Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the requested Prolia is medically necessary. The Plan 
denied your request. The Plan says the enrollee must have either, a history of osteoporosis-related fracture; OR, 
the member has failed, or has a contraindication to zoledronic acid. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that the Plan's 
step therapy criteria have not been met. Our physician reviewer found based on the medical records provided 
there is no indication that the enrollee has tried and failed the required drug. Records do not document that the 
enrollee has a history of an osteoporosis-related fracture. There is no indication that the plan's required drug 
would likely be less effective and/or likely 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the psychotherapy services provided on March 4, 2022. 
 
You asked the Plan to pay for the psychotherapy services. You say that you were referred to this provider by 
your in-network primary care physician. The Plan denied your request. The Plan says that the rendering 
provider is an OON provider, and the services received were neither emergent nor urgent and prior 
authorization was not obtained. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the psychotherapy services by a contract provider. The file does not show that the Plan 
provided notice that the psychotherapy services would not be covered. Under Medicare rules, this means the 
psychotherapy services is considered approved by the Plan. Therefore, we decided that the Plan has to pay for 
the psychotherapy services provided on March 4, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Facet Joint Injections provided on April 19, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for Facet Joint Injections. You say that you would like to appeal the denial of the 
claim. The Plan denied your request. The Plan says the provider is out-of-network and it was determined these 
services can be received in-network. 
 
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 Facet Joint Injections provided on April 19, 2021 
by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve continued home health physical therapy. 
 
You asked the Plan to pre-approve continued home health physical therapy. You say that the requested 
continuation of home health physical therapy is medically necessary. The Plan denied your request. The Plan 
says that the requested continuation of home health physical therapy is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a NOMNC must be issued prior to discontinuing 
coverage of home care services.  
 
There is no evidence that a NOMNC has been issued saying that coverage is ending for the home care services 
at issue in this appeal. Therefore, we decided that the Plan has to pre-approve continued home health physical 
therapy.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for radiation treatment delivery services 
provided from January 3, 2022, to January 31, 2022. 
 
You asked the Plan to waive the copayments for the radiation treatment. You say that you should only have one 
copayment for the treatment. 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 $60 
copayment for each radiation therapy service.  
 
You have been asked to pay a $60 copayment for each of the 20 radiation treatment services provided from 
January 3, 2022, to January 31, 2022. The total for all services is $1,200 ($60 copayment x 20 visits = $1,200). The radiation treatment falls within the Outpatient Diagnostic Tests and Therapeutic Services and 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 copayments for radiation treatment delivery 
services provided from January 3, 2022, to January 31, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician or allowed practitioner re-certification for 
Medicare-covered home health services under a home health plan of care (G0179) provided on November 18, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the physician or allowed practitioner re-certification. You say that physician 
certification for Medicare covered home health services are medically necessary and for the good of the patient. 
You also say that care is needed in order to adequately develop an effective treatment plan, and you would like 
this claim to be reprocessed. The Plan denied your request. The Plan says these services were not authorized by 
network/primary care providers.  
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
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 physician or allowed practitioner re-
certification for Medicare-covered home health services under a home health plan of care (G0179) provided on 
November 18, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Sanexas neoGen-Series Therapy and associated services 
(97014, 96372, J3490, J3420, J3415, J3411, J1955, and 97110) provided on November 18, 2021. 
 
You asked the Plan to pay for the outpatient therapy services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the experimental services are not medically necessary. 
 
Review of the file and publicly available records, we find that the physical therapy services at issue in this case 
were rendered by an NP/PA who is not licensed to provide physical therapy in the State of Ohio. The multiple 
drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that 
any compounded drug be billed using the not otherwise classified code J7999. As this compounded drug was 
not billed properly, payment cannot be made. Because the drugs are not paid as billed, the drug administration code, 96372, also cannot be paid. Therefore, we decided that the Plan does not have to pay for the Sanexas 
neoGen-Series Therapy and associated services (97014, 96372, J3490, J3420, J3415, J3411, J1955, and 97110) 
provided on November 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of prosthetic material or mesh (11008) provided 
on November 8, 2021. 
 
  You asked the Plan to pay for the removal of prosthetic material or mesh (11008). You say that this was an in-
network facility, and the patient did not have control over the availability of an in-network provider. You say 
that you are disputing the allowance on this claim and request review to determine if the claim processed 
correctly. The Plan denied your request. The Plan says CPT code 11008 was billed without an approved 
primary procedure code. 
 
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 11008 
is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for the removal of prosthetic material or mesh (11008) provided on November 8, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary visit provided on December 22, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the domiciliary visit. You say that the assisted living facility is responsible to 
obtain the prior authorization The Plan denied your request. The Plan says no prior authorization was obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
domiciliary visit. We found no exception that would require the Plan to pay for the domiciliary visit. The 
records provided for review do not show that the domiciliary visit was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the domiciliary visit provided on December 22, 2021, by an out-
of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on December 9, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the drug testing. You say that the service was medically necessary, and most in-
network providers cannot perform such complex drug testing services. The Plan denied your request. The Plan 
says no prior authorization was obtained. 
 
 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 drug testing in this appeal. The Plan did not pre-approve the drug 
testing. We found no exception that would require the Plan to pay for the drug testing. The records provided for 
review do not show that drug testing was urgent or emergent. Therefore, we decided that the Plan does not have 
to pay for the drug testing provided on December 9, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient office visit (99212) provided 
on February 8, 2022. 
 
You asked the Plan to waive the copayment for the outpatient office visit. You say that this was a pre-cataract 
surgery consultation for eye measurement that you believe should be part of the cataract surgery global fee. 
The Plan denied your request. The Plan says the copayment applied appropriately. 
 
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 $45 
copayment for Medicare-covered exams to diagnose and treat diseases and conditions of the eye for Vision 
care.  
 
 
  You have been asked to pay a $45 copayment for the outpatient office visit. The outpatient office visit falls 
within the Vision care benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the 
outpatient office visit (99212) provided on February 8, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Magnetic resonance imaging (MRI) on 
February 25, 2022. 
 
You asked the Plan to waive the copayment for Magnetic resonance imaging (MRI). You say that you states 
that you were under the impression that the provider would be billing the MRI under the 'X-rays and 
Diagnostic Radiology Services with a $15 copayment', not a $250 Advanced Imaging copayment. The Plan 
denied your request. The Plan says the cost share 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 $250 
copay for each Medicare-covered advanced imaging service for Magnetic resonance imaging (MRI). The 
allowed amount of the MRI is $206.40, which is less than the standard advanced imaging copayment of 
$250.00. 
 
 You have been asked to pay $250 copay for each Medicare-covered advanced imaging service for Magnetic 
resonance imaging (MRI). A Magnetic resonance imaging (MRI) falls within the Outpatient diagnostic tests 
and therapeutic services and 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 copayment for 
Magnetic resonance imaging (MRI) on February 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an X-ray on January 6, 2022. 
 
You asked the Plan to waive the copayment for an X-ray. You say that when you had coverage with another 
plan you did not have copays for services. The Plan denied your request. The Plan says the cost share 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 $15 
copayment for an X-ray.  
 
You have been asked to pay a $15 copayment for an X-ray. An X-ray falls within the Outpatient hospital 
services. 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 on January 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on January 10, 
2022. 
 
You asked the Plan to waive the copayment for the office visit. You say that this is a duplicate visit, the 
provider should not be charging. The Plan denied your request. The Plan says the copayment amount charged 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 $10 
copayment for consultation, diagnosis, and treatment by a specialist.  
 
You have been asked to pay a $10 copayment for the office visit. An 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 January 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on August 19, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the rendering physician is a 
hospitalist physician with the group and depends upon the hospital staff to verify eligibility and to obtain the 
proper authorization from the patient's insurance company. The Plan denied your request. The Plan says the 
rendering provider is a non-participating provider, and there is no referring provider involved in these services. 
The Plan also says they did not authorize any services for this 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 subsequent nursing facility care provided on 
August 19, 2021, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on January 
31, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that your doctor advised you 
to call an ambulance and you were unable to drive. The Plan denied your request. The Plan says the copayment 
was applied 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 $250 
copayment for in and out-of-network Medicare-covered ambulance services. Cost sharing applies for each one-
way trip.  
 You have been asked to pay $250 for the ambulance services. Ambulance services fall within the Ambulance 
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 the ambulance services 
provided on January 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional trips. You say that you have been told that this plan covers 
unlimited transportation. You also say that this is the only way you can get to your dialysis appointments. The 
Plan denied your request. The Plan says additional trips over the 52 in one direction are not covered. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 52 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting 
on January 3, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that you feel you should not owe for self-
administered medications. You say that you only had anti-nausea medications after surgery. The Plan denied your request. The Plan says the drugs you received are considered self-administered. The Plan says self-
administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs 
you received are not covered under Medicare Part B. 
 
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 pay for the self-administered drugs 
provided in an outpatient setting on January 3, 2022.