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

 
We decided that the Plan does not have to pay for the outpatient treatment provided on October 25, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient treatment. You say that you obtained an authorization, but it had 
the wrong code on it. The Plan denied your request. The Plan says the rendering provider is an out-of-network 
provider and there was no referral from an in-network provider or an approved authorization. Also, the service 
rendered was not urgent or emergent. 
 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 outpatient treatment provided on October 25, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital outpatient clinic visit provided on October 21, 2021. 
 
You asked the Plan to pay for hospital outpatient clinic visit. The Plan denied your request. The Plan says the 
provider failed to obtain a prior authorization prior to services being rendered. 
 
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 hospital outpatient clinic visit provided on October 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nipple reconstruction surgery (19350). 
 
You asked the Plan to pre-approve the reconstructive surgery. You say that the procedure is medically 
necessary. The Plan denied your request. The Plan says this procedure is cosmetic in nature and non-covered. 
 
The Plan follows Medicare rules. Medicare rules say that Cosmetic surgery performed to treat psychiatric or 
emotional problems 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 pre-approve the reconstructive surgery. Our 
reviewer says that the procedure is not medically necessary. Our physician reviewer found the record indicates 
that the enrollee has gender dysphoria and is being treated for active mental illness. The records provided 
indicate that the request is for nipple reconstruction without mastectomies. The requested service is not to repair a non-functional or malformed body part. The service requested is 
cosmetic. Cosmetic surgery performed to treat psychiatric or emotional problems is not covered by rules. 
 
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 reconstructive surgery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve nipple reconstruction surgery (19350).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene analysis provided from October 5, 2021, to October 
7, 2021. 
 
You asked the Plan to pay for the gene analysis. The Plan denied your request. The Plan says the testing was 
not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the gene analysis. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has a diagnosis of neutropenia/pancytopenia. There was no specific clinical rationale for 
the requested studies. The review has determined that the requested gene analysis in this case was 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 the gene analysis have not been met. Therefore, we decided that the Plan does 
not have to pay for the gene analysis provided from October 5, 2021, to October 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for cataract surgery provided on January 13, 
2022, and January 27, 2022. 
 
You asked the Plan to waive the copayments for cataract surgery. You say that you are on a fixed income and 
currently going through cancer treatment with huge bills. You also say if you would have known you had to 
pay this you would have waited until after your treatments. 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 each in-network outpatient surgery at an outpatient hospital.  
 
 You have been asked to pay a $325 copayment for each cataract surgery on January 13, 2022, and January 27, 
2022. Cataract surgery 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 copayments 
for cataract surgery provided on January 13, 2022, and January 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on November 10, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the genetic testing 
was not ordered/approved by ordering provider. 
 
The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory 
tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary.  
 
We looked at the file and Medicare rules. The records in this case do not show that the lab services were 
ordered by the enrollee's treating physician. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the 
lab services provided on November 10, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit from December 
22, 2021 to December 23, 2021. 
 
You asked the Plan to waive the copayment for emergency room visit. You say that you went to the emergency 
room for chest pain, and you were admitted even though you didn't want to be. You say no other tests were 
done, so you see no reason to be charged. The Plan denied your request. The Plan says copayment 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 $90 
copayment for in-network and out-of-network emergency room services.  
 
You have been asked to pay $90 copayment for the emergency room visit. The emergency room 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 the 
emergency room visit from December 22, 2021 to December 23, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency ambulance transportation services (A0429, 
A0425) provided on May 22, 2021. You asked the Plan to pay for the ambulance transportation. You say that these services were necessary. The 
Plan denied your request. The Plan says these services were not medically necessary, and the claim was billed 
with modifier GY. Services that are billed with modifier GY do not meet the Medicare criteria for medical 
necessity and will be automatically denied. 
 
The Plan must follow Medicare rules. Medicare pays for ambulance services only when an emergency exists or 
when other means of transport would endanger the patients health. The Plan follows the same rules. Medicare 
rules also say that services billed with the GY modifier are statutorily excluded or do not meet the definition of 
a Medicare benefit. 
 
We looked at the file and Medicare rules. The services in this case were billed with modifier GY. Based on this 
information, we decided that Medicare rules for coverage of the ambulance transportation have not been met. 
Therefore, we decided that the Plan does not have to pay for the emergency ambulance transportation services 
(A0429, A0425) provided on May 22, 2021.
Appeal type: Drugs
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 Prolia is medically necessary. The Plan denied your 
request. The Plan says a trial of Oral Bisphosphonates and Zoledronic Acid is required before alternatives can 
be considered. There is no trial of Zoledronic Acid documented. 
 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 Prolia is 
not medically necessary. Our physician reviewer found the record does not show a trial of the plan preferred 
drugs or any reason they would be unsafe or ineffective for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is medically necessary for the member to receive 
IRF services. The Plan denied your request. The Plan says they recommended nursing home placement. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is not expected to make a significant progress functionally in a 
reasonable period of time in an IRF, and her needs are at a skilled nursing facility level.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation. 
 
You asked the Plan to pre-approve radiofrequency ablation. The Plan denied your request. The Plan says 
radiofrequency ablation is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve radiofrequency ablation. Our reviewer 
says that the requested radiofrequency ablation is not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the record indicates that the enrollee has sacroiliitis. There is 
insufficient literature to demonstrate that the requested service is safe and efficacious, as defined by Medicare 
rules for the enrollee's specific clinical condition. The record provided does not establish the medical necessity 
and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage 
criteria are not satisfied.  
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient treatment provided on March 23, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient treatment. You say that you were told that you did not need an 
authorization and you submitted the claim to get a not covered service denial. The Plan denied your request. 
The Plan says the rendering provider is an out-of-network provider and there was no referral from an in-
network provider or an approved authorization. Also, the service rendered was not urgent or emergent. 
 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 outpatient treatment provided on March 23, 
2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc injections (J7324). 
 
You asked the Plan to pre-approve Orthovisc. You say that Orthovisc is medically necessary. The Plan denied 
your request. The Plan says a trial of Durolane, Gelsyn-3, Synvisc, or Synvisc-One is required before 
alternatives can be considered. Synvisc has been approved. 
 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 Orthovisc. Our reviewer says that 
Orthovisc is not medically necessary. Our physician reviewer found the record does not show a trial of the plan 
preferred drugs or any reason they would be unsafe or ineffective 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 Orthovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Orthovisc injections (J7324).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a nerve destruction procedure performed on 
December 17, 2021. 
 
You asked the Plan to waive the copayment for the nerve destruction procedure. You say that at the time of 
surgery you were informed you would not have any copayment. 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 $260 
copayment for each outpatient hospital visit.  
 
You have been asked to pay a $260 copayment for the nerve destruction procedure. The nerve destruction 
procedure 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 a nerve 
destruction procedure performed on December 17, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided to the enrollee on October 18, 
2021. 
 
You asked the Plan to pay for the services. You say that you decided not to go to the hospital, due to long wait 
times and high cases of COVID-19. The Plan denied your request. The Plan says since there was no transport, 
these charges are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on October 18, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance services provided to the enrollee on 
October 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you suffer from a chronic illness. The 
Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that an admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says an IRF admission is not medically necessary for the enrollee. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management (99239) provided on 
September 1, 2021. 
 
You asked the Plan to pay for hospital discharge day management (99239). The Plan denied your request. The 
Plan says the submitted discharge summary does not support hospital discharge day management of more than 
30 minutes was performed. 
 
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, the CPT Code Manual definition of code 99239 is hospital discharge day management; more than 
30 minutes. 
 
  We find that CPT code 99239 is not supported in the medical record. Specifically, the medical records do not 
document the time spent on discharge management services as required by the CPT code billed. Based on this 
information, we decided that Medicare rules for coverage of hospital discharge day management (99239) have 
not been met. Therefore, we decided that the Plan does not have to pay for hospital discharge day management 
(99239) provided on September 1, 2021.