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

 
We decided that the Plan does not have to pre-approve Eylea. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has diabetic retinopathy 
and diabetic macular edema. He has not tried and failed the Plan's required drug, bevacizumab. The records do 
not show that the required drug would be contraindicated or less effective; therefore, Eylea is not reasonable or 
medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Eylea.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic mammography and an 
ultrasound provided on July 06, 2022. 
 
You asked the Plan to waive the copayment for a diagnostic mammography and an ultrasound. You say that 
you were told one free mammography a year, and did not know an ultrasound was not included. 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 $100 
copayment for diagnostic procedures and tests in an outpatient hospital. 
 
You have been asked to pay a $100 copayment for a diagnostic mammography and an ultrasound. This 
item/service falls within the diagnostic procedures and tests in an outpatient hospital 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 diagnostic mammography and an ultrasound provided on 
July 06, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis (L1851, L2397) provided to the enrollee on 
July 15, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the records do not have any examination notes that show joint laxity. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the most recent exam provided for the review was from 4/4/22. There were no updated exams 
provided to corroborate any recent injury or surgery to the knee. The records do not support that there was an 
exam that shows knee instability with an objective description of joint laxity. Detailed documentation is not 
evident regarding laxity. The 4/4/22 exam did not provide any objective findings for the knees.  
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for a knee orthosis (L1851, L2397) provided to the enrollee on July 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for arthrocentesis of the major joint or bursa provided on April 
28, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for arthrocentesis of the major joint or bursa. You say that the provider listed is the 
facility and it should be the physician, who is in-network. The Plan denied your request. The Plan says based 
on how the claim was submitted and processed, the provider listed is not a contract 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 arthrocentesis of the major joint or bursa provided 
on April 28, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99306 billed for date of service April 29, 
2022. 
 
You asked the Plan to pay for procedure code 99306. You say that the service was medically necessary. The 
Plan denied your request. The Plan says payment for code 99306 is bundled into payment for code 93350. 
 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 99306 
is a column II code to column I code 93350. 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 99306 billed for date of service April 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the at-home COVID-19 test kit (codes 87811 and A9270) 
purchased on April 5, 2022. 
 
  You asked the Plan to pay for the at-home COVID-19 test kit. You say that this COVID-19 testing package 
was mandated by the cruise line 24 hours prior to sailing and 24 hours before returning. You also say you had 
no other option to use another source of reporting aside from this test kit package. The Plan denied your 
request. The Plan says this is a non-covered service. The Plan also says your payment request should be sent to 
Original Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that routine services required by third parties such as 
business establishments are not covered by Medicare.  
 
We looked at the file and Medicare rules. This testing was required by the cruise line for the purposes of 
routine travel. Based on this information, we decided that Medicare rules for coverage of screening testing have 
not been met. Therefore, we decided that the Plan does not have to pay for the at-home COVID-19 test kit 
(codes 87811 and A9270) purchased on April 5, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service June 26, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient 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 June 26, 2022.
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 20, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient 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 20, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has age-related 
osteoporosis without osteoporotic fracture. She has not tried and failed the Plan's required drug, Forteo. The 
records do not show that the required drug would be contraindicated or less effective; therefore, Evenity is not 
reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Evenity.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services (90837) provided on April 21, 2022. 
 
You asked the Plan to pay for the psychotherapy services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the claim was billed with an inappropriate modifier. 
 
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 90837 is not supported in the medical record. Specifically, the code was billed with the 
GQ modifier. The GQ modifier is only valid when used by providers in Alaska or Hawaii. The rendering 
provider was not in Alaska or Hawaii. Based on this information, we decided that Medicare rules for coverage 
of the psychotherapy services have not been met. Therefore, we decided that the Plan does not have to pay for 
psychotherapy services (90837) provided on April 21, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a skilled nursing facility (SNF) care 
provided from April 13, 2022, to April 29, 2022. 
 
You asked the Plan to waive the copayment for a SNF. You say that you disagree with the copayment and want 
the plan to reconsider. 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 $0 
copayment per day for days 1-20 and $188 copayment per day for days 21-100 for skilled nursing facility 
(SNF) care.  
 
You have been asked to pay a $0 copayment per day for days 1-20 and $188 copayment per day for days 21-
100 for a SNF. The total copayment amount for the SNF stay is $3,196.00 ($188 x 17 days = $3,196.) You are 
being asked to pay the lesser amount of $791.42 due to the maximum out-of-pocket amount of $3,800 being 
met and exhausted. 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 skilled nursing facility (SNF) 
care provided from April 13, 2022, to April 29, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says there is no evidence of the enrollee having tried and failed the preferred step 
therapy drugs. The Plan says that there is no indication that the preferred agents would likely be less effective, 
and/or cause adverse effects for the enrollee. 
 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 Euflexxa. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the Plan requires a trial of Orthovisc, 
Supartz FX, Durolane, Monovisc, or Synvisc-One before they will approve the requested drug. In this case, the 
record indicates that the enrollee has osteoarthritis of the knee. 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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on April 19, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollees network primary care provider (PCP) or plan must give the enrollee 
approval in advance before they can use providers not in the plan's network. This is called giving you a 
"referral." 
 
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 office visit provided on April 19, 2022, 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 an inpatient hospital stay provided from 
August 17, 2021, to August 25, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that there should be no 
copayment for an inpatient admission due to COVID-19. The Plan denied your request. The Plan says the 
COVID-19 waiver was effective until June 1, 2020; therefore, the 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 $225 
copayment per day for Medicare-covered hospital stays for days 1-7. There was a total of 8 days in the 
inpatient hospital stay. The day before you are discharged is your last inpatient day; therefore only 7 days were 
charged a copayment. The total copayment amount was $1,575 ($225 copayment per day x 7 days). 
 
  You have been asked to pay a $1,575 copayment for the inpatient hospital 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 
hospital stay provided from August 17, 2021, to August 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on June 10, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for drug testing. You say that you would like to request reconsideration of the denied 
claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was determined these 
services can be received in-network. 
 
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 drug testing provided on June 10, 2022, by an out-
of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient office visit provided on May 25, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for a new patient office visit. You say that this was denied because there wasn't a 
prime care provider preauthorization, but you are a prime care provider. The Plan denied your request. The 
Plan says you are still out of network, even if you are a prime care provider. The beneficiary needs to stay 
within network, unless it is an emergency. The decision is upheld. 
 
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 new patient office visit provided on May 25, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on March 17, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of our plans network) will not be 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 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 office visit provided on March 17, 2022, by an 
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive inpatient hospital services provided from June 10, 2022, to 
June 14, 2022. 
 
You asked the Plan to waive inpatient hospital services. You say that you received a bill from the hospital for 
$1,400, and you want to know why the insurance is not covering 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 $350 
copayment each day for day 1 to five each time you are admitted for Medicare-covered hospital care.  
 
 
  You have been asked to pay a $350 copayment each day for four days for inpatient hospital services, which is a 
total of $1,400 ($350 x 4 = $1,400). This item/service falls within the Medicare-covered 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 inpatient hospital services provided from June 10, 2022, to June 
14, 2022.