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

 
We decided that the Plan does not have to pay for the established patient domiciliary or rest home visit services 
(99349) provided on March 10, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the domiciliary or rest home visit services. 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 doctor. The Plan denied your request. The Plan says enrollees must receive 
their medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before 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 the established patient domiciliary or rest home 
visit services (99349) provided on March 10, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on February 13, 2023. 
 
You asked the Plan to pay for the home visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says members of the Plan must use in-network providers to get medical care and 
services. The only exceptions are emergencies, urgently needed care, when the network is not available, out-of-
area dialysis services, and cases in which the Plan authorizes use of out-of-network providers.  
 
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 a home visit provided on February 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies coded as A6219, A6446, A4450 and 
A6196 provided September 6, 2022. 
 
You asked the Plan to pay for the wound care supplies. You say that please review the attached documents 
showing the medical necessity for these supplies. The Plan denied your request. The Plan says these services 
are not paid separately when the patient is inpatient. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the wound care supplies were used in a SNF or hospital. Therefore, we decided that the Plan 
does not have to pay for the wound care supplies coded as A6219, A6446, A4450 and A6196 provided 
September 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0245U billed for date of service October 24, 
2022. 
 You asked the Plan to pay for procedure code 0245U. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says payment for code 0245U is bundled into payment for 
code 0018U. 
 
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 0245U 
is a column II code to column I code 0018U. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 0245U billed for date of service October 24, 
2022.
Appeal type: Step-Therapy
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 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 Synvisc. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the documentation does not support that the enrollee has tried and failed Orthovisc or Supartz FX. The 
documentation does not support that Orthovisc or Supartz FX 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 Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Synvisc.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diabetic shoes and inserts (A5513) and (A5500). 
 
You asked the Plan to pre-approve the diabetic shoes and inserts. The Plan denied your request. The Plan says 
the records sent on appeal show the enrollee has diabetes with a foot ulceration but we do not see a signed 
statement from the physician. 
 
The Plan must follow Medicare rules. Medicare rules say that the certifying physician must sign the 
certification statement on or after the date of the in-person visit and within 3 months prior to delivery of the 
shoes/inserts. We looked at the file and Medicare rules. Specifically, we did not receive a signed certification 
statement. Based on this information, we decided that Medicare rules for coverage of the diabetic shoes and 
inserts have not been met. Therefore, we decided that the Plan does not have to pre-approve diabetic shoes and 
inserts (A5513) and (A5500).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fulphila. 
 
You asked the Plan to pre-approve Fulphila. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Fulphila. 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 history of limited-stage small cell lung cancer being treated with cisplatin/etoposide, 
low febrile neutropenia risk. No risk factors identified. Per National Comprehensive Cancer Network 
guidelines, granulocyte colony-stimulating factors are not routinely recommended for individuals with low 
overall febrile neutropenia risk but may be considered for patients with risk factors. Those risk factors include: 
- Prior chemotherapy or radiation therapy - Persistent neutropenia - Bone marrow involvement by tumor - 
Recent surgery and/or open wounds - Liver dysfunction (bilirubin greater than 2.0) - Renal dysfunction 
(creatinine clearance less than 50) -Age greater than 65 years receiving full chemotherapy dose intensity. The 
review has determined that the documentation does not support that Fulphila is medically reasonable and necessary for the enrollee. The documentation does not support that Fulphila is safe and effective 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 Fulphila have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Fulphila.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit for evaluation provided on March 24, 2023. 
 
You asked the Plan to pay for home visit for evaluation. You say that you believe the services are 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 home visit for 
evaluation provided on March 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services provided on March 23, 2023. 
 
You asked the Plan to pay for ophthalmological services. You say that you say that a provider performing 
services at a nursing home is 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 ophthalmological 
services provided on March 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on May 3, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for psychotherapy services. You say that this is supported in the records. The Plan 
denied your request. The Plan says this 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 psychotherapy services provided on May 3, 2023, 
by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic radiology services provided on August 2, 2021. 
 
You asked the Plan to pay for diagnostic radiology services. You say that the claim was filed timely. The Plan 
denied your request. The Plan says the claim was beyond 12 months of the date of service and denied for 
timely filing submission. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for diagnostic radiology services was not filed until March 28, 2023. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for diagnostic radiology services provided on August 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 24, 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 24, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
February 24, 2023, to February 25, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were receiving 
care for pneumonia. 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 $250 
copayment per day for days 1-5 of each in-network inpatient hospital stay. Your contract with the Plan also 
clearly says that you then pay a $0 copayment per day for days 6-90 of each in-network inpatient hospital stay. You have been asked to pay a $250 copayment per day for day one of the inpatient hospital stay. This 
item/service falls within the inpatient hospital care benefit category. You have not been asked to pay after day 
one or for the day you were discharged. You have been asked to pay a total of $250 for the inpatient stay. 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 inpatient hospital stay provided from February 24, 2023, 
to February 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chronic care management services provided on April 30, 
2023. 
 
You asked the Plan to pay for chronic care management services. 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 chronic care 
management services provided on April 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection, Infliximab, excludes biosimilar, 10 mg provided on 
December 22, 2022. 
 
You asked the Plan to pay for injection, Infliximab, excludes biosimilar, 10 mg. The Plan denied your request. 
The Plan says the provider did not submit detailed medication administration report to support to total dose of 
Infliximab that was administered. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of injection, Infliximab, excludes 
biosimilar, 10 mg have been met. Therefore, we decided that the Plan does not have to pay for injection, 
Infliximab, excludes biosimilar, 10 mg provided on December 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the posterior non-segmental instrumentation (22840) 
and the arthrodesis (22612) using the Minuteman device. 
 
You asked the Plan to pre-approve the posterior non-segmental instrumentation (22840) and the arthrodesis 
(22612) using the Minuteman device. You say that the Minuteman device is approved by the Food and Drug 
Administration (FDA) and indicated to use in this case. The appellant states the surgery is medically necessary. 
The Plan denied your request. The Plan says the services are not medically necessary. The Plan says the 
Minuteman device is not intended for stand-alone use. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 the posterior non-segmental 
instrumentation (22840) and the arthrodesis (22612) using the Minuteman device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee was being treated for intervertebral disc disorders with radiculopathy. The enrollee presented 
with low back pain with numbness and tingling. The current evidence-based medical guidelines and peer-
reviewed literature do not fully support the interspinous fusion device procedure over the gold standard of 
lumbar fusion. There is a lack of large-volume, long-term peer-reviewed outcome studies to support the use of 
this device for this enrollees medical condition. In addition, fusion indications within guidelines/literature for 
(existing or potential intraoperative) instability have not been documented and/or met in this case. In addition, 
there are multiple alternate pain generators plausibly significantly contributing to the clinical condition that 
have not been fully documented as having been excluded and/or ruled out. There is no compelling rationale or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
requested Minuteman device at L4-5 is not medically reasonable or necessary.  
 
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 posterior non-segmental instrumentation (22840) and the arthrodesis 
(22612) using the Minuteman device have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the posterior non-segmental instrumentation (22840) and the arthrodesis (22612) using the 
Minuteman device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on January 18, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the nursing facility care. You say that you are requesting reconsideration of the 
denied claim. 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 nursing facility care provided on January 18, 
2023, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on April 17, 
2023, to April 18, 2023. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you want to appeal the amount 
being charged. 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 $350 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. 
 
You have been asked to pay a $350 copayment for outpatient 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 outpatient surgery provided on 
April 17, 2023, to April 18, 2023.