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

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
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 right knee unilateral 
primary osteoarthritis. She has not tried and failed the Plan's required drugs, Supartz FX or Orthovisc. The 
records do not show that the required drugs would be contraindicated or less effective; therefore, Euflexxa 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 Euflexxa.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient treatment services provided on 
January 17, 2020, and January 24, 2020. 
 
You asked the Plan to waive the copayment for outpatient treatment services. You say that you were under the 
impression that the copayment for this treatment was a one-time fee. The Plan denied your request. The Plan 
says this cost sharing was charged correctly. 
 
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 $360 
copayment per visit for outpatient hospital services.  
 
You have been asked to pay a $720 copayment for outpatient treatment services ($360 x 2). This item/service 
falls within the outpatient hospital 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 outpatient treatment services provided on January 17, 2020, and January 24, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (81529) provided on March 7, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that this claim should be paid. The Plan denied your 
request. The Plan says services are not covered when provided OON. 
 
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 lab services (81529) provided on March 7, 
2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve durable medical equipment purchase using SSBCI 
benefits. 
 
You asked the Plan to pre-approve the durable medical equipment. You say that you are at high risk due to 
your diabetes and high blood pressure together. The Plan denied your request. The Plan says in order to 
approve this request a signed attestation from your provider that shows you meet the program criteria must be 
received. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the durable medical equipment have 
been met. additional records was required and requested from the provider without success.. Therefore, we 
decided that the Plan does not have to pre-approve durable medical equipment purchase using SSBCI benefits.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Azacitidine (J9025). 
 
You asked the Plan to pre-approve Azacitidine. You say that this service is medically necessary. The Plan 
denied your request. The Plan says Original Medicare is liable for payment for this service. 
 The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve Azacitidine as part of a clinical trial. The Plan does not cover 
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-
approve Azacitidine (J9025).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory tests provided on September 09, 
2022. 
 
You asked the Plan to waive the copayment for laboratory tests. You say that you disagree with the copaymet. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $15 
copayment for outpatient diagnostic tests/Medicare-covered laboratory tests. 
 
You have been asked to pay a $15 copayment for laboratory tests. This item/service falls within the outpatient 
diagnostic tests/Medicare-covered laboratory 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 laboratory tests provided on September 09, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee needs more rehab before going home. 
 The Plan denied your request. The Plan says based on Medicare guidelines, the requested SNF services do not 
meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient mental health care services 
provided on July 15, 2022, to July 21, 2022. 
 
You asked the Plan to waive the copayment for inpatient mental health care services. You say that you are 
disputing the share cost. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $200 
copayment per day for days 1 to 6 for inpatient mental health care. This inpatient mental health care stay lasted 
6 days, resulting in a copayment amount of $1,200 ($200 per day for 6 days = $1,200). 
 
You have been asked to pay $200 copayment per day for days 1 to 6 for inpatient mental health care services. 
This item/service falls 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 care services provided on July 15, 2022, to July 21, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transport provided on August 13, 2022. 
 
You asked the Plan to pay for the ambulance transport.. You say that this should be covered as there was no 
other option as you had a broken hip and were over medicated. The Plan denied your request. The Plan says the 
ambulance transport was not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance transport. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found you did not require the expertise of 
trained personnel or the equipment available only on an ambulance in order to effectuate a safe transport. 
Transportation could have been provided by other means (stretcher van, wheelchair van, private care, taxi) 
without endangering your condition. 
 
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 ambulance transport. have not been met. Therefore, we decided that the Plan 
does not have to pay for ambulance transport provided on August 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for chiropractic visit provided on July 11, 
2022, to October 31, 2022. 
 
You asked the Plan to waive the copayment for chiropractic visit. You say that you are disputing the share cost. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $15 
copayment for chiropractic services.  
 
You have been asked to pay $15 copayment for each chiropractic visit. This item/service falls within the 
chiropractic 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 chiropractic visit 
provided on July 11, 2022, to October 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 52234 and 52214 provided on September 6, 
2022. 
 
You asked the Plan to pay for procedure codes 52234 and 52214. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says payment is included in the 
global surgery payment. 
 The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery. 
 
We looked at the file and Medicare rules. Payment for procedure codes 52234 and 52214 is included in the 
global surgery payment for the procedure (52601) provided on August 16, 2022. Separate payment cannot be 
made for procedure codes 52234 and 52214. Therefore, we decided that the Plan does not have to pay for 
procedure codes 52234 and 52214 provided on September 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair, single power 
option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0856). 
 
You asked the Plan to pre-approve a power wheelchair. You say that you need the chair to assist you in doing 
household chores without having the anxiety of possibly falling. The Plan denied your request. The Plan says 
the enrollee does not have a qualifying diagnosis causing mobility limitation for which K0856 group 3 power 
wheelchair is medically needed. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or 
congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a group 3 
standard power wheelchair, single power option, sling/solid seat/back, patient weight capacity up to and 
including 300 pounds (K0856).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation  new or established patient 
(D0150) provided on September 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that a tooth broke, and you had to get x-rays so the 
provider could determine the damage. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted. 
 
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. This benefit includes the 
requested comprehensive oral evaluation  new or established patient (D0150) but is limited to one procedure 
every three plan years. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested comprehensive oral evaluation  new or established patient (D0150) was 
exhausted on date of service January 26, 2021. Therefore, we decided that the Plan does not have to pay for 
comprehensive oral evaluation  new or established patient (D0150) provided on September 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cytopathology (88120) provided on June 6, 2022. 
 
You asked the Plan to pay for the Cytopathology (88120). You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the Cytopathology (88120), was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for the Cytopathology (88120) provided on June 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care services provided on 
September 23, 2022, to September 25, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care services. You say that you are disputing 
the share cost. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $150 per 
day for days 1 to 5 of a hospital stay for San Diego County plan members for inpatient hospital care. This 
inpatient hospital stay lasted 2 days, resulting in a copayment amount of $300.  
 
You have been asked to pay $150 per day for days 1 to 5 of a hospital stay for San Diego County plan members 
for inpatient hospital care services. This item/service 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 services provided on September 23, 
2022, to September 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy visit provided on June 27, 2022. 
 
You asked the Plan to pay for psychotherapy visit. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for psychotherapy visit 
provided on June 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care services provided on 
July 14, 2022, to July 19, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care services. You say that you are disputing 
the share cost. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $310 
copayment per day for days 1 to 6 for inpatient hospital care. This inpatient hospital stay lasted 5 days, 
resulting in a copayment amount of $1,550 ($310 per day for 5 days = $1,550). 
 
You have been asked to pay $310 copayment per day for days 1 to 6 for inpatient hospital care services. This 
item/service 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 services provided on July 14, 2022, to July 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Urgent care visits provided on May 24, 
2022, to May 31, 2022. 
 
You asked the Plan to waive the copayment for urgent care visits. You say that you are disputing the share cost. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $45 
copayment for Urgently needed services. There were two visits, resulting in a total copayment amount of $90. 
 
You have been asked to pay $45 copayment for each urgent care visit. This item/service 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 Urgent care 
visits provided on May 24, 2022, to May 31, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient therapy services provided on June 3, 2022 to June 
17, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient therapy. You say that the records attached support the services 
provided. The Plan denied your request. The Plan says services can be obtained from an in-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 outpatient therapy services provided on June 3, 
2022 to June 17, 2022, by an out-of-network (OON) provider.