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

We decided that the Plan does not have to waive the copayment for an office visit (99214) provided on 
September 28, 2020. 
 
You asked the Plan to waive the copayment for an office visit. You say that these services were billed 
incorrectly. The Plan denied your request. The Plan says these services processed 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 $40 
copayment for specialist office visits.  
 
You have been asked to pay a $40 copayment for an office visit. 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 (99214) provided on September 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on September 25, 
2020. 
 
You asked the Plan to waive the copayment for the office visit. You say that this was a post op visit and you 
were told there would be no charge. The Plan denied your request. The Plan says you were charged less than 
your copayment because the allowed amount was less. 
 
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 $25 
copayment for Specialty Physician Services.  
 
You have been asked to pay a $23.46 copayment for the office visit. the office visit falls within the Specialty 
Physician Services benefit category. The allowed amount for the service is $23.46. 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 office visit provided on September 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic test and specialist office visit 
provided by a participating provider on February 19, 2020. 
 
You asked the Plan to waive the copayment for a diagnostic test and specialist office visit. You say that you do 
not agree with these copayments. The Plan denied your request. The Plan says the correct copayments have 
been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment and a $40 copayment for outpatient diagnostic tests/diagnostic tests and practitioner/physician 
services/specialist office visit.  
 
You have been asked to pay $36.26 which is less than your copayment amount of $50 for a diagnostic test. You 
have been asked to pay a $40 copayment for a specialist office visit. The total amount you are being asked to 
pay is $76.26 ($36.26 + $40 = $76.26). A diagnostic test falls within the outpatient diagnostic tests/diagnostic 
tests benefit category and specialist office visit falls within the practitioner/physician services/specialist office 
visit benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for a diagnostic test and specialist 
office visit provided by a participating provider on February 19, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on September 22, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that because of your medical issues you were 
afraid to go to the ER due to COVID-19. The Plan denied your request. The Plan says these services are not a 
covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on September 22, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on September 22, 
2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the laboratory services rendered from 
April 14, 2020, to May 19, 2020. 
 
You asked the Plan to waive the copayments for these services. You say that the copayments should be waived 
due to you contracting a MRSA infection. The Plan denied your request. The Plan says the copayments were 
applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copayment for Medicare-covered laboratory tests.  
 
Review of the file shows that you received laboratory services on seven dates of service from April 14, 2020 to 
May 19, 2020. You have been asked to pay a $10 copayment per date of service for these services, for a total of 
$70. These services fall within the Medicare-covered laboratory tests 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 copayments for the laboratory services rendered from April 14, 2020, to May 19, 
2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) angiography of the 
abdomen (74175). 
 
You asked the Plan to pre-approve the CT angiography. You say that you are concerned about what is going on 
with your stomach and whether or not its cancer. You say that you got really sick with a cough and cold and 
went to the doctor. You say that the doctor then sent you straight to the hospital, and when the test was done, 
they couldn't see a clear image. The Plan denied your request. The Plan says the records provided do not 
describe that the enrollee has noted concerns about his belly between the bottom of the chest and top of the hip 
bones. 
 
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 the CT angiography. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found there are no abdominal 
complaints noted and the enrollee had a normal abdominal exam on two separate office visits. There is no 
documentation of bruits, anemia, vascular injury, or uncontrolled hypertension. The physician plan of care does 
not indicate a plan for a CTA of the abdomen. The requested CT angiography of the abdomen is not medically 
necessary or reasonable, based on the documentation provided. 
 
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 CT angiography have not been met. Therefore, we decided that the Plan 
does not have to pre-approve computed tomography (CT) angiography of the abdomen (74175).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-
network provider. 
 
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says that 
members may obtain services from an out-of-network provider only when providers of specialized services are 
not available in-network or in urgent and/or emergent situations. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the out-of-network provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for dialysis services provided from September 1, 2020, to September 30, 
2020. 
 
You asked the Plan to pay for the dialysis services. You say that you were moving and the services were 
authorized. The Plan denied your request. The Plan says that you were not enrolled on the dates of service. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We looked at the file and Medicare rules. The record shows a dialysis authorization with a starting date of 
August 13, 2020 and ending date of September 30, 2020. This was approved for the transitional period of 
moving out of the service area.  Based on this information, we decided that Medicare rules for coverage of 
dialysis services have been met. Therefore, we decided that the Plan has to pay for dialysis services provided 
from September 1, 2020, to September 30, 2020.  
 
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs this level of care. The 
Plan denied your request. The Plan says LTACH care is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided necessitating admission to an LTACH. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where he is 
currently receiving care. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be 
furnished safely and effectively only on an inpatient basis. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve office visit. You say that you have been going to this provider for quite 
some time, and they know how to treat your condition. The Plan denied your request. The Plan says the denial 
of authorization for this service is correct, because this provider is out-of-network with the Plan and you can be 
treated by an in-network ophthalmologist. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the medical services to be provided by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that the enrollee is unable to bear weight on 
her legs. You say that the enrollee is unable to move or care for herself at this time. You also say that the 
enrollee needs approval for a Skilled Nursing Facility (SNF) to continue her rehabilitative and 24/7 care. The 
Plan denied your request. The Plan says the admission to a SNF from an inpatient rehabilitative facility (IRF) 
does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 the SNF admission. Our reviewer says 
that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee 
does not need have 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 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 the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete maxillary denture and resin-based composite 
provided on October 5, 2020, and October 19, 2020. 
 
You asked the Plan to pay for the complete maxillary denture and resin-based composite. You say that you 
were advised that this provider accepted your insurance prior to the services being rendered. You also say that 
you did not find out until after the services were rendered that this provider is out-of-network. The Plan denied 
your request. The Plan says the total liability amount of $1,487.00 was applied correctly. The Plan also says 
that member liability is a contractual obligation under the Plan and cannot be waived. 
 
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, you are responsible for the difference 
between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to pay for 
the complete maxillary denture and resin-based composite provided on October 5, 2020, and October 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the member's needs have been stabilized 
and LTACH care is necessary. The Plan denied your request. The Plan says LTACH care is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided necessitating admission to a LTACH. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where he is 
currently receiving care. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be 
furnished safely and effectively only on an inpatient basis. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for mammography (77067) provided on August 18, 2020. 
 
You asked the Plan to pay for mammography. You say that the enrollee had multiple exams on this date. The 
Plan denied your request. The Plan says only one unit of this code is supported. 
 
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 an additional unit of CPT code 77067 is not supported in the medical record. The medical record 
only supports one unit of CPT code 77067, which was previously billed and paid. Based on this information, 
we decided that Medicare rules for coverage of mammography have not been met. Therefore, we decided that 
the Plan does not have to pay for mammography (77067) provided on August 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the therapeutic continuous glucose monitor. 
 
You asked the Plan to pre-approve the therapeutic continuous glucose monitor. You say that this service is 
medically necessary. The Plan denied your request. The Plan says the continuous glucose monitor is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections and does not require frequent self-adjustment of insulin dosage based on the 
blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the 
therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the therapeutic continuous glucose monitor.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan (J7321). 
 
You asked the Plan to pre-approve Hyalgan. You say that the requested drug, Halgan, is necessary. The Plan 
denied your request. The Plan says the documentation does not show that the enrollee has tried and failed the 
use of the preferred drugs, Orthovisc and Monovisc. The Plan also says that there is no indication our preferred 
agent would likely be less effective or cause adverse effects for the enrollee. 
 
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 Hyalgan. Our reviewer says that 
Hyalgan is not medically necessary. Our physician reviewer found the provided documentation does not show 
that the enrollee has tried and failed the required drugs. The reviewer found that the provided documentation 
does not indicate that the Plan's required drugs would likely be less effective or likely have adverse effects for 
the enrollee. Therefore, the reviewer found that the requested drug 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 Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hyalgan (J7321).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dupixent. 
 
You asked the Plan to pre-approve Dupixent. You say that the enrollee has failed all other medications. The 
Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's 
prescription drug 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 Dupixent.  
 
Benefits for Dupixent may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.