Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ophthalmology services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve Ophthalmology services. You say that you are requesting to continue to see 
a certain provider because she feels that the health plan does not have sufficient staff to accommodate her type 
of specialty. 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 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 
Ophthalmology services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an aspiration and/or injection of fluid from 
a large joint on December 8, 2021. 
 
You asked the Plan to waive the copayment for an aspiration and/or injection of fluid from a large joint. You 
say that this service seemed to be a rather standard procedure to treat your hip and lower back pain with an 
injection, and you asked why this was not covered by your Plan? The Plan denied your request. The Plan says 
you were 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 $350 
copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center, 
including but not limited to hospital or other facility charges and physician or surgical charges.  
 
You have been asked to pay $249.54, which is less than the $350 copayment for an aspiration and/or injection 
of fluid from a large joint. An aspiration and/or injection of fluid from a large joint fall within the outpatient 
surgery and other medical 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 an aspiration and/or injection of 
fluid from a large joint on December 8, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) provided on October 18, 2021. 
 
You asked the Plan to pay for the office visit. You say that this service was billed correctly with a modifier and 
separate payment should be made. The Plan denied your request. The Plan says a National Correct Coding 
Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 43239 and 99214. This PTP edit has a 
modifier indicator of 1, meaning modifiers associated with NCCI are allowed. Code 99214 was billed with modifier 25 to bypass this edit; however, the documentation does not support that modifier 25 was used 
appropriately in this case. 
 
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 99214 is a column II code to column I code 43239; however, 99214 
was billed with a modifier.  
 
We asked our coder 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 office visit. Our reviewer says that the use of modifier 25 
is not supported for separate payment in this case. Our reviewer found there is no documentation that supports 
billing modifier 25 to indicate that CPT code 99214 is separate and distinct from code 43239. The office visit's 
documentation is primarily related to the enrollee's endoscopy report, and the recommendations at the 
conclusion of the office visit are essentially identical to the recommendations reported for the endoscopy 
procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not 
have to pay for the office visit (99214) provided on October 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (code 99204) and the electrical stimulation 
(code G0283) you received from a chiropractor on November 9, 2021. 
 
You asked the Plan to pay for the office visit and the electrical stimulation. You say that you are trying to avoid 
back surgery.  You said that the chiropractor would not do the manual manipulation without the office visit and 
the electrical stimulation was done to relax the muscles before the manipulation. The Plan denied your request. 
The Plan says these are not covered services when provided by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.   
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the office visit (code 99204) and the electrical stimulation (code G0283) 
you received from a chiropractor on November 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an inpatient mental health hospital stay 
provided from December 10, 2021, to December 23, 2021. 
 
You asked the Plan to reduce the copayment for an inpatient mental health hospital stay. You say that it is 
unfair to impose a maximum cost share for inpatient hospital stay but not on mental health inpatient hospital 
stays. You also say that you were expecting to only pay $725 after paying the copayment for your mother's July 
hospital stay. 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). The enrollees contract with the Plan clearly says that enrollees must pay a $325 copayment per day for days 1-4 for an inpatient mental health hospital stay. The contract also 
says that there is a $0 copayment for days 5-90. The Plan contract says that cost sharing is charged for each 
inpatient stay. 
 
The record shows this claim was approved. According to the EOC, cost sharing is charged for each inpatient 
mental health hospital stay. The enrollee has been asked to pay a total of $1,300, which is a $325 copayment 
per day for days 1-4 for an inpatient mental health hospital stay ($$325 copayment x 4 days = $1,300). An 
inpatient mental health hospital stay falls within the Inpatient Mental Health 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 reduce the copayment for an inpatient mental health hospital stay provided from 
December 10, 2021, to December 23, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Evenity. 
 
You asked the Plan to pre-approve Evenity. You say that the enrollee tried oral bisphosophonates but had bad 
side effects. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, 
because the Plan requires a trial of Forteo before it will approve Evenity. 
 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 Evenity. Our reviewer says that the 
enrollee does not meet the Medicare criteria for a step therapy exception for Evenity. Our physician reviewer 
found the enrollee has not tried and failed the Plan's preferred drug of Forteo. The record does not show that 
this drug would likely be less effective and/or 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 Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve use of Evenity.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for blood work services provided on December 21, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for blood work services. You say that the services were medically necessary The 
Plan denied your request. The Plan says the services were provided out-of-network and were not 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 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 blood work services provided on December 21, 
2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
December 16, 2021, to December 28, 2021. 
 You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you reached your out-
of-pocket limit and should not have to pay for this service. 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 your in-network out-
of-pocket maximum is $4,800. Your contract with the Plan also clearly says that you must pay a $250 
copayment each day for days 1 to 7 for Medicare-covered in-network hospital care.  
 
You have been asked to pay $232.18 for an inpatient hospital stay. After this claim was submitted, you have 
reached your in-network out-of-pocket maximum. An inpatient hospital stay 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 December 16, 2021, to December 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer (J1439). 
 
You asked the Plan to pre-approve Injectafer. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, Infed (iron dextran) 
and Venofer (iron sucrose). 
 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 Injectafer. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the medical records provided there is no 
indication that the patient has tried and failed the required drugs, Infed and Venofer. The reviewer found that 
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 Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer (J1439).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided November 
26, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you arrived at the hospital 
and were sent home after you received a false positive COVID-19 test. You say that you should not have to pay 
due to a fault that was not your own. The Plan denied your request. The Plan says you have been charged the 
correct copayment 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 $75 
copayment per day for a Medicare-covered stay at a network hospital for days 1 to 5.  You have been asked to pay a $75 copayment for inpatient hospital care. Inpatient hospital care 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 inpatient 
hospital care provided November 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) of the 
lumbar spine provided on February 3, 2022. 
 
You asked the Plan to waive the copayment for an MRI. You say that you are on a fixed income and this cost is 
a burden. 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 $350 
copayment for diagnostic radiology services, including MRIs.  
 
You have been asked to pay the allowed amount of $275.09, which is less than the $350 copayment for an 
MRI. An MRI 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 magnetic resonance imaging (MRI) of the 
lumbar spine provided on February 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an infliximab injection, chemotherapy 
administration, and a specialist office visit provided on December 9, 2021. 
 
You asked the Plan to waive the cost share for an injection, chemotherapy administration, and a specialist 
office visit. You say that the cost share was applied to your 2022 out-of-pocket. 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 20% 
coinsurance for Part B drugs. The Plan contract also says that enrollees must pay a $45 specialist office visit. 
 
The record shows services received on December 9, 2021, were applied to your 2021 out-of-pocket amount. 
You have been asked to pay 20% coinsurance of the allowed amounts for an injection and chemotherapy 
administration. An injection and chemotherapy administration falls within the Medicare Part B Prescription 
Drugs benefit category.  
 
Code Allowed Amount 20% Coinsurance 
Q5103 $2,002.50 $400.50 
96413 $141.21 $28.24 
96415 $30.12 $6.02 
 
You have been asked to pay a $45 copayment for a specialist office visit. A specialist office visit falls within 
the Physician/Practitioner Services, Including Doctors Office Visits benefit category. You have been asked to 
pay a total of $479.76 ($400.50 coinsurance + $28.24 coinsurance + $6.02 coinsurance + $45 copayment = 
$479.76). 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 share for an infliximab injection, chemotherapy 
administration, and a specialist office visit provided on December 9, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve high-intensity focused ultrasound (HIFU) treatment. 
 You asked the Plan to pre-approve HIFU. You say that the requested service has comparable oncologic 
efficacy with minimal morbidity. The Plan denied your request. The Plan says the requested service is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that whole gland HIFU is considered medically necessary 
as a local treatment for recurrent prostate cancer (PCa) following radiation therapy (RT). 
 
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 HIFU. Our reviewer says that the 
requested HIFU is not medically necessary. Our physician reviewer found HIFU has not been compared with 
other standard treatment approaches in randomized trials, nor is it included in guidelines for the initial 
management of men with prostate cancer. The reviewer found that high-intensity focused ultrasound (HIFU) is 
recommended by the NCCN Guidelines, category 2B, for patients with local recurrence without evidence of 
metastases after treatment with prior radiation. The provided documentation does not indicate that the enrollee 
has had prior treatment. Therefore, the reviewer found that the requested HIFU 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 HIFU have not been met. Therefore, we decided that the Plan does not have to 
pre-approve high-intensity focused ultrasound (HIFU) treatment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PureWick female catheter system. 
 
You asked the Plan to pre-approve a PureWick catheter. You say that the requested item is a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for coverage for durable medical equipment 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that catheters are not covered because they are 
considered a nonreusable supply. 
 
While a catheter may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a PureWick female catheter system.
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 11, 2020, to August 17, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that out-of-network services 
should still apply towards your maximum out-of-pocket amount. 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 $275 copayment per day for days 1-6 for an inpatient hospital stay. The contract also says there is a $0 copayment 
after day 6. The Plan contract also says that the must you will have to pay out-of-pocket for in-network covered 
services is $3,400. 
 
The record shows this claim was approved, and a cost sharing amount applies to your out-of-network hospital 
stay from August 11, 2020, to August 17, 2020. You have been asked to pay a total of $1,650, which is a $275 
copayment per day for days 1-6 for an inpatient hospital stay ($275 copayment x 6 days = $1,650). An inpatient 
hospital stay 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 11, 2020, to August 17, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xanax for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
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 Xanax for the enrollee.  
 
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.