to pay for the smoking and tobacco use 
cessation counseling visit (99406) provided September 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 17, 2023. 
 
You asked the Plan to pay for an office visit. You say that there is a referral for this service. 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 April 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit provided on April 20, 2023, by an out-of-network 
(OON) provider.  
 
You asked the Plan to pay for home visit. You say that the assisted living facility is responsible to obtain prior 
authorization for all of their patients, which should also cover for the medical treatments provided by the provider. The Plan denied your request. The Plan says the provider is out-of-network with the Plan and 
authorization was not obtained prior to the services being rendered. 
 
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 home visit provided on April 20, 2023, by an out-
of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for debridement, subcutaneous tissue provided on April 13, 
2023. 
 
You asked the Plan to pay for debridement, subcutaneous tissue. You say that the services were medically 
necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for debridement, 
subcutaneous tissue provided on April 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on May 9, 2023. 
 
You asked the Plan to pay for chiropractic services. You say that you were unaware the provider was able to 
bill for this service. The Plan denied your request. The Plan says the requested services is excluded from 
Medicare coverage. 
 
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 service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for chiropractic services provided on May 9, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Lemtrada. 
 You asked the Plan to pre-approve Lemtrada. You say that the enrollee is an excellent candidate for Lemtrada. 
The Plan denied your request. The Plan says the Plan requires a trial of Ocrevus before it will approve 
Lemtrada. 
 
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 Lemtrada. Our reviewer says that the 
enrollee does not meet criteria for a step therapy exception for Lemtrada. Our physician reviewer found the 
enrollee has not tried and failed the Plan's preferred drug of Ocrevus. The record does not show that this drug 
would likely be less effective and/or have adverse effects for the 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 Lemtrada have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Lemtrada.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a switch extension identified with code K0108. 
 
You asked the Plan to pre-approve a switch extension. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a switch extension cannot be requested 
separately. 
 
We looked at the file and Medicare rules. Review of the file shows that the requested switch extension is part 
of the requested expandable controller. This means the switch extension cannot be requested separately. Based 
on this information, we decided that Medicare rules for coverage of a switch extension have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a switch extension identified with code 
K0108.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Prolia. 
 You asked the Plan to pre-approve Prolia. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the Plan requires a trial of zoledronic acid before it will approve Prolia. 
 
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 Prolia. Our reviewer says that the 
enrollee does not meet criteria for a step therapy exception for Prolia. Our physician reviewer found the 
enrollee has not tried and failed the Plan's preferred drug of zoledronic acid. The record does not show that this 
drug would likely be less effective and/or have adverse effects for the 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve use of Prolia.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc. 
 
You asked the Plan to pre-approve Synvisc. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered service. 
 
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 Synvisc.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ozempic. 
 
You asked the Plan to pre-approve Ozempic. You say that the medication is medically necessary. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ozempic.  Benefits for Ozempic 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 17, 2023, billed with 
codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335, 81479, 81238. 
 
You asked the Plan to pay for the genetic testing billed. You say that please review the medical records and 
process the claim for payment. The Plan denied your request. The Plan says panel testing should be billed using 
one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code.  
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 17, 2023, billed with codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 
81335, 81479, 81238.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on April 28, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on April 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the miscellaneous durable medical equipment 
(DME) purchased October 3, 2022, to October 2022. 
 
You asked the Plan to reimburse you for the miscellaneous DME. You say that you do not understand why you  
have not been fully reimbursed. The Plan denied your request. The Plan says the item was received from a 
supplier who is not certified with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to reimburse you for the miscellaneous durable 
medical equipment (DME) purchased October 3, 2022, to October 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S1015 billed for date of service April 11, 
2023. 
 
You asked the Plan to pay for procedure code S1015. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S1015 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code S1015 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S1015 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S1015 billed for date of service April 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup (D2950) for tooth #22 and to pay more for a 
lower partial denture (D5214) provided on May 8, 2023, and May 15, 2023. 
  
You asked the Plan to pay for the dental services. You say that you could not get an appointment with an in-
network provider and the dental services were an emergency. The Plan denied your request. The Plan says your 
annual dental maximum benefit for the year has already been exhausted. Also, the core buildup is not covered 
by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid $1,625 for dental services on May 8, 2023. On May 15, 2023, the Plan paid $1,375 for 
dental services. For the year of 2023 the Plan paid $3,000 ($1,625 paid + $1,375 paid) for dental services; 
therefore, your annual dental maximum benefit for the year of 2023 was exhausted on the date of service of 
May 15, 2023. The core buildup is not covered under the Plan's dental benefit. Therefore, we decided that the 
Plan does not have to pay for the core buildup (D2950) for tooth #22 and to pay more for a lower partial 
denture (D5214) provided on May 8, 2023, and May 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on March 08, 2023. 
 
You asked the Plan to pay for the home visit. You say that the assisted living facility is responsible to obtain 
prior authorization for all of their 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 the home visit provided 
on March 08, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 15, 2023. 
 
You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the Plan requires utilization of network providers when possible and 
available and requires authorization for certain services. No medical necessity for an out-of-network provider 
such as an urgent or an emergent situation that has been documented.   
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on May 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (DNA or 
RNA); candida species, amplified probe technique (87481) provided January 19, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that before the specimen arrives at the facility, 
you are unable to determine the enrollee's insurance status and cannot and will not turn specimens away based 
on the enrollee's insurance. The Plan denied your request. The Plan says the documentation supports only one 
multiple pathogen line with one result was tested. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 3 units of CPT code 87481 are not supported in the medical record. The medical record only 
supports 1 unit of CPT code 87481. Based on this information, we decided that Medicare rules for coverage of 
the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay for the 
infectious agent detection by nucleic acid (DNA or RNA); candida species, amplified probe technique (87481) 
provided January 19, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital stay provided on May 23, 2022, to July 12, 
2022. 
 
You asked the Plan to pay for inpatient hospital stay. You say that you are requesting 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 inpatient hospital stay 
provided on May 23, 2022, to July 12, 2022.