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

 
We decided that the Plan does not have to pay for the laboratory services provided on July 29, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the services were performed by a 
participating provider and the referring physician deemed it medically necessary. The Plan denied your request. 
The Plan says both the rendering and referring providers are out-of-network providers and there was no 
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 laboratory services provided on July 29, 2021, 
by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that the requested Botox is medically necessary. The Plan 
denied your request. The Plan says the enrollee must try and fail 1 urinary anticholinergic (e.g., oxybutynin, 
trospium) AND Myrbetriq. 
 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 Botox. Our reviewer says that the Plan's 
step therapy criteria have not been met. Our physician reviewer found Oxybutynin was tried and failed. 
Myrbetriq has not been tried and failed. The documentation does not support that Myrbetriq would likely be 
less effective, and/or would likely have adverse effects for the enrollee in this case. The documentation does 
not support that the enrollee is actively receiving the affected medication. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (0037U). 
 
You asked the Plan to pre-approve the genetic testing. You say that the service is medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 the genetic testing. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found molecular testing is not reasonable or necessary in this case. National Comprehensive Cancer 
Network guidelines do not support the use of genetic testing in this case. 
 
 
 
 
 
 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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve genetic testing (0037U).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an anticoagulant management for a patient 
taking warfarin (93793) provided on June 24, 2021. 
 
You asked the Plan to waive the copayment for an anticoagulant management for a patient taking warfarin. 
You say that you should not pay for this. You also say that it is a blood check, and it should be covered. 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 $50 
copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse 
practitioner or physician's assistant or other non-physician health care professionals in a specialist's office.   
You have been asked to pay a $50 copayment for an anticoagulant management for a patient taking warfarin. 
an anticoagulant management for a patient taking warfarin falls within the services obtained from a specialist, 
or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician 
health care professionals in a specialist's office 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 anticoagulant management for a patient taking warfarin (93793) provided on June 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interrogation device evaluation provided on November 1, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the interrogation device evaluation. You say that you would like the 
documentation to be reviewed and the claim to be reprocessed for payment. 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 interrogation device evaluation provided on 
November 1, 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 inpatient mental health services provided 
from December 13, 2021, to December 20, 2021. 
 
You asked the Plan to waive the copayment for inpatient mental health services. You say that you think that 
you were charged for four visits to a mental hospital, and you did not need that. You also say you were needing 
physical assistance, but the police took you to the mental hospital instead against your will. 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 $295 
copayment per day for days 1 to 6 for inpatient mental health care.  
 
You have been asked to pay a $295 copayment per day for days 1 to 6 for inpatient mental health services, 
which is a total of $1,770 ($295 x 6 = $1,770). Inpatient mental health services fall within the inpatient mental 
health 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 mental health 
services provided from December 13, 2021, to December 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Domiciliary care provided on December 6, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for Domiciliary care. You say that you are requesting reconsideration of denial of 
claim. The Plan denied your request. The Plan says this provider is not an in-network provider and We have 
also determined that these services are not urgent or emergent, nor were they approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
  
The requested provider in this case is not a network provider with the Plan. The Plan 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 Domiciliary care provided on December 6, 2021 
by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a blepharoplasty (15823). 
 
You asked the Plan to pre-approve a blepharoplasty (15823). You say that you went in for an eye exam and 
found out you need surgery because of droopy eyes. The Plan denied your request. The Plan says the denial is 
upheld as the member's vision did not improve by 30 percent or higher and only improved by 7 degrees with 
taping. 
 
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 a blepharoplasty (15823). Our reviewer 
says that the elements of the coverage criteria are not satisfied, and the requested service is not recommended. 
Our physician reviewer found that the record does not indicate that there is significant interference with vision 
or superior or lateral visual field. The record provides photographs which are inconsistent with the reported 
margin to reflex distance. The records as provided are insufficient to establish that the coverage criteria are 
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 a blepharoplasty (15823) have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a blepharoplasty (15823).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an injection of a diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), lumbar or sacral; third and any additional level (64495) provided on November 16, 2021, by an out-of-
network (OON) provider. 
 You asked the Plan to pay for an injection of a diagnostic or therapeutic agent, paravertebral facet 
(zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or 
sacral; third and any additional level. You say that this code was denied as the decision was based on a local 
coverage determination (LCD). The Plan denied your request. The Plan says the non-urgent services are not 
authorized because this provider is a non-network provider with the Plan, and the servicing provider is listed as 
the referring provider. The Plan also says that the Plan requires utilization of network providers when possible 
and available, and requires authorization for certain services. The Plan also says that no necessity for an out-of-
network provider, such as an urgent or emergency situation has been documented, and that there is an on-line 
Medicare site to verify eligibility. The Plan also says that any and all codes on this claim are denied, and in 
addition, previous payments to these providers for this member are subject to recoupment. 
 
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 injection of a diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), lumbar or sacral; third and any additional level (64495) provided on November 16, 2021, by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an office visit provided on August 4, 2021. 
 
You asked the Plan to waive the deductible for an office visit. You say that you received valid treatment from 
your primary physician, and it should be paid. The Plan denied your request. The Plan says the enrollee did not 
meet their deductible prior to the date of service. Therefore, the proper deductible was assessed for the service 
provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $110 deductible which applies to this is the amount you have to pay 
out-of-pocket before we will pay our share for your covered medical services. Prior to the date of service, the 
enrollee paid $0 of the $110 deductible. The total amount allowed for the date of service was $94.12 which is 
less than the $110 deductible. Therefore, the $94.12 was charged towards the $110 deductible. 
 
  The item or service you asked the Plan to waive the deductible for falls within the benefit category this is the 
amount you have to pay out-of-pocket before we will pay our share for your covered medical services. The 
Plan has followed Medicare rules by clearly disclosing in the contract that there is a $110 deductible which 
applies to this is the amount you have to pay out-of-pocket before we will pay our share for your covered 
medical services. This cost sharing is a contractual obligation that had not been met at the time an office visit 
was received on August 4, 2021. Therefore, we decided that the Plan does not have to waive the deductible for 
an office visit provided on August 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and 
pelvis with contrast (74177). 
 
You asked the Plan to pre-approve a CT scan of the abdomen and pelvis with contrast. You say that a CT scan 
is medically necessary. The Plan denied your request. The Plan says a CT scan is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 a CT scan of the abdomen and pelvis 
with contrast. Our reviewer says that a CT scan of the abdomen and pelvis with contrast is not medically 
necessary. Our physician reviewer found you have a history of hepatitis A for which you have received acute 
therapy. There is no ultrasound in the records submitted to evaluate the liver and presence or absence of 
ascites. The diagnosis of hepatitis A is not associated with an elevated risk of Hepatocellular carcinoma (HCC). 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CT scan of the abdomen and pelvis with contrast have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the 
abdomen and pelvis with contrast (74177).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 6, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed this service correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on August 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 
18, 2021. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 18, 
2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy to be provided by a 
participating provider. 
 
You asked the Plan to pre-approve physical therapy. You say that additional physical therapy is medically 
necessary. The Plan denied your request. The Plan says additional physical therapy is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 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 physical therapy. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has functional range of motion and can continue an 
independent home exercise program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve additional physical therapy to be provided by a participating provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an arteriovenous anastomosis provided on 
October 27, 2021. 
 
You asked the Plan to waive the copayment for an arteriovenous anastomosis. 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 $250 
copayment for outpatient surgery at an ambulatory surgical center.  
 
You have been asked to pay a $250 copayment for an arteriovenous anastomosis. An arteriovenous 
anastomosis 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 an arteriovenous anastomosis provided on October 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and deductible for Practitioner Services on 
July 12, 2021 to July 27, 2021. 
 
You asked the Plan to waive the copayment and deductible for Practitioner Services. You say that you had met 
your deductible. The Plan denied your request. The Plan says the cost share amount applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $5 
copayment, a $500 deductible for Practitioner Services. At the time this claim was processed, $167.33 of the 
$500 deductible had been met. The allowed amount of the two claims from July 27, 2021 is $270.19, resulting 
in a deductible amount of $270.19. In addition to the $5 copayment from July 12, 2021 your total cost-sharing 
amount is $275.19. 
 You have been asked to pay a $5 copayment, a $500 deductible for Practitioner Services. Practitioner Services 
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 and deductible for Practitioner Services on July 12, 2021 to July 27, 
2021.