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

We decided that the Plan does not have to pre-approve Dronabinol capsules. 
 
You asked the Plan to pre-approve Dronabinol capsules. You say that the prescription should have been for 
5mg and the enrollee is not in hospice. You say that the enrollee has nausea associated with pancreatic cancer.  
The Plan denied your request. The Plan says the drug is not eligible for coverage under Part B as prescribed. 
 
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 Dronabinol capsules.  
 
Benefits for Dronabinol capsules 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network chiropractic services provided on August 22, 
2019. 
 
You asked the Plan to pay for these services. You say that the Plan should pay for these services. The Plan 
denied your request. The Plan says you did not have prior authorization for out of network chiropractic care. 
 
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 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. 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 out of network chiropractic 
services provided on August 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto make additional payment forthe laser retinal scan provided on January 30, 2020.You asked the Planto make additional payment forthe laser retinal scan. You say that you do not feel that anything should be denied.The Plandenied your request. The Plansayspayment has been made for the routine eye exam; however, you elected to have a noncovered laser scan done and paid out of pocket for this service.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers one annual routine eye exam with refraction. Laser retinal scanning is not listed as covered. In this case, the only denied service is the retinal scan which is not covered by your Plan and you paid out of pocket at the time of the visit.Therefore, we decided that the Plandoes not haveto make additional payment forthe laser retinal scan provided on January 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oximeter device for measuring blood oxygen levels non-
invasively (CPT Code E0445RR). 
 
You asked the Plan to pre-approve the device. You say that the member was diagnosed with chronic pulmonary 
disease, which significantly affects their daily life. The Plan denied your request. The Plan says this is not 
covered by the Plan or Medicare. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the device have not been met. The service E0445RR is denied 
because it is a non-covered item under Medicare regulation. Therefore, we decided that the Plan does not have 
to pre-approve oximeter device for measuring blood oxygen levels non-invasively (CPT Code E0445RR).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Ilumya (J3245). 
 
You asked the Plan to pre-approve Ilumya. You say that the enrollee has tried and failed Cosentyx and topical 
steroids. You say that without approval, the enrollee's symptoms will worsen, affecting his daily living 
activities. You also say that without this drug, the enrollee not be able to effectively manage their disease. The 
Plan denied your request. The Plan says that the requested drug does not meet the guidelines for coverage. 
 
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 Ilumya. Our reviewer says that the 
requested drug is medically necessary. Our physician reviewer found the documentation does not show that the 
required drugs were trialed and failed by the enrollee. However, the reviewer found that the coverage of the 
requested drug Ilumya should be warranted by the community standard of care. Therefore, the reviewer found 
that the requested drug is medically reasonable and 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 Ilumya have been met. Therefore, we decided that the Plan has to pre-approve 
Ilumya (J3245).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for the arthrocentesis and hyaluronan injection 
provided on July 21, 2020. 
 
You asked the Plan to waive the cost for the arthrocentesis and hyaluronan injection. You say that you don't 
agree with being charged for every visit. You say that you were previously only charged a one-time fee. The 
Plan denied your request. The Plan says the cost share 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 $35 
copayment per visit to a specialist and 20% coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay a total of $50.15 for the arthrocentesis and hyaluronan injection.  
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
July 21, 2020 Arthrocentesis $150.93 $35 $35 
July 21, 2020 Hyaluronan 
Injection 
$75.73 20% $15.15 
TOTAL:    $50.15 
 
  
 
 
The arthrocentesis falls within the "Physician/Practitioner services, including doctor?s office visits" benefit 
category. The hyaluronan injection falls within the ?Medicare Part B prescription drugs? 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 for the arthrocentesis and hyaluronan injection provided on July 21, 
2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services you received 
from August 11, 2020, to August 14, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you cannot afford 
this copayment The Plan denied your request. The Plan says you were charged this copayment 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 $393 
copayment per day for days 1-5 for inpatient hospital care.  
 
Records show that you were in the hospital for three days. You have been asked to pay a $393 copayment per 
day for the inpatient hospital services, for a total of $1,179.  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 inpatient hospital services you received from August 11, 2020, to August 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on July 14, 2020. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that this was a post-operative follow-
up visit so you should not owe a copayment. The Plan denied your request. The Plan says the claims were 
processed correctly and you are being charged the correct amount. 
 
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 $30 
copayment for each specialist visit.  
 
You had a follow-up visit on July 14, 2020. Follow-up visits are subject to cost-sharing charges. Therefore, you 
are responsible to pay the $30 copayment.  
 
You have been asked to pay a $30 copayment for a specialist visit. A specialist visit falls within the 
physician/practitioner services, including doctor's office visits 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 specialist visit provided on July 14, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lower extremity arteries studies (93924). 
 
You asked the Plan to pre-approve lower extremity arteries studies. You say that this is medically necessary. 
The Plan denied your request. The Plan says this is similar to an approved test. 
 
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 lower extremity arteries studies. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found based on the records provided, you have diabetes, documented polyneuropathy 
and claudication symptoms. SudoScan is a test that provides an evaluation of sweat gland function by focusing 
on small nerve fibers that innervate the sweat glands. Sudomotor dysfunction is an early detectable abnormality 
in diabetic small fiber neuropathy.  In this circumstance where you already have documented polyneuropathy, a 
treatment change based on results of SudoScan, the requested testing has not been shown to improve outcomes. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lower extremity arteries studies have not been met. Therefore, we decided that 
the Plan does not have to pre-approve lower extremity arteries studies (93924).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 cone beam CT (D0367), 3 implants (D6010), 3 
custom fabricated abutments (D6057), 3 abutment supported crowns (D6058), 3 radiographic and surgical 
implant index (D6190), 2 bone replacement graft for ridge preservation (D7953), and a fixed partial denture 
sectioning (D9120). 
 
You asked the Plan to pre-approve the dental services. You say that you feel the implants are necessary for 
function on your lower right mandible. You say that without the implants, you would endure significant 
medical consequences. You say that without the implants you would need a 4-unit bridge. You also say that 
you would need an additional implant for tooth # 31 as the existing implant will not support a bridge. The Plan 
denied your request. The Plan says the requested dental services are not listed as covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested dental services are not 
among those covered under this benefit. The Evidence of Coverage clearly states that any services not listed are 
not covered. Therefore, we decided that the Plan does not have to pre-approve 2 cone beam CT (D0367), 3 
implants (D6010), 3 custom fabricated abutments (D6057), 3 abutment supported crowns (D6058), 3 
radiographic and surgical implant index (D6190), 2 bone replacement graft for ridge preservation (D7953), and 
a fixed partial denture sectioning (D9120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on July 8, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 
physician's services. 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 physician's services provided on July 8, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe SNF stay provided from May 1, 2020, through May 13, 2020.You asked the Plan to waive the copayment fortheSNF stay. The Plan denied your request. The Plan says the copayment 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 $0 copayment each day for days 1 to 20 and a $125 copayment each day for days 21 to 40.You have been asked to pay a $1,500 copayment for the SNF stay. The SNF stay falls within the "Skilled Nursing Facility (SNF) 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 copayment forthe SNF stay provided from May 1, 2020, through May 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for needle electromyography (958640) provided to the enrollee 
on April 23, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says Medicare coverage criteria are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT 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 this service. Our reviewer says that Medicare coverage criteria are not met. Our physician 
reviewer found the documentation does not support needle electromyography 4 extremities.  Medicare 
coverage criteria are not met. We looked at this physician's review, the file, and Medicare rules. Based on this 
information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we 
decided that the Plan does not have to pay for needle electromyography (958640) provided to the enrollee on 
April 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the guided tissue regeneration (D4266) and bone 
replacement graft (D7953). 
 
You asked the Plan to pre-approve the guided tissue regeneration (D4266) and bone replacement graft 
(D7953). You say that it is very difficult to chew, and you don't have the money to pay the dentist. You say that 
the denied procedures need to be approved in order to proceed with the implant. The Plan denied your request. 
The Plan says the services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
guided tissue regeneration (D4266) and bone replacement graft (D7953).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for targeted genomic sequence analysis (0037U) provided on 
June 2, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says Medicare billing criteria are not met. The Plan must follow Medicare rules. Medicare 
rules say that providers must report services correctly. Providers must report services with the appropriate CPT 
code and provide medical records to support the services billed. In this case, there are insufficient medical 
records provided to show the services billed were medically necessary at the time of service.  Therefore, we 
decided that the Plan does not have to pay for targeted genomic sequence analysis (0037U) provided on June 2, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided January 20, 2020 to 
January 29, 2020. 
 
You asked the Plan to pay for the home health services. You say that type of bill used was 323 which is correct. 
323 is a continuing claim for home health. Attaching a copy of the claim so claim can be reprocessed and paid 
accordingly. The Plan denied your request. The Plan says resubmit claim with correct bill type. The billed 
claim is for a nonparticipating Home Health provider and the appropriate home health data Type of Bill was 
not billed correctly. 
 
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 find that the home health services were not billed correctly. Specifically, per Medicare 
guidelines, the claim form does not have the appropriate home health data to process and pay claim. The Final 
claim must have the appropriate Type of Bill. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to 
pay for the home health services provided January 20, 2020 to January 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy services provided from December 19, 
2019, to December 24, 2019. 
 
You asked the Plan to pay for home infusion therapy services (S9500). You say that the Plan should pay this 
claim. The Plan denied your request. The Plan says this procedure code is not valid 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 CPT code. 
 
In this case, the CPT Code Manual definition of code S9500 is Home infusion therapy, antibiotic, antiviral, or 
antifungal therapy; once every 24 hours; administrative services. 
 
We find that CPT code S9500 is not a valid code for Medicare purposes. S codes are unique temporary codes 
established by BCBSA and HIAA for private payor use. They are not valid nor payable by Medicare. Medicare 
uses another code for reporting of, and payment for, these services. Based on this information, we decided that 
Medicare rules for coverage of home infusion therapy management have not been met. Therefore, we decided 
that the Plan does not have to pay for home infusion therapy services provided from December 19, 2019, to 
December 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exam rendered on February 25, 
2020. 
 
You asked the Plan to waive the copayment for these services. You say that the services should be fully 
covered. The Plan denied your request. The Plan says the copayment was 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 $75 
copayment for each out-of-network Medicare-covered eye exam.  
 
Review of the file shows that you received an eye exam from an out-of-network provider on February 25, 
2020. You have been asked to pay a $75 copayment for these services. These services fall within the out-of-
network Medicare-covered eye exam 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 
the eye exam rendered on February 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on January 2, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that your physician provided 
medically necessary services to the enrollee in good faith. In consideration of the services rendered, you feel 
your doctor is entitled to reimbursement. 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 has network providers 
available who can provide 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 subsequent nursing facility care provided on 
January 2, 2020 by an out of network (OON) provider.