Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Dexcom G6 sensor.
You asked the Plan to pre-approve the sensor. You say that this is medically necessary. The Plan denied your
request. The Plan says they are unable to determine if the service is medically necessary.
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. Based on this information, we decided that Medicare rules for the
services at issue have not been met. Specifically, the case file did not contain medical records for the billed
services. Without the medical records, the billed services cannot be verified. The records show that the plan
tried multiple times to get the records from the prescriber. Therefore, we decided that the Plan does not have to
pre-approve the Dexcom G6 sensor.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to waive the copayment forthe cataract surgery provided on September 3, 2019.You asked the Plan to waive the copayment forthe cataract surgery. You submitted your bill for review.The Plan denied your request. The Plan says that you have been charged the correct cost sharing 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 does not say in clear and accurate terms how much you should expect to pay for outpatient surgery. You pay 0% or 20% coinsurance for each Medicare-covered visit to an ambulatory surgical center (including epidural injections). We looked at your contract with the Plan. The contract says enrollees must pay 0%or 20% coinsurance for the cataract surgery. The Explanation of Benefits shows you are responsible for a $0/ $219.27 coinsurance amount.The Plancontract does not explain which amount you should be expected to pay. Therefore, we cannot clearly decide which amountyou would be expected to pay. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information.Therefore, we decided that the Plan has to waive the copayment forthe cataract surgery provided on September 3, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe transthoracic echocardiogram (93306) provided August 20, 2020.You asked the Plan to waive the copayment forthe transthoracic echocardiogram. You say that you have always used this provider and was advised that you would need to contact the insurance company because it was coded incorrectly.The Plan denied your request. The Plan says this claim was processed and the correct copayment was applied per the Evidence of CoverageThe 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 $25-$150 copayment for each Medicare covered diagnostic radiology service (not including x-rays) for Outpatient diagnostic tests and therapeutic services and supplies. You have been asked to pay $25-$150 copayment for each Medicare covered diagnostic radiology service (not including x-rays) for the transthoracic echocardiogram. the transthoracic echocardiogram 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 forthe transthoracic echocardiogram (93306) provided August 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on July 23, 2020 by an out of network (OON) provider.You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the referring provider is also out-of-network.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 lab work provided on July 23, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to adjust the copaymentfor the knee arthroscopy surgery (29880) provided on July 30, 2020.You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the copayment has been applied correctly to the service 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 $350 copayment for outpatient surgery provided at a hospital outpatient facility and a $275 copayment for outpatient surgery provided at a freestanding ambulatory surgical center. You have been asked to pay a $350 copayment for the outpatient surgery provided at ahospital outpatient facility. 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 adjust the copaymentfor the knee arthroscopy surgery (29880) provided on July 30, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forenteral feeding supplies (B4034) provided May 20, 2020.You asked the Plan to pay forthe enteral feeding supplies. You say that the items were medically necessary.The Plan denied your request. The Plan says the documentation doesnot support the items billed.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery for the supplies provided in this case. There was no itemized shipping invoice. The record shows that the Plan made several attempts to obtain the necessary documentation without success.Therefore, we decided that the Plan does not have to pay forenteral feeding supplies (B4034) provided May 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided on September 3, 2020, by an out-of-network (OON) provider.You asked the Plan to pay forphysician services. You say that you would like this claim reprocessed and paid.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the referring provider is also out-of-network.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 had network providers available who could have provided 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 forphysician services provided on September 3, 2020, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the visual field test (92081) refraction (92015) and deluxe
frames (V2020) provided July 10, 2020.
You asked the Plan to pay for the vision services. You say that you are appealing the denial of payment for
vision services. The Plan denied your request. The Plan says you have already received the maximum amount
of coverage allowed for this service. The health plan overpaid to the enrollee for the services provided.
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 allows $200 every 24 months towards the cost of eye wear. The health plan overpaid to the
enrollee for the services provided but is not seeking reimbursement. Based on this information, we decided that
the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does
not have to pay for the visual field test (92081) refraction (92015) and deluxe frames (V2020) provided July
10, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.You asked the Plan to pre-approve Euflexxa. 

You say that this is medically necessary.The Plan denied your request. The Plan says step therapy criteria have 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 Euflexxa. Our reviewer says that the criteria for coverage of Euflexxa have not been met. Our physician reviewer found the enrollee has not trialed visco supplemental 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 or likely 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 Euflexxa have not been met.Therefore, we decided that the Plan does not have to pre-approveEuflexxa.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient mental health services to be provided by a
non-Medicare provider.
You asked the Plan to pre-approve the requested services. You say that you have been an established patient
with the provider. The Plan denied your request. The Plan says your plan requires you to obtain services from
providers who are certified to see Medicare members.
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. Furthermore, a licensed mental health counselor
is not eligible to provider services under Medicare. We found no exception that would require the Plan to preapprove
these services. Therefore, we decided that the Plan does not have to pre-approve outpatient mental
health services to be provided by a non-Medicare provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rituxan (J9312).
You asked the Plan to pre-approve the Rituxan. The Plan denied your request. The Plan says this request does not meet the Plan's Part B step therapy criteria for Rituxan.
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 Rituxan. Our reviewer says that Rituxan is not medically reasonable and necessary for the enrollee. Our physician reviewer found the Plan requires a trial of drug Remicade or Inflectra and Simponi Aria before they will approve the requested drug. Our reviewer found that in this case, the enrollee has not tried and failed the required drugs. Our physician reviewer also found that there is no documentation provided indicating that the Plan's required drugs 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 the Rituxan have not been met. Therefore, we decided that the Plan does not have to pre-approve Rituxan (J9312).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay forirrigation of implanted venous access device (96523) heparin injection (J1642) general pharmacy (0250) provided on August 12, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe injection and infusion services. You say that you are request a retroactive authorization for this treatment.The Plan denied your request. The Plan says enrollee's 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 onlyin 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 had network providers available who could have provided 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 forirrigation of implanted venous access device (96523) heparin injection (J1642) general pharmacy (0250) provided on August 12, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an OON provider.

You asked the Plan to pay for the medical services. You say that these services were medically necessary.The Plan denied your request. The Plan says rules for payment have not been met.

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 medical services provided by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CT pelvis with or without dye.
You asked the Plan to pre-approve a CT pelvis with or without dye (72194). You say that the enrollee needs a
CT pelvis with or without dye. The Plan denied your request. The Plan says the clinical information provided
does not describe pelvic clinical concerns.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are
medically necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve a CT pelvis with or without dye
(72194). Our reviewer says that the CT pelvis with or without dye is not medically reasonable and necessary.
Our physician reviewer found a CT scan of the abdomen/kidneys is the appropriate study for monitoring renal
angiomyolipomas. The medical records do not support any indications for CT scan of the pelvis.
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 CT pelvis with or without dye (72194) have not been met. Therefore, we
decided that the Plan does not have to pre-approve a CT pelvis with or without dye.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility.
You asked the Plan to pre-approve SNF admission. 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 Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF admission. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found the enrollee is currently on room air and
a regular diet. The enrollee required moderate independence for bed mobility. The enrollee required contact
guard assistance to walk 80 feet using a walker. The documentation does not support that the enrollee requires
the specialized skills, knowledge, or judgment of a skilled professional nurse or qualified therapist to safely and
effectively provide medically necessary and reasonable treatment. The documentation does not support that
skilled nursing or skilled therapy services are required on a daily basis. As a practical matter, the enrollee does
not require the necessary services on an inpatient basis, at a SNF level of care.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe outpatient office visit (99205) individual psychotherapy (90833) interactive complexity (90785) provided on January 16, 2020, by an out-of-network (OON) provider.You asked the Plan to pay forthe behavioral health services. You say that you are sending the medical records to appeal the denial for this date of service.The Plan denied your request. The Plan says enrollee's 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 had network providers available who could have provided 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 forthe outpatient office visit (99205) individual psychotherapy (90833) interactive complexity (90785) provided on January 16, 2020, by an out-of-network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on June 15, 2020.
You asked the Plan to pay for the nurse practitioner 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 services at issue. 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 nurse practitioner services provided on June 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aimovig 140MG Injection.
You asked the Plan to pre-approve the medication. You say that the enrollee requires Aimovig for chronic
migraine (G43.709). You state the enrollee has tried and failed many therapies, and has experienced decrease in
migraines and migraine intensity since starting Aimovig. You state continued use of Aimovig will help
decrease the use of acute/rescue medications. The Plan denied your request. The Plan says this medication is
not covered by Medicare.
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 looked at this physician's review, the file, and
Medicare rules. Based on this information, we decided that Medicare rules for coverage of the medication have
not been met. This medication falls under Part D coverage, but member has no Part D pharmacy benefit. This
medication does not fall under Part B. The plan has confirmed that the member has no commercial pharmacy
benefit administered by the Plan. Therefore, we decided that the Plan does not have to pre-approve Aimovig
140MG Injection.
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.