Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee 
from June 12, 2020, to August 12, 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 the provider is not an eligible Medicare provider. 
 
Medicare rules say that plans can require enrollees to get care from Medicare eligible providers. The contract 
with the Plan says outpatient mental health care requires prior authorization.  
 
The billing provider is not a Medicare eligible provider. The enrollee did not have prior authorization. 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 physician services provided to the enrollee from  June 12, 2020 to 
August 12, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. 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 March 30, 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incisional biopsy of oral tissue (D7286). 
 
You asked the Plan to pre-approve dental code D7286. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says the service is not covered. 
 
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, 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 
incisional biopsy of oral tissue (D7286).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan 
has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care 
and pre-approved care. The Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regenerate-resorbable barrier (D4266), 
bone replacement graft (D4263), and other drugs (D9630). 
 
You asked the Plan to pre-approve dental codes D4266, D4263, and D9630. You say that you would like the 
Plan to reconsider their denial. The Plan denied your request. The Plan says the services are not covered. 
 
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, 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 
guided tissue regenerate-resorbable barrier (D4266), bone replacement graft (D4263), and other drugs (D9630).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided. 
 
You asked the Plan to pay for this service. You say that these services should be covered by the Plan. The Plan 
denied your request. The Plan says you did not have prior authorization to use an out of network provider. 
 
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 physician services provided.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 additional speech therapy visits. 
 
You asked the Plan to pre-approve speech therapy. You say that the enrollee will benefit from this therapy. The 
Plan denied your request. The Plan says the denial of authorization for additional speech therapy visits is 
correct. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 speech therapy. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the requested additional therapy is not generally accepted as specific 
and effective therapy for the enrollee's condition. The enrollee has had prior therapy for this condition and it 
does not appear that the enrollee's functional and cognitive level requires the unique skills of a professional 
speech therapist to safely and effectively provide ongoing treatment, or that the services can be safely and 
effectively performed only by a therapy or under the supervision of a therapist. The enrollee has been 
authorized additional sessions to review a caregiver maintenance plan and ensure safety. The ongoing 
specialized skill, knowledge, and judgment of a qualified therapist is not required to establish, design, and/or 
deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration.  
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of speech therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 12 additional speech therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the automatic external defibrillator 
provided on June 24, 2020. 
 
You asked the Plan to waive the coinsurance for the automatic external defibrillator. You say that there was no 
charge when you previously had the vest. The Plan denied your request. The Plan says the coinsurance 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 20% 
coinsurance for durable medical equipment, oxygen/oxygen equipment and related supplies. 
 
You have been asked to pay $618.28, which is 20% of the allowed amount for the automatic external 
defibrillator. The allowed amount is $3,091.40 (20% x $3,091.40 = $618.28). The automatic external 
defibrillator falls within the "Durable medical equipment (DME) and related supplies" 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 coinsurance for the automatic external defibrillator provided on June 24, 
2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing rendered on November 4, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code G0480 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes G0480 and G0481. Code G0480 is a column II code with a 
modifier indicator of 1 when billed with column I code G0481. Code G0480 was not billed with an appropriate 
modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the 
definitive drug testing rendered on November 4, 2019.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee. 
 
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 due to the enrollee's hospice status at the time of service, this claim must be submitted to 
Original Medicare. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit 
for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for 
physician services provided to the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided on July 28, 2020. 
 
You asked the Plan to pay for this service. You say that these services should be covered by the Plan. The Plan 
denied your request. The Plan says you did not have prior authorization for out of network 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 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 out of network physician services provided on 
July 28, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-One (J7325). 
 
You asked the Plan to pre-approve Synvisc-One (J7325). You say that you want the enrollee treated with this 
drug. The Plan denied your request. The Plan says he enrollee has not first tried and had a contraindication or 
intolerance to Orthovisc and Monovisc. 
 
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-One (J7325). Our reviewer 
says that the drug is not reasonable or medically necessary. Our physician reviewer found the enrollee has not 
trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the plan, 
requires these be trialed first. The documentation does not outline contraindications or reasons these 
medications were not considered or that the plan?s required drugs would likely be less effective and/or likely 
 
 
have adverse effects for the enrollee. Without the support of the documentation, Synvisc-One is not approved 
as step criteria have not been 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 Synvisc-One (J7325) have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Synvisc-One (J7325).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ropinirole. 
 
You asked the Plan to pre-approve Ropinirole. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee has a medical only policy which does not include Part D prescription 
coverage, therefore the criteria for self-administered drug coverage has not been met. 
 
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 Ropinirole.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a walker purchased on June 1, 2020. 
 
You asked the Plan to pay for this walker. You say that the Plan should pay for this walker. The Plan denied 
your request. The Plan says you purchased this walker without prior authorization, out of network and from a 
provider who is not a Medicare eligible provider. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who is not a Medicare eligible provider. 
The Plan contract says that durable medical equipment requires prior authorization and is not covered when 
purchased out of network. You did not follow your Plan contract rules when you purchased this equipment.  
Therefore, we decided that the Plan does not have to pay for a walker purchased June 1, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ER visit provided on May 7, 2020. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you went to the ER because the 
doctor's office and urgent care turned you down. You say that you should have only had an office visit so you 
shouldn't be billed for the ER. The Plan denied your request. The Plan says the ER 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 $120 
copayment for emergency care.  
 
You have been asked to pay a $120 copayment for the ER visit. The ER visit falls within the "Emergency care" 
benefit category. The records show that you were treated in the ER. 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 ER visit provided on May 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the office visits (99203, 99214) and the 
x-ray exam of the cervical spine (72040) provided from June 1, 2020, through July 2, 2020. 
 
You asked the Plan to issue reimbursement for the office visits and the x-ray exam. You say that you are 
requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says 
these services are not a covered benefit under your contractual policy. 
 
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 services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to issue reimbursement for the office visits (99203, 99214) and the x-ray exam of 
the cervical spine (72040) provided from June 1, 2020, through July 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral sacroiliac (SI) joint injections. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has back pain with 
associated lumbosacral disturbances. There is no evidence of a clinical picture suggestive of SI injury and/or 
disease. There is no evidence that she has participated in a four to six week aggressive physical therapy 
program, an activity modification program, or an active rehabilitation/therapeutic exercise program. There are 
not at least three positive exam findings of SI joint dysfunction present on physical exam such as: Patrick's test, 
thigh thrust, SI compression test, Yeoman's test, or Gaenslan's test. The SI joint injections are therefore not 
reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bilateral sacroiliac (SI) joint injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a removable molded shoe insert (L3010) and metatarsal 
bar wedge (L3400). 
 
You asked the Plan to pre-approve a removable molded shoe insert and metatarsal bar wedge. You say that you 
would like the Plan to reconsider their denial. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve a removable molded shoe insert 
(L3010) and metatarsal bar wedge (L3400).
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 out-of-
network services are covered if you require specialized services that are not available from a provider in the 
Plan's network. Members are entitled to receive services from out-of-network providers for emergency or out-
of-area urgently needed services. 
 
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: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic treatment provided. 
 
You asked the Plan to pay for the chiropractic treatment. 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 
chiropractic treatment.  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 chiropractic treatment provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the chiropractic services. 
 
You asked the Plan to pre-approve the chiropractic services. The Plan denied your request. The Plan says each 
plan PCP has certain plan specialists they use for referrals. This means that the PCP the enrollee selects may 
determine the specialists the enrollee may see. 
 
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 the 
chiropractic services.