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

 
We decided that the Plan does not have to pre-approve use of Gel-One. 
 
You asked the Plan to pre-approve Gel-One. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan requires 
a trial of Orthovisc, Supartz FX, Durolane, Monovisc, or Synvisc-One before it will approve Gel-One. 
 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 Gel-One. Our reviewer says that the 
enrollee does not meet the Medicare criteria for a step therapy exception for Gel-One. Our physician reviewer 
found the enrollee has not tried the Plan's preferred drugs of Orthovisc, Supartz FX, Durolane, Monovisc, or 
Synvisc-One. The record does not show that these drugs 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 Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Gel-One.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral evaluation (D0150), prophylaxis (D1110), bitewing 
x-rays (D0274), and panoramic x-ray (D0330) provided on September 30, 2021. 
 
You asked the Plan to pay for the dental services. You say that you requested a list of in network dentists from 
the plan. You say that you did not receive one. You say that you found a dentist near your home. You also say 
that you were advised by the office staff that they accepted your plan. The Plan denied your request. The Plan 
says dental services received out of network are not covered. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the oral 
evaluation (D0150), prophylaxis (D1110), bitewing x-rays (D0274), and panoramic x-ray (D0330) provided on 
September 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Lidocaine patch.
You asked the Plan to pre-approve Lidocaine patch. You say that the requested drug is a necessity for your care. 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 Lidocaine patch.
Benefits for Lidocaine patch 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gradient compression wraps identified with code 
A6545. 
You asked the Plan to pre-approve the compression wraps. You say that the item is medically necessary for 
recuperating. The Plan denied your request. The Plan says the enrollee does not have a qualifying wound. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6545 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The file shows that the compression garments were requested to treat the enrollees lymphedema. The record 
does not show that the enrollee has open venous stasis ulcers or a qualifying wound. This means that the 
enrollee does not have a medical condition for which compression stockings can be covered or paid for by 
Medicare. Therefore, we decided that the Plan does not have to pre-approve gradient compression wraps 
identified with code A6545.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and coinsurance for a diagnostic colonoscopy 
provided on September 8, 2021. 
 
You asked the Plan to waive the deductible and coinsurance for the colonoscopy. You say that you had this 
procedure done before and you did not have to pay anything. The Plan denied your request. The Plan says the 
correct amount was applied to your deductible and the correct cost sharing amount was charged. 
 
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 $300 deductible which applies to certain items and services. 
 
Your contract with the Plan says that you must pay a 10% coinsurance for each surgery or service provided at 
an outpatient hospital facility, after the deductible is met.   
The item or service you asked the Plan to waive the deductible and coinsurance for falls within the Outpatient 
Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $300 
deductible which applies certain items and services. This cost sharing is a contractual obligation that had not 
been fully met at the time the colonoscopy was received on September 8, 2021. The file shows that $10.68 was 
applied first, which then met your deductible. The 10% coinsurance was then applied to the remaining 
$2,343.28, for a total of $234.33. 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 a 
diagnostic colonoscopy provided on September 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral exam (D0120) and cleaning (D1110) provided on 
November 18, 2021. 
 
You asked the Plan to pay for the dental services. You say that you feel you should not be charged for your 
second teeth cleaning. You also say that you are entitled to 2 cleanings a year. The Plan denied your request. 
The Plan says there is a $1,500 maximum allowance for covered dental services. The Plan also says that the 
maximum allowance has been exceeded prior to processing this claim. 
 
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 and the services are listed as covered, 
the $1,500 maximum allowance has been exhausted. The record shows that the Plan paid $241 for services 
received on August 9, 2021, $81 for services received on August 10, 2021, $739 for services received on 
August 16, 2021, and $439 for services received on August 18, 2021. $241 + $81 + $739 + $439 = $1,500. The 
Evidence of Coverage also states that you are responsible for any amount over and above the allowance 
amount. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120) and cleaning 
(D1110) provided on November 18, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for an inpatient hospital stay provided from September 4, 2021, to September 8, 2021.
You asked the Plan to reduce the copayment for an inpatient hospital stay. You say that you should have only been in the hospital for two days. You also say that you stayed longer for a procedure that did not end up happening. 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 1-5 of inpatient hospital care. The contract also says there is no copayment after day 5.
You received inpatient hospital services from September 4, 2021, to September 8, 2021. You have been asked to pay a total of $1,100 for an inpatient hospital stay ($275 per day x 4 days= $1,100 copayment). There is no charge for the day of discharge. 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 reduce the copayment for an inpatient hospital stay provided from September 4, 2021, to September 8, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy visits provided from 
August 18, 2021, to September 27, 2021. 
 
You asked the Plan to waive the copayment for physical therapy visits. You say that you had three physical 
therapy visits but should not have been charged. 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 $35 
copayment for each physical therapy service.  
 
You had physical therapy visits on August 18, 2021, August 27, 2021, and September 27, 2021. You have been 
asked to pay a $35 copayment for each physical therapy visit which is a total of $105 ($35 for each visit x 3 visits = $105). Physical therapy visits fall within the Outpatient Rehabilitation 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 physical therapy visits provided from August 18, 2021, to 
September 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive coinsurance for a knee immobilizer provided on June 4, 2021. 
 
You asked the Plan to waive coinsurance for a knee immobilizer. You say that you were given it while in the 
emergency room and were never told there would be a patient responsibility. You also say that it was awkward, 
and no one showed you how to use it. 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 prosthetic devices and related supplies, including braces. 
 
The record shows you received the immobilizer. You have been asked to pay $14.43, which is 20% of the 
allowed amount for a knee immobilizer ($72.17 allowed amount x 20% coinsurance = $14.43). A knee immobilizer 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 coinsurance for a knee immobilizer provided on June 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transforaminal epidural steroid injection (TFESI). 
 
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 ESIs are 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 you have a history of chronic low back 
pain after a motor vehicle accident. The pain is rated at eight out of 10 with radiation down to your left leg and 
foot. You have been treated with medical therapy including opiates, physical therapy, and a home exercise 
program. The requested TFESI is for at more than two nerve root levels. This service is not covered per the 
Medicare 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a transforaminal epidural steroid injection (TFESI).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid (V5257), provided on August 20, 2020.
You asked the Plan to pay for the hearing aid. You say that the item is medically necessary. The Plan denied your request. The Plan says there is no coverage if Hearing Aids or related services are received from an out-of-network Provider and the hearing benefit is not covered if the services are not registered in advance.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when purchased through a network provider and registered with the Plan first. We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aid have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aid (V5257), provided on August 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on November 
8, 2021. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that you feel that you should not 
be charged for these services. 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 $50 
copayment for each urgent care visit.  
 
You have been asked to pay a $50 copayment for the urgent care visit. The 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 provided on November 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesiology services (procedure code 64999) provided to the enrollee on August 17, 2021.
You asked the Plan to pay for the services. You say that the claim was denied as a duplicate, but it was found not to be a duplicate. The Plan denied your request. The Plan says this was billed without a description of the services.
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 64999 is "Unlisted procedure, nervous system." 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found CPT 64999 was billed to the health plan on August 17, 2021. Based on the claim history documents submitted as part of this review, CPT 64999 was billed and processed on the Claim associated with Check/Remit dated 9/26/2021. It was paid at $0.00. Based on this information, CPT 64999 billed on Claim # 
associated with Check/Remit XXXXXXXXXXX555 would be a duplicate submission of the same code and is not eligible for reimbursement. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesiology services (procedure code 64999) provided to the enrollee on August 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 27, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that Medicare does not require prior authorization and 
you were unaware that the enrollee had the Plan as a primary payer. The Plan denied your request. The Plan 
says there was no referral from the enrollee's primary care physician to see an out-of-network provider and the 
services provided were 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 an office visit provided on September 27, 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 an immunization provided on October 15, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for an immunization. You say that services were provided to the enrollee so payment 
should be made. The Plan denied your request. The Plan says there was no referral from an in-network provider 
to receive this service from an out-of-network provider. 
  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 an immunization provided on October 15, 2021, 
by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional inpatient detoxification care. 
 
You asked the Plan to pre-approve additional inpatient detoxification care. You say that the requested inpatient 
detoxification care is medically necessary. The Plan denied your request. The Plan says the requested inpatient 
detoxification care 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 inpatient detoxification care. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found you have improved significantly and continue to improve but you are still 
experiencing mild withdrawal symptoms of nausea, shakes, and sweating. Vitals are stable, however, there was 
no report of hallucinations, mania, or psychosis, and medications were tolerated without complications with 
treatment. Due to you tolerating treatment and being quite stable, additional treatment of symptoms can be 
safely administered 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 inpatient detoxification care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional inpatient detoxification care.