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

 
We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating 
provider on May 22, 2020. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you already paid a $150 copayment. 
You say that you feel like that should cover all the charges. The Plan denied your request. The Plan says the 
correct coinsurance 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 20% 
coinsurance for Medicare Part B prescription drugs/in-network.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed 
amount is $237.48. The total amount you are being asked to pay is $47.50 ($237.48 x 20% = $47.50). The 
correct coinsurance has been applied to the injection that was provided. An injection falls within the Medicare 
Part B prescription drugs/in-network 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 
an injection provided by a participating provider on May 22, 2020.
Appeal type: Step-Therapy
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 medication is necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 the 
medication is not medically necessary. Our physician reviewer found based on the medical records provided 
there is no indication that the plan's required drug would likely be less effective and/or likely have adverse 
effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hyalgan (J7321).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit with a specialist to be provided by an out 
of network (OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that your primary care physician believes the best 
care for you, at this time, is a procedure that no in-network provider can render and recommends an out-of-
network provider. The Plan denied your request. The Plan says there are in-network providers that can provide 
this service for 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 
the office visit with a specialist to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray provided by a participating 
provider on May 11, 2020. 
 
You asked the Plan to waive the copayment for an x-ray. You say that you do not agree with this deductible. 
The Plan denied your request. The Plan says the correct deductible has been applied. 
 
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 $750 deductible for outpatient diagnostic tests/x-rays.  
 
The item or service you asked the Plan to waive the copayment for falls within the benefit category outpatient 
diagnostic tests/x-rays. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 
$750 deductible for outpatient diagnostic tests/x-rays. This cost sharing is a contractual obligation that had not 
been met at the time an x-ray was received on May 11, 2020. The total amount you are being asked to pay is 
$72.54. Therefore, we decided that the Plan does not have to waive the copayment for an x-ray provided by a 
participating provider on May 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve addition to lower extremity orthosis, soft interface for 
molded plastic, below knee section (CPT Code L2820), addition to lower extremity, lacer molded to patient 
model, for custom fabricated orthosis only  (CPT Code L2330) and ankle foot orthosis, plastic or other 
material, custom fabricated (CPT Code L1940). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the DME is 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 the DME. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the review indicates that the physical exam is described in general terms that do not qualify or 
substantiate the request for bilateral RYBO Air Balance Custom Braces. The clinical note does not show that 
the member has tried and failed a prefabricated brace. The phrase that states, "pre-fabricated AFO will not 
provide adequate stabilization" is not supported by objective data. In addition, there is no information provided 
in this case that supports that these types of braces will improve the member's fall risk which is the primary 
reason for why they are being requested. The review has determined that the requested DME (RYBO Air 
Balance Custom Braces) is not 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 the DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve (CPT Code L2820), (CPT Code L2330) and (CPT Code L1940).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on March 2, 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 March 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee and billed under 
code CPT 99349. 
 
You asked the Plan to pay for this service. You say that these services should be covered. 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. 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 billing criteria are not met. Our physician 
reviewer found a home visit was performed by LVN.  CPT 99349 is a physician or other qualified healthcare 
professional reporting code.  In this case, and LVN is not considered a "qualified healthcare professional" and 
therefore, this code would not be reported. 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 physician services provided to the enrollee and 
billed under code CPT 99349.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the services performed by a qualified 
physical therapist (G0151), skilled nursing services of a registered nurse (G0299), and the services performed 
by a qualified occupational therapist (G0152) provided from January 2, 2020, through January 9, 2020. 
 
You asked the Plan to waive the cost share. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the cost share amount has been applied 
correctly to the services provided. 
 
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 $750 
deductible. This is the amount you have to pay out of pocket before the Plan will pay their share for your 
covered medical services. Additionally, enrollees pay a $0 copayment after the deductible is met for home 
health services. 
 
You have been asked to pay $750 for the home health services provided. This is the Plan allowed amount for 
these services, which has been applied to the yearly deductible. Enrollees have to pay a deductible of $750 
before the Plan will pay their share for your covered medical services.  
 
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 services performed by a qualified physical 
therapist (G0151), skilled nursing services of a registered nurse (G0299), and the services performed by a 
qualified occupational therapist (G0152) provided from January 2, 2020, through January 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power operated vehicle, group 1 heavy duty, patient 
weight capacity 301 to 450 pounds (CPT Code K0801). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says you do not meet medical criteria for coverage of the requested mobility device. The Plan 
states you are requesting coverage of the scooter for community use and you ambulate in the home with the use 
of a quad cane. 
 
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 DME have not been met. The Plan or Medicare do not cover a 
power  scooters for use in the community. Therefore, we decided that the Plan does not have to pre-approve 
power operated vehicle, group 1 heavy duty, patient weight capacity 301 to 450 pounds (CPT Code K0801).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the requested additional 
transportation is necessary. The Plan denied your request. The Plan says the requested additional transportation 
trips exceed the benefit limit. Therefore, coverage criteria has not been met. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Yervoy for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the information provided states that the enrollee previously experienced progression 
while on Opdivo. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the 
requested drug is medically reasonable and necessary. Our physician reviewer found in this case the enrollee 
has limited treatment options. He had disease progression on Lenvima and his oncologist wants to try a 
regimen of Yervoy,Nivolumab,and Odansetron. The review has determined that the documentation support 
that the Yervoy 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 the drug have been met. Therefore, we decided that the Plan has to pre-approve 
Yervoy for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study (95807). 
 
You asked the Plan to pre-approve a sleep study. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been 
met. 
 
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 a sleep study. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the review of the medical literature considers the use of an abbreviated cardiorespiratory sleep 
study to acclimate an individual to positive airway pressure (PAP) as unproven and investigational (represented 
by CPT code 95807). The review has determined that the items/services at issue in this case are 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 a sleep study have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sleep study (95807).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sleep study (95811). 
 
You asked the Plan to pre-approve the sleep study. You say that the study is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
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 sleep study. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found it is not clear from the medical records why the enrollee would need an attended CPAP titration 
study at this time, given that his therapy is effective. If there is a desire to determine the need for supplemental 
oxygen while on CPAP, an overnight oximetry study would be more appropriate. 
 
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 sleep study have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sleep study (95811).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe dental services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe dental services. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says the requested service are neither emergent nor urgent to seek out-of-network care. The Plan says there are in-network dental providers available to you that can provide the care and treatment you are requesting.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-approvethe dental services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Facet Joint Radiofrequency Ablation (64635). 
 
You asked the Plan to pre-approve the Facet Joint Radiofrequency Ablation. You say that the ablation is 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that repeat denervation procedures involving the same 
joint will only be considered medically necessary if the patient experienced at least 50% improvement of pain. 
 
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 Facet Joint Radiofrequency 
Ablation. Our reviewer says that the ablation procedure is not medically necessary. Our physician reviewer 
found the previous procedure only resulted in temporary pain relief. The records do not support a repeat 
procedure. 
 
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 Facet Joint Radiofrequency Ablation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Facet Joint Radiofrequency Ablation (64635).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the colonoscopy and related services provided on August 18, 
2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the colonoscopy and related services. You say that you were not aware of the in-
network requirements. The Plan denied your request. The Plan says prior authorization was not obtained by the 
facility or the provider; therefore, payment has been correctly 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 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 colonoscopy and related services provided on 
August 18, 2020, by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services for an office visit and diagnostic 
tests to be provided by the out-of-network provider. 
 
You asked the Plan to pre-approve the physician's services. You say that you had to delay your appointment 
with the in-network provider due to your husband's prior engagement and no one at the provider's office 
answered your call. The Plan denied your request. The Plan says must receive care from a network provider 
and in most cases, care received from an out-of-network provider (a provider who is not part of our plan's 
network) will not be covered, except for the following: emergency care or urgently needed service and needed 
medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care 
(authorization is required). 
 
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 for an office visit and diagnostic tests to be provided by the  
out-of-network provider.