Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on September 9, 2021, 
September 14, 2021, and October 1, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health services. You say that services were provided to the enrollee so 
the claim should be paid. The Plan denied your request. The Plan says there was no in-network referring 
provided for the services provided. The rendering provider is out-of-network and the services provided was not 
urgent or emergent. 
 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 for home health services provided on September 9, 
2021, September 14, 2021, and October 1, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient arthroscopic knee surgery with lateral release 
for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says the documentation shows changes to the joint surface. 
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found detailed documentation is not evident regarding trial and failure of recent, reasonable, and 
comprehensive less invasive conservative care measures. The documentation is not evident re. any conservative 
treatment modalities having been tried and failed. Additionally, there are limited large-scale, long-term 
references showing the safety and efficacy of the requested surgery in this clinical setting. The x-rays 
demonstrate advanced degenerative joint disease of the femoropatellar joint, with a significant lateral patellar 
tilt and initial subluxation. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception to guidelines.  Therefore, the request for outpatient arthroscopic knee surgery with lateral release is 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 the surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve outpatient arthroscopic knee surgery with lateral release for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided the Plan does not have to pay for imaging services provided to the enrollee on October 16, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists 
between 93010 and 92960. This PTP edit has a modifier indicator of 1, which indicates modifiers associated 
with NCCI are allowed, however, an appropriate NCCI modifier was not billed with this PTP code edit. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code and when required the appropriate modifier.  
In this case, this claim cannot be paid as billed due to the omission of the required modifier. Medicare rules for 
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for 
imaging services provided to the enrollee on October 16, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a pembrolizumab injection and 
administration provided on June 8, 2021. 
 
You asked the Plan to waive the coinsurance for the injection and administration. You say that the charges are 
too high and you are unable to afford the bill. 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 a 20% 
coinsurance for Part B drugs, including chemotherapy drugs. 
 
 
 Drug/Service Allowed Amount 20% Coinsurance 
Pembrolizumab Injection $10,324.00 $2,064.80 
Drug Administration $167.39 $33.48 
Total:  $2,098.28 
 
You have been asked to pay $2,098.28, which is 20% of the allowed amount for the injection and 
administration. The injection and administration falls within the Medicare Part B Prescription Drugs benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the coinsurance for a pembrolizumab injection and administration 
provided on June 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an MRI provided on September 7, 2021. 
 
You asked the Plan to waive the deductible for an MRI. You say that you disagree with the deductible charges 
because you were told that you would only owe a $150 copayment. The Plan denied your request. The Plan 
says the claims were processed correctly, and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $300 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies.  
 
You received an MRI on September 7, 2021. The record shows that you had only paid $138.33 toward the 
$300 deductible prior to receiving the services. Therefore, you are responsible to pay the remaining deductible 
balance of $161.67.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient 
diagnostic tests and therapeutic services and supplies.  
 The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $300 deductible which 
applies to outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual 
obligation that had not been met at the time an MRI was received on September 7, 2021. Therefore, we decided 
that the Plan does not have to waive the deductible for an MRI provided on September 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyaluronan or derivative, synvisc or synvisc-one, for 
intra-articular injection, 1 mg- bilateral knees (CPT code J7325), for the enrollee. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the documentation provided does not show the member tried a preferred agent or 
why a preferred single injection agent cannot be used. The Plan states the request for Euflexxa to treat this knee pain has been approved under a different authorization and it cannot be said treatment with Synvisc is 
reasonable or necessary at this time. 
 
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 medication. Our physician reviewer 
found the record indicates that the enrollee has osteoarthritis of the knee. The requested medication is a new 
start. The provided records do not indicate that the enrollee has tried and failed the plan's preferred step one 
alternative. The record does not indicate that the enrollee has a contraindication to or would have an adverse 
effect from the plan's preferred step one alternative. The record indicates that Euflexxa has been approved for 
the enrollee. The record does not indicate that the enrollee has failed treatment with Euflexxa. The elements of 
the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
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. Therefore, we decided that the Plan does not 
have to pre-approve hyaluronan or derivative, synvisc or synvisc-one, for intra-articular injection, 1 mg- 
bilateral knees (CPT code J7325), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve grab bars, a shower chair, and a wheelchair ramp. 
 
You asked the Plan to pre-approve the grab bars, a shower chair, and a wheelchair ramp. You say that the items 
are medically necessary. The Plan denied your request. The Plan says these items are not eligible for coverage. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 
 
 
 
 
 
 
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve grab bars, a shower chair, and a wheelchair ramp.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99215) provided on July 12, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that prior authorization is not required for an office visit. 
The Plan denied your request. The Plan says the member does not have out of network benefits and the services 
provider is not a participating provider with the Plan. 
 
 
 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 for an office visit (99215) provided on July 12, 2021, 
by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from May 4, 2021, through 
May 25, 2021. 
 
You asked the Plan to pay for home health services. You say that you were not aware until after the services 
were provided that the member's coverage did not transfer until June 1, 2021. You say that supporting 
documentation was submitted and payment should be made. The Plan denied your request. The Plan says the 
provider submitted the claim number without a 30-day period of care and invalid codes payable by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that before January 1, 2020, a case-mix adjusted 
payment for a 60-day episode is made using one of 153 Home Health Resource Groups (HHRGs). After 
January 1, 2020, under the Patient-Driven Payment Model, a case-mix adjusted payment for a 30-day period of 
care is made using one of 432 HHRGs.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, the HIPPS codes billed are not valid for 
services billed after 2019. Therefore, we decided that the Plan does not have to pay for home health services 
provided from May 4, 2021, through May 25, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Skilled Nursing Facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that you would like reconsideration because the 
requested SNF services are medically necessary. The Plan denied your request. The Plan says you do not meet 
Medicare criteria for coverage of the SNF services. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 the SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the documentation submitted does 
not support that you require the necessary services on an inpatient basis, in a skilled nursing facility setting. 
 
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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Skilled Nursing Facility (SNF) services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine home health skilled nursing visits. 
 
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are no skilled nursing needs. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 
 
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 visits. Our reviewer says that the 
requested visits are not medically reasonable or necessary. Our physician reviewer found the documentation 
doesnt support that the enrollee requires skilled nursing services or skilled rehab services to provide treatment 
that is medically necessary. The enrollee does not require skilled nursing or rehab services to effectively 
provide treatment, care, and/or services in order to improve the enrollee's condition, perform a maintenance 
program to maintain the enrollees condition and/or prevent deterioration. The enrollee has been medically 
stable without any recent exacerbations of chronic medical problems or hospitalizations. 
 
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 visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve nine home health skilled nursing visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit (99215) provided on April 26, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a specialist office visit. You say that prior authorization is not required for an 
office visit. The Plan denied your request. The Plan says the member does not have out of network benefits and 
the services provider is not a participating provider with the Plan. 
 
 
 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 for a specialist office visit (99215) provided on April 
26, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from 
April 15, 2021, to April 22, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that the services should 
be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on 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 $335 
copayment per day for days 1-5 of for Inpatient hospital care.  
 
 You have been asked to pay a $1,675 copayment for five days of inpatient hospital care ($335 x 5 = $1,675). 
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 inpatient hospital services provided from April 15, 2021, to 
April 22, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home health physical therapy services. 
 
You asked the Plan to pre-approve additional home health physical therapy services. You say that you would 
like reconsideration because the requested home health services are medically necessary. The Plan denied your 
request. The Plan says you do not meet Medicare criteria for coverage of the home health services. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 additional home health physical therapy 
services. Our reviewer says that based on the available records you appear to have improved with therapy with 
improvement in your pain level. After 60 visits for this condition further skilled therapy at this point does not 
appear likely to achieve any significant improvement in your symptoms or functional status. Our physician 
reviewer found further utilization of the home exercise program appears appropriate at this point. Provided 
records do not document any acute or unstable medical conditions or changes in medication or treatment which 
would necessitate any further skilled therapy visits beyond what have already been approved. No medical notes 
from your treating physician are provided documenting an order or need for additional skilled therapy services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional home health physical therapy services have not been met. Therefore, 
we decided that the Plan does not have to pre-approve additional home health physical therapy services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you an additional amount for eyeglasses provided on 
October 13, 2021. 
 
You asked the Plan to reimburse you an additional amount for the eyeglasses. You say that you were surprised 
to receive only $100 for a $299.26 purchase. The Plan denied your request. The Plan says you received the 
maximum allowed reimbursement as stated in the Evidence of Coverage. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 We looked at the file and the Plan's rules. The file shows that the Plan has reimbursed you the maximum 
allowed eyewear amount of $100. Therefore, we decided that the Plan does not have to reimburse you an 
additional amount for eyeglasses provided on October 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 70450. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says Our records indicate a National Correct Coding Initiatives (NCCI) Procedure to 
Procedure (PTP) edit exists between 70496 and 70450. This PTP edit has a modifier indicator of 1, which 
indicates modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed 
with this PTP code edit. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes and when necessary, the appropriate modifier.  
In this case, this claim cannot be paid as billed due to an issue with the required modifier. Medicare rules for 
coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for 
medical services provided to the enrollee on September 19, 2021 and billed under code 70450.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you are appealing this denial. The Plan denied your 
request. The Plan says the denial of authorization for SNF care is correct. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not have daily skilled nursing needs 
that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have 
daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional 
therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled 
nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.