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

 
We decided that the Plan does not have to waive the copayment for an urgent care visit on November 16, 2021. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that the provider told you there 
would not be a copayment for this visit. Therefore, you do not feel you should pay this copayment. 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 $25 
copayment for urgently needed services.  
 
You have been asked to pay a $25 copayment for an urgent care visit. An urgent care visit falls within the 
Urgently Needed 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 copayment for an urgent 
care visit on November 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on March 23, 
2022. 
 
You asked the Plan to waive the copayment for the office visit. You say that this copay is a hardship. Your 
primary care physician was not available to see you, but due to your condition you had to go. 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 $40 
copayment per visit with a specialist.  
 
You have been asked to pay a $40 copayment for an office visit with a specialist. The office visit falls within 
the Physician/Practitioner Services, Including Doctors Office Visits 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 office visit provided on March 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11721 billed for date of service January 19, 
2022. 
 You asked the Plan to pay for procedure code 11721. You say that these services were medically necessary and 
provided in good faith. The Plan denied your request. The Plan says payment for code 11721 is bundled into 
payment for code 11055. 
 
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 11721 
is a column II code to column I code 11055. 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 11721 billed for date of service January 19, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on December 7, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately paid. 
 
The Plan must follow Medicare rules. Medicare rules say that additional medical or surgical services are 
included in the global surgical package. 
 
We looked at the file and Medicare rules. The services billed on December 7, 2021 were billed with the 90-day 
global surgical period for major procedure 14301 billed on November 29, 2021. The services were related to 
the major procedure and payment is included in the global surgical package. Therefore, we decided that the 
Plan does not have to pay for the surgical services rendered on December 7, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on October 24, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that your oxygen level was in the 80s. You say 
that you called the ambulance as that was the only choice you had. You also say that you did not go to the 
emergency room. The Plan denied your request. The Plan says since there was no transport provided, there is 
no payable service. 
 
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 24, 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 the ambulance response and treatment, no 
transport, (A0998) provided on October 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression and cold therapy system you 
received on July 27, 2021. 
 
You asked the Plan to pay for the pneumatic compression and cold therapy system. You say that you should be 
reimbursed for this device. The Plan denied your request. The Plan says this provider is not Medicare-eligible. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the pneumatic compression and cold 
therapy system you received on July 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says Keytruda is not medically necessary for the enrollee. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Keytruda. Our reviewer says that the 
enrollee does not meet the Medicare criteria for Keytruda. Our physician reviewer found Keytruda is not Food 
& Drug Administration (FDA) approved for the enrollee's diagnosis of stage IIIA non-small cell lung cancer 
with no definitive diagnosis of metastatic disease or EGFR/ALK tumor aberration status and no designation 
that the enrollee is not a candidate for definitive chemoradiation. The requested use of Keytruda is not 
supported by one of the major drug compendia or by clinical research appearing in a Medicare-approved 
medical journal. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Keytruda.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
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 services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that Botox is covered when specific criteria are met. 
 
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 migrained headaches. 
Botox is indicated for the prophylaxis of headaches in adult patients with chronic migraine (at least 15 days per 
month with headache lasting 4 hours a day or longer). The provided records do not document the enrollee has 
been having migraine headaches at least 15 days per month with headache lasting 4 hours a day or longer. The 
services are therefore 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 Botox.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray provided on April 26, 2022. 
 
You asked the Plan to waive the copayment for an x-ray. You say that you should not have a copayment 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 you must pay a $50 
copayment for outpatient diagnostic tests.  
 
You have been asked to pay a $50 copayment for an x-ray. An x-ray falls within the outpatient diagnostic tests 
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 x-ray provided on April 26, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and coinsurance for out-of-network (OON) 
inpatient hospital care provided from March 31, 2022, to April 6, 2022. 
 
You asked the Plan to waive the deductible and coinsurance for the OON inpatient care. You say that you were 
not aware the facility was not in-network. The Plan denied your request. The Plan says the correct deductible 
and coinsurance was applied. 
 
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 $750 deductible which applies to certain items and services. 
 
Your contract with the Plan also clearly says that you must pay a 40% coinsurance for each out-of-network 
inpatient admission. 
 
The out-of-network inpatient care falls within the Inpatient Hospital Care benefit category. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is $750 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 inpatient care was received from March 31, 2022, to April 6, 2022.  
 
The file shows that the Plan verified the facility is not a network facility. At the time of admission, you had a 
total of $368.31 remaining to meet your deductible. This amount is applied first. Once the deductible was met, 
the 40% coinsurance was applied to the remaining allowed amount of $16,408.09 ($$16,776.40 allowed 
amount - $368.31 deductible = $16,408.09). 40% of this amount is $6,563.24 ($16,408.09 remaining amount x 
40% coinsurance = $6,563.24). The total for the services is $6,931.55. 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 
deductible and coinsurance for out-of-network (OON) inpatient hospital care provided from March 31, 2022, to 
April 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oxygen concentrator rental (E1390) provided December 25, 
2021. 
 
You asked the Plan to pay for the oxygen concentrator. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the number of units allowable for this service has already been paid. 
 
The Plan must follow Medicare rules. Medicare rules say that reimbursement for oxygen equipment is limited 
to 36 monthly rental payments. 
 
We looked at the file and Medicare rules. 36 units were already paid for this service. Additional units are non-
covered. Based on this information, we decided that Medicare rules for coverage of the oxygen concentrator 
have not been met. Therefore, we decided that the Plan does not have to pay for oxygen concentrator rental 
(E1390) provided December 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a Synvisc injection provided on  
October 13, 2020. 
 
You asked the Plan to waive the coinsurance for a Synvisc injection. You say that the Plan could not provide a 
copy of the 2020 Evidence of Coverage (EOC) proving the coinsurance amount. The Plan denied your request. 
The Plan says the coinsurance 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). The Plan provided us with a copy of the 2020 EOC. Your contract 
with the Plan clearly says that you must pay a 20% coinsurance for in-network Medicare Part B drugs. The 
allowed amount of the claim is $490.46, resulting in a coinsurance amount of $98.09 ($490.46 x 20%). 
 
 You have been asked to pay $98.09 for a Synvisc injection. Synvisc injections fall within the Medicare Part B 
Prescription Drugs 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 coinsurance for a Synvisc injection 
provided on October 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an ankle and foot orthosis (brace) 
provided on January 11, 2022. 
 
You asked the Plan to waive the coinsurance for the foot brace. You say that the brace did not fit properly and 
you could not use it. The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for each prosthetic device and related supplies, including braces.  
 
You have been asked to pay $30.52, which is 20% of the allowed amount for the foot brace ($152.60 allowed 
amount x 20% coinsurance = $30.52). The foot brace falls within the Prosthetic Devices and Related 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 coinsurance for an ankle and foot orthosis 
(brace) provided on January 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on March 11, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that as a result of an emergency 
situation, you did not have an opportunity to obtain an authorization prior to the treatment. The Plan denied 
your request. The Plan says services from non-participating providers are not covered unless preauthorized. 
 
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 subsequent nursing facility care provided on 
March 11, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341) and bone 
replacement graft for ridge preservation (D7953). 
 
You asked the Plan to pre-approve the dental services. You say that you would like these services covered. The 
Plan denied your request. The Plan says your benefit for the periodontal scaling and root planing has already 
been exhausted, and the bone replacement graft is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the periodontal scaling and root planing was exhausted on date of service July 15, 2021. 
The bone replacement graft is not among those services covered under your dental benefits.  Therefore, we 
decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341) and bone 
replacement graft for ridge preservation (D7953).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on March 30, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that as a result of an emergency 
situation, you did not have an opportunity to obtain an authorization prior to the treatment. The Plan denied 
your request. The Plan says services from non-participating providers are not covered unless preauthorized. 
 
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 subsequent nursing facility care provided on 
March 30, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Farxiga 10MG tablet. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says Farxiga is a self-administered drug and does not fall under Part B coverage. 
 
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 Farxiga 10MG tablet.  
 Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia 
 
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 osteoporosis. She has 
not tried and failed the Plan's required drug, zoledronic acid. The records do not show that the required drug 
would be contraindicated or less effective; therefore, Prolia 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 Prolia
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Humira. 
 
You asked the Plan to pre-approve Humira. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Humira.  
 
  Benefits for Humira may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.