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

We decided that the Plan does not have to pre-approve facet joint injections (64493, 64494). 
 
You asked the Plan to pre-approve the facet joint injections. You say that the injections are 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 facet joint injections are covered when 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 the facet joint injections. Our reviewer 
says that the records do not show that the injections are medically necessary. Our physician reviewer found 
there is no physical examination provided with documented signs that the facet joint is the primary source of 
pain. 
 
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 injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections (64493, 64494).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient surgery provided on May 9, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for an outpatient surgery. You say that you would like this appeal reprocessed and 
paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that 
there are in-network providers available for these services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 an outpatient surgery provided on May 9, 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 an eye examination provided on September 3, 2020. 
 
You asked the Plan to pay for the eye examination. The Plan denied your request. The Plan says it is important 
to know which providers are part of our network because, with limited exceptions, while you are a member of 
our plan you must use network providers to get your medical care and services. The only exceptions are 
emergencies, urgently needed services when the network is not available (generally, when you are out of the 
area), out-of-area dialysis services, and cases in which the Plan authorizes use of out-of-network providers. 
 
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 
eye examination. 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 an eye examination provided on September 3, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility occupational therapy services provided 
on June 26, 2020. 
 
You asked the Plan to pay for the nursing facility occupational therapy services. You say that you would like 
the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
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 find that the nursing facility occupational therapy services are not supported in the medical record. 
Specifically, this service was not billed with the proper modifier. The plan also notes that a corrected claim can 
be submitted for review. Based on this information, we decided that Medicare rules for coverage of the nursing 
facility occupational therapy services have not been met. Therefore, we decided that the Plan does not have to 
pay for the nursing facility occupational therapy services provided on June 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an orthopaedic surgery office visit provided 
on September 14, 2020. 
 
You asked the Plan to waive the copayment for specialist visit. You say that you have not had to pay for this in 
the past. The Plan denied your request. The Plan says the copayment amount you are being charged is correct. 
 
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 $15 
copayment for specialist visit.  
 
You have been asked to pay $15 copayment for specialist visit. Specialist visit falls within the 
Physician/Practitioner Services, Including Doctor's Office Visits 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 an orthopaedic surgery office visit provided on September 14, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services received on August 19, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services received were billed incorrectly. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patient's health. The Plan follows the same rules.  
 
We looked at the file and Medicare rules. Review of the file shows that the claim was billed incorrectly. The 
first position represents the origin and the second the destination. The claim submitted by the provider shows 
that the origin of transport was "HS" representing hospital and the destination of the transport was billed as 
scene of accident or acute event. Based on this information, we decided that Medicare rules for coverage of the 
ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the 
ambulance services received on August 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services received on August 27, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services received are not a covered benefit when 
provided by an OON provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The 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 laboratory services received on August 27, 
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 on August 17, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the pain management services. You say that you would like reconsideration 
because there was a miscommunication regarding the member's insurance. The Plan denied your request. The 
Plan says prior authorization is required for out-of-network services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 on August 17, 2020 
by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the echocardiography services provided from July 29, 2020 
to August 14, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the echocardiography services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered 
benefit. 
 
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 echocardiography services provided from July 
29, 2020 to August 14, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on August 19, 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. 
 
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 August 19, 2020 by an out 
of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic imaging provided on July 22, 2020, to September 
29, 2020 by an out of network (OON) provider.
 
You asked the Plan to pay for diagnostic imaging. You say that obtained prior authorization is almost 
impossible. The Plan denied your request. The Plan says prior authorization was not obtained by the facility; 
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 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 diagnostic imaging provided on July 22, 2020, to 
September 29, 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 office visit (99205) provided on July 1, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for an OON office visit. You say that this was medically necessary. The Plan denied 
your request. The Plan says this was 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 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 office visit (99205) provided on July 1, 2020 
by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the automatic external defibrillator (AED) rendered on July 
1, 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 services are not covered. 
 
The Plan must follow Medicare rules. The rules say that capped rental items are paid on a lump-sum basis. The 
rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim 
line are denied. 
 
We looked at the file and Medicare rules. The billed K0606 services are a capped rental item and there is no 
documentation that the services were performed on the date of service at issue. The Plan has previously paid 
for these services within a 28 day period. Therefore, we decided that the Plan does not have to pay for the 
automatic external defibrillator (AED) rendered on July 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 5, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you would like reconsideration because you should 
not be held responsible for your provider not following proper protocol. The Plan denied your request. The 
Plan says prior authorization is required for out-of-network services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 on August 5, 2020 
by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Vitrectomy, mechanical, pars plana 
approach (67039) provided September 25, 2020. 
 
You asked the Plan to waive the copayment for the vitrectomy. You say that you are on a fixed income and 
cannot afford 2 copays and feel that you should not have to pay since the infection that you got was not your 
fault. The Plan denied your request. The Plan says the claim was processed and the correct copayment was 
applied per the Evidence of Coverage 
 
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 $350 
copayment per date of service in an outpatient hospital facility.  
 
You have been asked to pay $350 copayment for the vitrectomy. The vitrectomy falls 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 Vitrectomy, mechanical, pars plana approach 
(67039) provided September 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion supplies (A4222) provided January 23, 2019. 
 
You asked the Plan to pay for the home infusion supplies. You say that the services were medically necessary. 
The Plan denied your request. The Plan says this code is not separately payable. 
 
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 find that CPT code A4222 is not supported in the medical record. Specifically, Medicare rules state that 
payment for the administration of a drug or biological billed to the MAC will also include payment for 
equipment  used in furnishing the service. The supplies are not separately payable. Based on this information, 
we decided that Medicare rules for coverage of the home infusion supplies have not been met. Therefore, we 
decided that the Plan does not have to pay for home infusion supplies (A4222) provided January 23, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zilretta (J3304). 
 
You asked the Plan to pre-approve Zilretta. You say that Zilretta is medically necessary. The Plan denied your 
request. The Plan says a trial of dexamethasone and triamcinolone is required before alternatives can be 
considered. 
 
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 Zilretta. Our reviewer says that Zilretta 
is not medically necessary. Our physician reviewer found the record shows no trial of the plan preferred drugs. 
There is no documentation to show that the plan preferred drugs would be unsafe or ineffective for this 
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 Zilretta have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Zilretta (J3304).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for venipuncture provided on June 8, 2020, and 
August 11, 2020. 
 
You asked the Plan to waive the copayment for the services. You say that the venipuncture should be included 
with the laboratory work and you should not owe these. The Plan denied your request. The Plan says the claims 
were processed accordingly with your 2020 EOC 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). Review of the file show that you received venipuncture on June 8, 
2020, and August 11, 2020. The health plan contract says that an office visit or outpatient facility copayment 
may apply for additional services including venipuncture. Therefore, you are responsible for the copayments. 
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 venipuncture provided on June 8, 2020, and August 11, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on September 10, 2020, by an 
OON provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that these services were provided to the 
enrollee out of medical necessity. 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 on September 10, 
2020, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the lumbar-sacral orthosis (L0650), 
pneumatic segmental leg appliances (E0667 x 2), and the pneumatic compressor (E0651) provided on  
August 3, 2020 and August 12, 2020. 
 
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to 
the durable medical equipment 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 20% 
coinsurance for Medicare-covered in-network and out-of- network durable medical equipment.  
 
You have been asked to pay $560.55 (Plan allowed amount of $2,802.71 x 20% coinsurance) for the Medicare-
covered out-of-network durable medical equipment provided. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance 
for the lumbar-sacral orthosis (L0650), pneumatic segmental leg appliances (E0667 x 2), and the pneumatic 
compressor (E0651) provided on August 3, 2020 and August 12, 2020.