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

 
We decided that the Plan does not have to pay for the take home supply of Buprenorphine (G2079) provided on 
September 1, 2022. 
 
You asked the Plan to pay for the take home supply of Buprenorphine. You say that you believe the Plan did 
not have all the necessary information to process this claim correctly. The Plan denied your request. The Plan 
says the rendering provider was not certified/eligible to be paid for this procedure or service. 
 
The Plan must follow Medicare rules. Medicare rules say that only an entity enrolled with Medicare as an OTP 
can bill these codes.  
 
We looked at the file and Medicare rules. The claim was billed by the rendering provider and not an OTP 
facility. Individual providers cannot bill for OTP services. The rules say that Medicare Part B coverage is 
available for outpatient Opioid Treatment Program (OTP) services provided by hospitals, Critical Access 
Hospitals (CAHs), and Free-Standing Opioid Treatment Program facilities. The rules say that only an entity 
enrolled with Medicare as an OTP can bill these codes. Based on this information, we decided that Medicare 
rules for coverage of the take home supply of Buprenorphine have not been met. Therefore, we decided that the 
Plan does not have to pay for the take home supply of Buprenorphine (G2079) provided on September 1, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiologic (x-ray) imaging for evaluation of the 
swallowing function provided on July 26, 2022. 
 
You asked the Plan to pay for x-ray examination. You say that the enrollee was not enrolled in hospice on the 
date of service. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on July 24, 2022. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the radiologic (x-ray) 
imaging for evaluation of the swallowing function provided on July 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care billed with code 99221 for July 18, 
2022. 
 
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 payment is included in the global surgical package. 
 
The Plan must follow Medicare rules. The rules say that pre-operative services are included in the global 
surgical package. 
 
We looked at the file and Medicare rules. Procedure code 99221 was related to and billed on the same day as 
minor surgical procedure 49180. Payment for code 99221 is included in the global surgical package. Therefore, 
we decided that the Plan does not have to pay for the initial hospital care billed with code 99221 for July 18, 
2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hymovisc. 
 
You asked the Plan to pre-approve Hymovisc. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 Hymovisc. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found 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 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 Hymovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hymovisc.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology services billed with code 88305 for 
August 9, 2022. 
 
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 not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare requires that surgical pathology, including 
gross and microscopic  examination, of any and all submitted prostate needle biopsy specimens from a single 
patient be reported with one unit of service of HCPCS code G0416 rather than CPT code 88305. 
 
We looked at the file and Medicare rules. The file shows that the services were billed with code 88305 and not 
required code G0416. Based on this information, we decided that Medicare rules for coverage of these services 
have not been met. Therefore, we decided that the Plan does not have to pay for the surgical pathology services 
billed with code 88305 for August 9, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided 
from May 1, 2022, to May 31, 2022. 
 
You asked the Plan to waive the copayment for the SNF care. You say that you were informed that nothing 
would be owed for the services. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $180 copayment per day for days 21-45 for skilled nursing facility (SNF) care.  
 
 
  Per the EOC, the enrollee must pay a $180 copayment per day for days 21-44 for the SNF care, for a total of 
$4,320. However, the enrollee had $3,545.95 remaining to meet the $5,000 maximum out-of-pocket (MOOP). 
Therefore, the enrollee is only responsible for the lesser amount of $3,545.95. This item/service falls within the 
skilled nursing facility (SNF) care benefit category. This means that the enrollee has been asked to pay the 
correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee 
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for skilled nursing facility (SNF) care provided from May 1, 2022, to May 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthroplasty of the patella with prosthesis. 
 
You asked the Plan to pre-approve arthroplasty of the patella with prosthesis. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
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 arthroplasty of the patella with 
prosthesis. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found detailed documentation is not evident regarding a trial and 
failure of recent, reasonable, comprehensive less invasive conservative care measures. She was noted on the 
December 6, 2022, exam to not have been seen in 4 years. Moreover, there is limited published, large-scale, 
long-term peer-reviewed literature that shows this request to be an effective and/or safe treatment for the noted 
pathology. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the requested arthroplasty of the patella with a 
prosthesis, in this case, 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 arthroplasty of the patella with prosthesis have not been met. Therefore, we 
decided that the Plan does not have to pre-approve arthroplasty of the patella with prosthesis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4595 billed for date of service August 18, 
2022. 
 
You asked the Plan to pay for procedure code A4595. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is statutorily excluded. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code A4595 has a Status Indicator of X on the Physician Fee Schedule. This means that 
procedure code A4595 is statutorily excluded from Medicare payment. Based on this information, we decided that Medicare rules for coverage of procedure code A4595 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code A4595 billed for date of service August 18, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the take home supply of methadone billed with code G2078 
for August 15, 2022. 
 
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 only an entity enrolled with Medicare as an opioid 
treatment program (OTP) can bill codes G2067-G2075, G2076-G2080, G2215, G2216, and G1028. 
 
We looked at the file and Medicare rules. The file shows that code G2078 was not billed by an entity enrolled 
with Medicare as an OTP. Based on this information, we decided that Medicare rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pay for the take home supply 
of methadone billed with code G2078 for August 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood smear interpretation and report billed with code 
85060 for August 15, 2022. 
 
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 a professional component (PC)/technical component 
(TC) indicator of 8 identifies professional component of clinical laboratory codes for which separate payment 
may be made only if the physician interprets an abnormal smear for hospital inpatient. 
 
We looked at the file and Medicare rules. The file shows that procedure code 85060 was not performed to a 
hospital inpatient. Therefore, we decided that the Plan does not have to pay for the blood smear interpretation 
and report billed with code 85060 for August 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found documentation was/is lacking regarding reasonably detailed and/or evidenced 
findings supportive of the spinal vertebral bodies as being the overwhelming primary generators of the 
enrollees chronic persistent pain. Documentation does not support actual formal surgical ablation of pre-
designated basivertebral nerves as being medically necessary and/or reasonable at this time. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested Intracept intraosseous basivertebral nerve ablation at L4 and 
L5, in this case, 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 an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visits provided on 
February 24, 2022, to August 11, 2022. 
 
You asked the Plan to waive the copayment for specialist office visits. You say that you disagree with the 
copayment. 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 $45 
copayment per visit for physician/practitioner service/specialist.  
 
You have been asked to pay a $45 copayment per visit for specialist office visits. The total amount you are 
being asked to pay $135 ($45 x 3 visits =$135). This item/service falls within the physician/practitioner 
service/specialist 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 specialist office 
visits provided on February 24, 2022, to August 11, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to lower the copayment for Skilled nursing facility (SNF) care provided 
on July 1, 2022, to July 25, 2022. 
 
You asked the Plan to lower the copayment for SNF. You say that you disagree with the copayment. 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 $20 
copayment per day for days 1-20 and a $188 copayment per day for days 21-100 for Skilled nursing facility 
(SNF) care.  
 
You have been asked to pay a $20 copayment per day for days 1-20 and a $188 copayment per day for days 21-
100 for SNF. The total allowed amount for the SNF is $796 ($20 x 21 days = $420) ($188 x 2days =$376) 
($420 + $376 = $796). However, you are only being charged $790 which is less than the required amount. This 
item/service 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 lower the copayment for Skilled nursing facility (SNF) care provided on July 1, 2022, to July 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
September 29, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you would like to be 
reimbursed for the services performed. 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 $30 
copayment for specialist office visit. 
 
You have been asked to pay a $30 copayment for a specialist office visit. This item/service falls within the 
specialist office visit 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 specialist office 
visit provided on September 29, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from June 30, 2022, through 
July 8, 2022. 
 
You asked the Plan to pay for these services. You say that the acute inpatient hospital care provided was 
medically necessary. The Plan denied your request. The Plan says that the acute inpatient hospital care 
provided was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 these services. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found that the enrollee presented to the emergency department (ED) on June 3, 2022 with increasing back pain 
and shortness of breath. She underwent evaluations and imaging. She was re-evaluated by Neurosurgery. She 
was treated with supplemental oxygen, nebulizers, analgesics, and therapy services. Her condition stabilized 
and improved and she was discharged on July 8, 2022 when considered medically stable. The review indicates 
that the record showed that at the time of the inpatient admission, the admitting physician reasonably expected 
that the enrollees necessary hospital care (including earlier ED and/or observation care) would span two 
midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient hospital care provided from June 30, 2022, through July 8, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit provided on July 05, 2022, to 
August 16, 2022. 
 
You asked the Plan to pay for domiciliary or rest home visit. You say that you are appealing the claim payment 
denial. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for domiciliary or rest home 
visit provided on July 05, 2022, to August 16, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 Prolia. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found there is no evidence that the enrollee is 
allergic to or intolerant of these other forms of medication. There is no evidence that the enrollee has tried and 
not responded to these other forms of medication. There is no documentation as to why these other forms of 
medication would not be expected to be safe and effective for the enrollee. Therefore, the requested Prolia is 
not shown to be currently medically necessary and reasonable. 
 
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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for injections provided on October 27, 2022. 
 
You asked the Plan to waive the copayment for injections. You say that you want to appeal the amount being 
charged. 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 $250 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. 
 
You have been asked to pay a $250 copayment for injections. This item/service 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 injections provided on October 27, 2022.