Persius/hicric huggingface dataset:
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 an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve outpatient mental health services. You say that you do not want to see a new 
psychiatrist. The Plan denied your request. The Plan says the requested services can be provided by a network 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
outpatient mental health services to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 18, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment provided to the enrollee on May 
26, 2022. 
 
You asked the Plan to pay for the services. You say that the provider obtained authorization for these services. 
The Plan denied your request. The Plan says there was no new authorization obtained for this date of service. 
 
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 durable medical equipment provided to the 
enrollee on May 26, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs (A9270 x 2) provided from  
May 18, 2022, through May 19, 2022. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says these items are not covered under your contractual 
policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs provided are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
(A9270 x 2) provided from May 18, 2022, through May 19, 2022.   
Benefits for these items 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 inpatient mental health services provided on November 3, 
2021, to November 12, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for inpatient mental health services. You say that the services provided were 
medically necessary. The Plan denied your request. The Plan says the health plan should have been given the 
opportunity, in a timely manner, to transfer the member to an in-network facility. 
 
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 inpatient mental health services provided on 
November 3, 2021, to November 12, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF care. The Plan denied your 
request. The Plan says the enrollee does not require an intensive level of therapy requiring physician oversight. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation 
does support a need for physical and/or occupational therapy, there is no documented need for an intensive, 
multi-disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to 
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897), 60 mg every 6 months. 
 
You asked the Plan to pre-approve Prolia. You say that the enrollee is not able to try the recommended 
medications due to their medical history. The Plan denied your request. The Plan says the enrollee has not tried 
and failed the preferred drugs, an oral bisphosphonate drug and zoledronic acid. 
 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 Prolia. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
that the enrollee has tried and failed the preferred drugs. The reviewer found there is no indication that the 
plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 
Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897), 60 mg every 6 months.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Iovera therapy (64640). 
 
You asked the Plan to pre-approve Iovera therapy. You say that the requested service is necessary for treatment 
of the enrollee's knee pain. The Plan denied your request. The Plan says the requested service is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Iovera therapy. Our reviewer says that 
the requested Iovera therapy is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided documentation does not indicate that the requested therapy is clearly supported for 
the enrollee's diagnosis. Therefore, the reviewer found that the requested Iovera therapy 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 Iovera therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Iovera therapy (64640).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nexletol. 
 
You asked the Plan to pre-approve Nexletol. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Nexletol.  
 
Benefits for Nexletol 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B coverage criteria for Prolia. 
 
 
 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 Prolia. Our reviewer says that the 
enrollee does not meet the coverage criteria for Prolia. Our physician reviewer found there is no indication that 
the enrollee has tried and failed the required drug. Our reviewer also found that there is no indication that the 
Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vivelle-dot. 
 
You asked the Plan to pre-approve Vivelle-dot. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested drug is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Vivelle-dot.  
 
Benefits for Vivelle-dot 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat epidural steroid injections (63383). 
 
You asked the Plan to pre-approve the repeat injections. You say that the repeat 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 for repeat injections to be covered, previous Epidural 
steroid injections must provide at least 50% sustained improvement of pain and/or 50% objective improvement 
in function (using the same scale). 
 
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 repeat injections. Our reviewer says 
that the repeat injections are not medically necessary. Our physician reviewer found the previous injection has 
not directly and significantly provided improvement of the pain by at least 50%. 
 
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 repeat injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve repeat epidural steroid injections (63383).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient care provided on October 20, 2021 to November 3, 
2021. 
 You asked the Plan to pay for the inpatient care. You say that the correct DRG was billed. The Plan denied 
your request. The Plan says the records do not support DRG 189. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 189. 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 the inpatient care. Our reviewer says that DRG 189 is not supported in the 
records. Our physician reviewer found the hospital record did not support reporting the diagnosis code for 
Acute and chronic respiratory failure with hypoxia in this case. The review has determined that DRG 202 is 
appropriate.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient care provided on October 20, 2021 to November 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy and office visit provided on June 10, 2022, by 
an OON provider. 
 
You asked the Plan to pay for psychotherapy and office visit. You say that there is a referral from your primary 
care physician and you are requesting the denied claim be reprocessed for payment. The Plan denied your 
request. The Plan says the out-of-network 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 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 psychotherapy and office visit provided on June 
10, 2022, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient stay after surgery provided 
from February 10, 2022, to February 22, 2022. 
 
You asked the Plan to waive the copayment for an inpatient stay. You say that this copayment is too high, and 
you cannot afford it. The Plan denied your request. The Plan says this cost sharing was charged 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 $320 
copayment per day for days 1-5 for inpatient hospital care ($320 x 5 days = $1,600).  
 
You have been asked to pay a $1,600 copayment per day for an inpatient stay. This item/service falls within the 
inpatient hospital 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 an inpatient 
stay after surgery provided from February 10, 2022, to February 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 14, 2022. 
 
You asked the Plan to pay for the lab services. You say that the specimens received are from providers who 
have performed intraoperative biopsies and must be processed without delay. You say that you are requesting 
payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on February 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81455 billed for date of service March 30, 
2022. 
 
You asked the Plan to pay for procedure code 81455. You say that this testing was necessary and is supported 
in the medical record. The Plan denied your request. The Plan says testing billed with this code is automatically 
denied as not reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that certain codes are automatically denied as not 
medically necessary as they are unlikely to impact therapeutic decision making in the clinical management of a 
patient.  
 
We looked at the file and Medicare rules. Code 81455 was listed under the Group 3 Paragraph of Article 
A56199 on the date in question. This means that this service is considered automatically denied as not 
medically necessary. Based on this information, we decided that Medicare rules for coverage of procedure code 
81455 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 81455 
billed for date of service March 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for out of pocket costs incurred for the repair of two 
standard hearing aids provided from March 28, 2022, to April 22, 2022. 
 
You asked the Plan to reimburse for out of pocket costs incurred for the repair of two standard hearing aids. 
You say that the policy clearly states that hearing aid repair is covered. You also say there was an error in the 
billing code. The Plan denied your request. The Plan says the member is beyond the 3-year warranty coverage 
in 2017. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for the 
repair for hearing aid only within the first three years of the purchase of the hearing aids.  
 
We looked at the file, and the Plan's rules. The record shows the hearing aids were purchased in 2017. 
Therefore, it is past the 3-year warranty period, which ended in 2020. Based on this information, we decided 
that the Plan's rules for coverage of out-of-pocket costs incurred for the repair of two standard hearing aids 
have not been met. Therefore, we decided that the Plan does not have to reimburse for out of pocket costs 
incurred for the repair of two standard hearing aids provided from March 28, 2022, to April 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a COVID-19 test provided in the Country of Aruba on March 
25, 2022. 
 
You asked the Plan to pay for COVID-19 test. You say that this test was required before returning to the United 
States, and it was impossible to use an in-network provider. The Plan denied your request. The Plan says this 
testing is not covered because it was performed out-of-network. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services provided outside of the United 
States and its territories are excluded from coverage, except under certain specified circumstances. The Plan 
offers a worldwide coverage benefit that exceeds Medicares coverage. For that reason, the Plans rules apply 
to this case. The Plan covers emergency and urgent care services worldwide. 
 
We looked at the file and Medicare rules. This COVID-19 testing was not performed due to any emergent or 
urgent care need, but rather as a screening service required prior to return travel to the United States. Based on 
this information, we decided that neither Medicare rules nor the Plans rules for coverage of COVID-19 test 
have been met. Therefore, we decided that the Plan does not have to pay for a COVID-19 test provided in the 
Country of Aruba on March 25, 2022.