Persius/hicric huggingface dataset:
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. You say that your office does not administer Orthovisc or 
Monovisc. The Plan denied your request. The Plan says step therapy requirements 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 Synvisc-One. Our reviewer says that 
the criteria for coverage of Synvisc-One have not been met. Our physician reviewer found the Plan requires a 
trial of Monovisc and Orthovisc before they will approve the requested drug. Based on the medical records 
provided, the patient has not tried and failed the required drugs and there is no indication that the Plan's 
required drugs would likely be less effective or have adverse effects for the patient. 
 
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 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 Gamunex-C. 
 
You asked the Plan to pre-approve the Gamunex. You say that you would like reconsideration because the 
infusions are medically necessary. The Plan denied your request. The Plan says the immune globulin does not 
fall under Medicare Part B coverage. 
 
The Plan must follow Medicare rules. The rules say that the use of intravenous immune globulin (IVIG) should 
be reserved for patients with serious defects of antibody function.  
 
We looked at the file and rules. Based on this information we have determined that Medicare coverage criteria 
for the Gamunex has not been met. Specifically, the member does not have a required indication for the 
services requested. Therefore, we decided that the Plan does not have to pre-approve Gamunex-C.  
 
Benefits for the Gamunex may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for post-stabilization inpatient care provided January 17, 2020 to 
January 18, 2020. 
 
You asked the Plan to pay for post-stabilization inpatient care. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the enrollee was stable for transfer to an in-network 
hospital after initial stabilizing care. 
 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 post-stabilization inpatient care. Our 
reviewer says that the inpatient care was not medically necessary. Our physician reviewer found the enrollee 
was stable for ambulance transfer to a plan contracted facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of post-stabilization inpatient care have not been met. Therefore, we decided that 
the Plan does not have to pay for post-stabilization inpatient care provided January 17, 2020 to January 18, 
2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a total hip arthroplasty (27130) performed 
on March 12, 2020. 
 
You asked the Plan to waive the coinsurance for a total hip arthroplasty. You say that the charge is excessive 
compared to a similar surgery performed in a prior benefit year. The Plan denied your request. The Plan says 
the correct coinsurance was 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 20% 
coinsurance for each covered surgery or observation room service in an outpatient hospital.  
 
You have been asked to pay $2,278.89, or 20% of the total Plan-allowed cost of $11,394.45, for a total hip 
arthroplasty. A total hip arthroplasty performed in an outpatient hospital setting falls 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 coinsurance for a total hip arthroplasty 
(27130) performed on March 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision services provided on August 9, 2019 by an out of 
network (OON) provider. 
 
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 the services were rendered by an out-of-network provider without 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 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 vision services provided on August 9, 2019 by 
an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray services coded 71045 provided on April 6, 2020. 
 
You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 71045 is radiologic examination, chest; single view. 
 
We find that CPT code 71045 is not supported in the medical record. Specifically, this code was billed with 
diagnosis code J91.8 (Pleural effusion in other conditions classified elsewhere) as the first diagnosis code. This 
diagnosis code is classified as a "manifestation" code and should be billed in the proper sequencing order of the 
codes. Based on this information, we decided that Medicare rules for coverage of the x-ray services have not 
been met. Therefore, we decided that the Plan does not have to pay for the x-ray services coded 71045 provided 
on April 6, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a stay at a SNF from April 7 to May 12, 
2020. 
 
You asked the Plan to waive the copayment for a stay at a SNF. You say that you should not have to pay the 
cost-share for the first 100 days of a stay at a SNF. The Plan denied your request. The Plan says the correct 
copayment was 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 $178 
copayment for each day for days 21 through 100 of a stay at a SNF.  
 
You have been asked to pay a $2,670 copayment ($178 for 15 days beyond the first 20 days) for a stay at a 
SNF. A stay at a SNF falls within the "Skilled nursing facility (SNF) care" benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for a stay at a SNF from April 7 to May 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for periodontal maintenance provided on August 8, 2019 
and December 18, 2019. 
 
You asked the Plan to pay more for periodontal maintenance. You say that you had two cleanings and expected 
$90 to be paid for each cleaning. You say that you didn't know until after that the service was considered 
periodontal maintenance. The Plan denied your request. The Plan says the August claim was reprocessed as an 
exception and the December claim remains denied. 
 
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, periodontal maintenance is not among 
those covered under this benefit. Although periodontal maintenance is normally not a covered benefit, the Plan 
made an exception to reprocess the August claim toward your restorative benefit. Therefore, we decided that 
the Plan does not have to pay more for periodontal maintenance provided on August 8, 2019 and December 18, 
2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and copayment for a corneal transplant (65756) 
performed on May 1, 2020. 
 
You asked the Plan to waive the deductible and copayment for a corneal transplant. You say that the service 
you received was a complication of cataract surgery and should be fully covered. The Plan denied your request. 
The Plan says the correct cost-sharing was 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 $975 deductible that you must pay out of pocket before the Plan will 
pay its share. Your contract also clearly says that you must pay a $100 copayment for each covered surgery in 
an ambulatory surgical center. 
 
You have been asked to pay $915.14 for a corneal transplant. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $975 deductible that you must pay out of pocket before the Plan will 
pay its share, and that you must pay a $100 copayment for each covered surgery in an ambulatory surgical 
center. In this case, you had $815.14 remaining of your deductible at the time a corneal transplant was received 
on May 1, 2020. A corneal transplant when performed in an ambulatory surgical center falls within the 
Outpatient surgery benefit category. This means that you have been asked to pay the correct amount ($815.14 
to satisfy the deductible and a $100 copayment = $915.14) 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 deductible and copayment for a corneal transplant (65756) performed on 
May 1, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood glucose testing rendered on March 2, 2020 to 
March 31, 2020. 
 
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 the testing is not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. The rules say that blood glucose testing is covered for management of 
diabetes. 
 
The test at issue in this appeal, blood glucose testing, was requested solely for screening purposes. The file 
shows that the testing was not performed for management of diabetes. Medicare does not cover this test solely 
for screening purposes. Therefore, we decided that the Plan does not have to pay for the blood glucose testing 
rendered on March 2, 2020 to March 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full cost of eyewear frames and bifocal lenses with polarization provided on May 1, 2020.

You asked the Plan to pay the full cost of eyewear frames and bifocal lenses with polarization. You say that you cannot afford these charges. The Plan denied your request. The Plan says the $200 benefit applied correctly.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a $200 allowance for supplemental eyewear every year.

We looked at the file and the Plan's rules. The record shows that the cost of your eyewear as $557. After the $200 allowance, you are responsible for $357. Based on this information, we decided that the Plan's rules for coverage of eyewear frames and bifocal lenses with polarization have not been met. Therefore, we decided that the Plan does not have to pay the full cost of eyewear frames and bifocal lenses with polarization provided on May 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99348) provided on September 23, 2019.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not supported.

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 coding 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 the services. Our reviewer says that the use of CPT code 99348 is not supported by the records provided. Our coding reviewer found that the home visit does not specify that a physician or other qualified healthcare provider was in the home at the time of visit. CPT 99348 is not an appropriate code to bill a nurse visit. A home visit cannot be billed by a physician unless the physician was actually present in the beneficiary's home.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (CPT 99348) provided on September 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the full cost for bifocals (V2203) provided on March 12, 2020. 
 
You asked the Plan to pay the full cost for bifocals. You say that you lost your glasses and needed a new pair. 
The Plan denied your request. The Plan says you have used your $150 allowance. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when a $150 allowance every 24 months for use towards the purchase 
price of eyewear. 
 
We looked at the file and the Plan's rules. The record shows that the Plan paid $150 towards frames and these 
bifocal lenses. You are responsible for the remaining cost.  Based on this information, we decided that the 
Plan's rules for coverage of bifocals have not been met. Therefore, we decided that the Plan does not have to 
pay the full cost for bifocals (V2203) provided on March 12, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on January 7, 2020. 
 
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says services 
from non-participating providers are not covered under your plan unless they are authorized by the Plan before 
the services are provided. 
 
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 psychotherapy services provided on January 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 21, 2019 by
an out of network (OON) provider.
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 the services were rendered by an out-of-network provider without 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 referring provider 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 laboratory services provided on November 21, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductibles for an eye examination, injections, and eye 
imaging provided from August 1, 2019 to January 23, 2020. 
 
You asked the Plan to waive the deductibles for eye exam, injections, and eye imaging. You say that you have 
an authorization to use this provider as an in-network provider. The Plan denied your request. The Plan says the 
deductible amounts you are being charged are correct. The Plan also says that they have reprocessed the claims 
for dates of service August 14, 2019, August 27, 2019, September 20, 2019, and December 5, 2019 at the in-
network rate and the claim for date of service December 23, 2019 has no cost-sharing for you. 
 
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 $1,000 deductible for out-of-network eye exams in 2019, and a 
$1,000 deductible for out-of-network Part B drugs and diagnostic tests in 2020. At the time the claim for 
August 1, 2019 was processed, $461.68 of the $1,000 out-of-network deductible for 2019 had been met. The 
allowed amount of the claim is $160.60, resulting in a deductible amount of $160.60. At the time the claims 
from January 8, 2020 to January 23, 2020 were processed, $0 of the $1,000 out-of-network deductible for 2020 
had been met. The allowed amounts of these claims total $253.84, resulting in a deductible amount of $253.84. 
Your total cost-sharing obligation is therefore $414.44. 
 
The items or services you asked the Plan to waive the deductibles for fall within the benefit categories "Vision 
Care", "Medicare Part B Prescription Drugs", and "Outpatient Diagnostic Tests and Therapeutic Services and 
Supplies". The Plan has followed Medicare rules by clearly disclosing in the contract that there is $1,000 
deductible in 2019 and a separate $1,000 deductible in 2020 for these services, when obtained from an out-of-
network provider. This cost sharing is a contractual obligation that had not been met at the time eye exam, 
injections, and eye imaging was received on August 1, 2019 to January 23, 2020. Therefore, we decided that 
the Plan does not have to waive the deductibles for an eye examination, injections, and eye imaging provided 
from August 1, 2019 to January 23, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient surgical services rendered on 
March 17, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that the services were routine and 
should have no copayment. The Plan denied your request. The Plan says the copayment was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $450 
copayment per visit for outpatient surgery, including services provided at hospital outpatient facilities and 
ambulatory surgical centers.  
 
Review of the file shows that you received a diagnostic colonoscopy on March 17, 2020. The services were 
diagnostic and not screening in nature because they were performed for a medical diagnosis and not screening. 
You have been asked to pay a $450 copayment for these services. These services fall within the outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for the outpatient surgical services rendered on 
March 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on March 26, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider 
on March 26, 2020.