Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane. 
 
You asked the Plan to pre-approve Durolane. 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 Durolane. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found you have not tried and failed the required 
drug(s). There is no documentation provided indicating that the Plans required drug(s) would likely be less 
effective and/or likely have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durolane.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services: medical examination and 
evaluation, with initiation or continuation of diagnostic and treatment program provided on March 11, 2022. 
 
You asked the Plan to pay for ophthalmological services: medical examination and evaluation, with initiation 
or continuation of diagnostic and treatment program. You say that your eye doctor does not require pre-
authorization for treatment. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they 
approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for ophthalmological services: medical examination and evaluation, 
with initiation or continuation of diagnostic and treatment program provided on March 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 8, 2022. 
 
You asked the Plan to pay for office visit. You say that this Plan should not be used as your primary insurance. 
The Plan denied your request. The Plan says the denial of payment for this service is correct, because the claim 
is currently being processed with the Department of Labor because this is covered by your workers 
compensation benefits. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has submitted this claim to the Department of Labor as well as your primary insurance carrier for processing. As the 
secondary insurer, the Plan cannot be held responsible for office visit until the primary insurer has denied the 
claim for these services. Therefore, we decided that the Plan does not have to pay for an office visit provided 
on April 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing on behalf of the 
enrollee based on medical necessity. The Plan denied your request. The Plan says the enrollee can receive the 
same services at the current level of care. Once deemed appropriate, transfer to a lower level of care for 
rehabilitation or skilled services can be considered. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the 78 year old enrollee was admitted to the acute care hospital with acute respiratory 
failure related to an anaphylactic reaction to prednisone. The course was complicated by emphysema, delirium, 
aspiration, pneumothorax. The enrollee was treated with epinephrine and oxygen support. Recent notes 
describe the enrollee as having responded to treatment and now on low dose oxygen support near baseline 
requirements with stable vitals. The enrollee does not require services at the LTACH that are not available at 
the current facility.  There are no services at the LATCH that the enrollee requires that are not already available and covered at the 
current facility. Transfer to LTACH is not medically necessary as it would not be clinically advantageous. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care (99309) provided on February 24, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for nursing facility care. You say that the medically necessary services at issue were 
provided to the enrollee in good faith. The Plan denied your request. The Plan says rules for payment for OON 
care have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 nursing facility care (99309) provided on February 
24, 2022, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar orthosis provided on March 31, 2022. 
 
You asked the Plan to pay for a lumbar orthosis. The Plan denied your request. The Plan says the records do 
not contain the necessary information to support the item ordered/service(s) billed. The medical records 
submitted indicate the visit was for COVID-19 with no mention of prescribing or need for the lumbar orthosis 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a lumbar orthosis provided on  
March 31, 2022 have been met. Therefore, we decided that the Plan does not have to pay for a lumbar orthosis 
provided on March 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on February 2, 2022 by an out-of-
network (OON) provider. 
 
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 rendered by an out-of-network provider without prior authorization. 
 
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 the office visit provided on February 2, 2022 by an 
out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for neuroimaging services (93892, 93890, 
93880, 93886) provided on March 29, 2022. 
 
You asked the Plan to waive the deductible for neuroimaging services. You say that this should be covered as 
an in-network service. The Plan denied your request. The Plan says this processed correctly. 
 
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 $750 deductible which applies to most out-of-network services.  
 
The item or service you asked the Plan to waive the deductible for was provided by an out-of-network provider. 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which 
applies to most out-of-network services. This cost sharing is a contractual obligation that had not been met at 
the time neuroimaging services was received on March 29, 2022. Therefore, we decided that the Plan does not have to waive the deductible for neuroimaging services (93892, 93890, 93880, 93886) provided on March 29, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450-26 billed for date of service March 28, 
2022. 
 You asked the Plan to pay for procedure code 70450-26. You say that this was denied as a duplicate in error. 
The Plan denied your request. The Plan says payment for code 70450-26 is bundled into payment for code 
70496-26. 
 
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 
70450-26 is a column II code to column I code 70496-26. 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 70450-26 billed for date of service 
March 28, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for out-of-network (OON) psychotherapy 
services provided on March 7, 2022. 
 
You asked the Plan to waive the deductible for the OON psychotherapy services. You say that you were not 
aware that the provider was not in-network. The Plan denied your request. The Plan says the correct amount 
was applied to your deductible. 
 
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 $490 in-network and out-of-network combined deductible which 
applies to certain items and services.  
 
The out-of-network psychotherapy services fall within the Outpatient Mental Health Care benefit category. The 
Plan has followed Medicare rules by clearly disclosing in the contract that there is $490 in-network and out-of-
network combined deductible which applies to certain items and services. This cost sharing is a contractual 
obligation that had not been met at the time the OON psychotherapy services were received on March 7, 2022. 
Therefore, we decided that the Plan does not have to waive the deductible for out-of-network (OON) 
psychotherapy services provided on March 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rolling walker provided on May 6, 2022 by a non-
participating provider. 
 
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 rendered by a non-participating provider without prior authorization. 
 
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 the rolling walker provided on May 6, 2022 by a 
non-participating provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for outpatient surgery on March 09, 2022, to 
March 16, 2022. 
 
You asked the Plan to waive the cost sharing for outpatient surgery. You say that you already paid this bill, but 
you think the plan should. The Plan denied your request. The Plan says the cost sharing you are being charged 
is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $400 
copayment surgery services at outpatient hospital. Covered services include but are not limited to services in an 
emergency department or outpatient clinic, such as observation services or outpatient surgery. $400 + $129.97 
deductible = $529.97. Therefore, results in the total cost sharing amount of $529.97. You have been asked to pay a $129.97 deductible and $400 copayment for outpatient surgery. Outpatient 
surgery falls within the Outpatient hospital services 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 
cost sharing for outpatient surgery on March 09, 2022, to March 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rest home visit provided on April 21, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the rest home visit. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services rendered are not a covered benefit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 the rest home visit provided on April 21, 2022 by 
an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided on 
November 11, 2021. 
 
You asked the Plan to waive the copayment for the mammogram. You say that something was found during 
your screening mammogram and you were advised to have a second test. You say that you feel you should not 
be responsible for the second test since it was medically necessary. The Plan denied your request. The Plan 
says you have been charged the correct cost sharing amount. 
 
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 an $80 
copayment for a diagnostic mammography at an outpatient hospital.  
 
You have been asked to pay an $80 copayment for the mammogram. The mammogram falls within the 
Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 mammogram provided on November 11, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continued inpatient skilled nursing facility (SNF) care 
provided from January 15, 2022, through January 20, 2022. 
 
You asked the Plan to pay for the SNF care. You say that the skilled nursing facility care provided was 
medically necessary. The Plan denied your request. The Plan says the skilled nursing facility care provided was 
not medically necessary.  
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 pay for the continued SNF care. Our reviewer says 
that the continued inpatient skilled nursing facility care provided was not medically necessary. Our physician 
reviewer found that based on the documentation provided, you no longer qualified for SNF coverage. You did 
not have documented skilled nursing or skilled therapy needs. Daily skilled services were not required to 
establish a maintenance program or to prevent deterioration of your condition. As a practical matter, your care 
needs, custodial and intermittent, could been provided at a lower level of care. 
 
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 care have not been met. Therefore, we decided that the Plan does not 
have to pay for the continued inpatient skilled nursing facility (SNF) care provided from January 15, 2022, 
through January 20, 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 March 17, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that you have provided medical records to 
support the service billed. 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 March 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive or reduce the copayment for a lesion destruction procedure 
performed on May 20, 2022. 
 
You asked the Plan to waive or reduce the copayment for the lesion destruction. You say that this was a routine 
dermatology visit and you should not be charged $325 for this. The Plan denied your request. The Plan says 
you have been charged the correct cost sharing amount. 
 
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 $325 
copayment for surgery or services provided at an outpatient hospital.  
 
You have been asked to pay a $325 copayment for the lesion destruction. The lesion destruction is considered a 
surgical procedure and 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 or reduce the 
copayment for a lesion destruction procedure performed on May 20, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on May 
1, 2021. 
 
You asked the Plan to waive the copayment for an ER visit. You say that you should have this waived because 
you waited too long in the room, then left before being treated. The Plan denied your request. The Plan says the 
copayment applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for emergency care.  
 
You have been asked to pay the allowed amount of $70.01 which is less than the $90 copayment for an ER 
visit. An ER visit falls within the Emergency 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 emergency room visit provided on May 1, 2021.