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

 
We decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex). 
 
You asked the Plan to pre-approve Vertiflex. You say that this would provide significant clinical and quality of 
life benefits for the enrollee. The Plan denied your request. The Plan says the denial of authorization for this 
service is correct, because Vertiflex is considered experimental/investigational. 
 
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 Vertiflex. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this device is experimental. More research is needed to show its safety and efficacy. There is no 
spinal instability. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve insertion of an interspinous spacer device (Vertiflex).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Coflex interlaminar stabilization device for the 
enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical studies have not proven that this device is helpful for treatment of the health 
problem. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the device is experimental. More research is needed to show the safety and efficacy. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Coflex interlaminar stabilization device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the injection provided on June 23, 2020. 
 
You asked the Plan to waive the cost share for the services provided. You say that you receive the same shot 
twice a year and have never received a bill. The Plan denied your request. The Plan says the cost share issued is 
correct in accordance with your plan benefits. 
 
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% of 
the cost for Medicare Part B prescription drugs.  
 
The file shows that you received a denosumab (Prolia) injection. You have been asked to pay 20% of the cost 
for the services provided. The services fall 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 share for the injection provided on June 23, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Genvisc850 injections (J7320). 
 
You asked the Plan to pre-approve the injection. You say that Genvisc850 injections will allow the enrollee to 
improve his daily quality of life regarding his mobility. You say that Genvisc850 is the only option for gel 
injections that you provide in your office. You also say that you have seen success in regards to prior treatment 
plans with other patients diagnosed with bilateral osteoarthritis. The Plan denied your request. The Plan says 
exceptions to Part B step therapy may be made when medically necessary. The Plan says that the requested 
drug in this case is not medically necessary. 
 
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 the injection. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the provided documentation does not show 
 
 
that the enrollee has tried and failed first line medication use such as Orthovisc or Monovisc. Therefore, the 
reviewer found that the criteria for coverage has 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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Genvisc850 injections (J7320).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copay for the medical services provided on July 30, 2020. 
 
You asked the Plan to waive the copay for the services provided. You say that you were told your insurance 
would cover the procedure. The Plan denied your request. The Plan says the claim paid correctly according to 
your plan benefits. 
 
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 $150 
copay for each Medicare-covered outpatient surgery or procedure at an ambulatory surgical center.  
 
The file shows that you received facet joint injections. The services are considered a surgical procedure. You 
have been asked to pay a $150 copay for the services provided. The services fall within the outpatient surgery 
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 copay for the medical services provided on July 
30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second opinion visit to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the second opinion visit. You say that you believe this enrollee needs to be 
seen by a neuromuscular specialist. The Plan denied your request. The Plan says this patient has already seen 
by a neuromuscular specialist.  The Plan attempted to contact you after your appeal to 
see if you still wanted to pursue the request given the fact that the patient had already have a neuromuscular 
specialty second opinion with a network provider, but the Plan was unsuccessful in connecting with you. 
 
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 
a second opinion visit to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abutment supported porcelain/ceramic crown (D6058) 
and prefabricated abutment (D6056) provided on May 21, 2020. 
 
You asked the Plan to pay for the abutment supported porcelain/ceramic crown and prefabricated abutment. 
You say that these services were medically necessary. The Plan denied your request. The Plan says these 
services are not covered under your supplemental benefit. 
 
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 pay for the 
abutment supported porcelain/ceramic crown (D6058) and prefabricated abutment (D6056) provided on May 
21, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for observation services provided by a 
participating provider on December 24, 2019, to December 26, 2019. 
 
You asked the Plan to waive the copayment for observation services. You say that this was an emergency 
situation. The Plan denied your request. The Plan says the correct copayment has 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 $200 
copayment for outpatient surgery/other outpatient services.  
 
You have been asked to pay a $200 copayment for observation services. Observation services fall within the 
outpatient surgery/other outpatient services 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 observation services provided by a participating provider on December 24, 2019, to December 26, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copay for the outpatient surgery services provided on June 
26, 2020. 
 
You asked the Plan to waive the copay for the services provided. You say that there should be no copay. The 
Plan denied your request. The Plan says the copay was applied in accordance to your plan benefits. 
 
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 $265 
copay for each Medicare-covered ambulatory surgical center visit for outpatient surgery.  
 
The file shows that you received an esophagogastroduodenoscopy procedure. This is a considered a surgery 
service. You have been asked to pay a $265 copay for the services provided. The services fall within the 
outpatient surgery 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 copay for the outpatient surgery 
services provided on June 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the extraction of erupted tooth (D7210) and deep 
sedation/general anesthesia (D9222, D9223) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the extraction of erupted tooth and deep sedation/general anesthesia . You 
say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The 
Plan says they only cover these services when performed by your assigned dentist. 
 
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. The Plan covers the extraction 
of erupted tooth, deep sedation/general anesthesia when the services are performed by your contracted dentist 
with the Plan.  
 
We looked at the the file and Medicare rules. Based on this information that you would be receiving these 
services with someone other than your contracted dentist, we decided that the Plan's rules for coverage of the 
extraction of erupted tooth, deep sedation/general anesthesia have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the extraction of erupted tooth (D7210) and deep sedation/general anesthesia 
(D9222, D9223) to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a breast ultrasound provided on July 14, 
2020. 
 
You asked the Plan to waive the copayment for a breast ultrasound. You say that you disagree with the increase 
in charges and cannot afford it. 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 $160 
copayment for ultrasounds.  
 
You have been asked to pay the total allowed amount of $133.40, which is less than the $160 copayment for a 
breast ultrasound. A breast ultrasound falls within the outpatient diagnostic tests and therapeutic services and 
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 copayment for a breast ultrasound 
provided on July 14, 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 you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested admission 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 the enrollee was admitted to the hospital for a scheduled endovascular aneurysm 
repair. Per the documentation, the enrollee has been extubated and re-intubated since November 6, 2020, with 
most recent re-intubation on December 6, 2020. The documentation supports that the enrollee still requires 
acute hospital level of care services and is receiving appropriate care at the present acute care hospital. 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. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee scooter provided on July 15, 2020 by a non-
Medicare certified provider. 
 
You asked the Plan to pay for the knee scooter. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the item received is not a covered benefit when provided by a non-
Medicare certified provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are 
furnished by a provider or supplier enrolled in the Medicare program. 
 
Review of the file shows that the provider was not Medicare-certified for the date of service 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 knee 
scooter provided on July 15, 2020 by a non-Medicare certified provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for portable oxygen purchased on February 9, 2020. 
 
You asked the Plan to pay for this equipment. You say that this equipment is medically necessary. The Plan 
denied your request. The Plan says neither Medicare nor the Plan pays for purchased oxygen equipment. 
 
Medicare rules say that plans can require enrollees to get care from network providers and can require enrollees 
to get prior authorization. The contract with the Plan says that durable medical equipment requires prior 
authorization. You purchased oxygen equipment without following the rules of your Plan contract. Medicare 
and the Plan cover rented oxygen equipment because there are specific criteria that must be met for coverage. 
Medicare and the Plan do not cover purchased oxygen equipment. Therefore, we decided that the Plan does not 
have to pay for portable oxygen purchased on February 9, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oncology gene expression testing services coded 0012M 
provided on June 23, 2020. 
 
You asked the Plan to pay for the oncology gene expression testing services. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the documentation is missing 
required information. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Review of the file shows that medical records or any other 
documentation to support how the enrollee came to the servicing provider or whether the services are medically 
necessary. Based on this information, we decided that Medicare rules for coverage of the oncology gene 
expression testing services have not been met. Therefore, we decided that the Plan does not have to pay for the 
oncology gene expression testing services coded 0012M provided on June 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the consultation services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the consultation services. You say that your doctor left his practice and 
referred you to this out-of-network provider.  You said that you don't want to go to the network providers 
offered to you. The Plan denied your request. The Plan says it has offered numerous other providers to you to 
provide you with care in-network.  The Plan says that because care is available with network providers, this 
request has been denied. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assistant at surgery services provided on June 11, 2020. 
 
You asked the Plan to pay for surgical assistant services. You say that this provider is a certified surgical 
assistant, and his presence was requested for this procedure by the surgeon. The Plan denied your request. The 
Plan says the denial of payment for this service is correct, because these services are not covered when 
performed by a Certified Surgical First Assistant. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for assistant at surgery services provided 
on June 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the medical eye exam (92014) provided on 
August 5, 2020. 
 
You asked the Plan to waive the cost share for the medical eye exam. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says the cost share applied 
correctly in this case. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $198 deductible for vision care followed by a 0-20% coinsurance.  
 
The item or service you asked the Plan to waive the cost share for falls within the benefit category vision care. 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $198 deductible for 
vision care. This cost sharing is a contractual obligation that had not been met at the time the medical eye exam 
was received on August 5, 2020. You still had $114.54 remaining in your deductible which left a total amount 
of $7.05 that was subject to coinsurance ($7.05 x 20% coinsurance = $1.41). Your total cost share was 
correctly calculated at $115.95. Therefore, we decided that the Plan does not have to waive the cost share for 
the medical eye exam (92014) provided on August 5, 2020.