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

 
We decided that the Plan does not have to pay for the psychotherapy services (90833) and telehealth visit 
(99443) provided on March 8, 2023, by an out-of-network (OON) provider.  
 You asked the Plan to pay for the telehealth services. You say that for telehealth services for Medicare during 
COVID-19 telehealth coverage was expanded to allow most psychology services to be provided by telephone 
without video. You also say that this service should be reprocessed and paid. The Plan denied your request. The 
Plan says the provider in this case is out-of-network. The Plan says the services were not urgent or emergent in 
nature. The Plan also says the enrollee was not referred by a network provider or their primary care physician 
(PCP). 
 
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 psychotherapy services (90833) and telehealth 
visit (99443) provided on March 8, 2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood glucose test strips (A4253) and lancets (A4259) 
provided from February 17, 2022 to November 16, 2022, by an out-of-network (OON) provider.  
 
  You asked the Plan to pay for the blood glucose test strips and lancets. You say that you did not note that these 
supplies required an authorization and billed correctly according to the fee schedule allowable. The Plan denied 
your request. The Plan says there was no valid authorization on file for the services performed by a non-
participating 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 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 blood glucose test strips (A4253) and lancets 
(A4259) provided from February 17, 2022 to November 16, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for registered nurse services provided on February 3, 2023. 
 
You asked the Plan to pay for registered nurse services. The Plan denied your request. The Plan says the 
services are not covered by Medicare and therefore not covered by the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that a Registered Nurse is not eligible to participate in 
the Medicare program.  
 
We looked at the file and Medicare rules. The provider at issue in this case is a Registered Nurse. Medicare 
says that a Registered Nurse is not eligible to participate in the Medicare program. Therefore, we decided that 
the Plan does not have to pay for registered nurse services provided on February 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 00732 provided on December 24, 2022. 
 
You asked the Plan to pay for procedure code 00732. 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 as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 00732 is not supported in the medical record. Specifically, this service was billed on the 
same date of service as code 00790 (anesthesia). If multiple procedures are performed on the same date of 
service, the provider should indicate the separately identifiable sessions using specific modifiers. One of these 
modifiers was not billed with this claim. This means the claim is not payable as submitted. Based on this 
information, we decided that Medicare rules for coverage of the anesthesia services have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 00732 provided on December 24, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for out-of-network inpatient hospital care, out-
of-network Medicare Part B drugs, out-of-network x-ray services, out-of-network laboratory services, out-of-
network outpatient surgeries and out-of-network office visits provided on December 4, 2022, to February 3, 
2023. 
 
You asked the Plan to waive the cost share for out-of-network inpatient hospital care, out-of-network Medicare 
Part B drugs, out-of-network x-ray services, out-of-network laboratory services, out-of-network outpatient 
surgeries and out-of-network office visit. You say that you disagree with the cost share. 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. Your 
contract with the Plan says that there is a $500 deductible which applies to most out-of-network services in 
both 2022 and 2023, and a 20% coinsurance for out-of-network inpatient hospital care, Medicare Part B drugs 
outpatient diagnostic tests, outpatient surgery, and out-of-network physician/practitioner services.  
 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible. You 
are being asked to pay $28.47 towards your $500 deductible for 2022 and $229.42 towards your $500 
deductible for 2023. This cost sharing is a contractual obligation that had not been met at the time out-of-
network laboratory services and the out-of-network office visits was received on December 4, 2022, to 
February 3, 2023. 
 
The total allowed amount for the inpatient hospital care is $10,333.01 ($10,333.01 x 20% = $2,066.60). 
However, you are only being asked to pay $1,100 which is less than the required amount. You are being asked 
to pay $68.68 ($343.44 allowed amount x 20% =$68.68). You are being asked to pay $153.37 ($766.85 
allowed amount x 20% = $153.37) for the diagnostic test. You are being asked to pay $320.43 ($1,602.13 
allowed amount x 20% = $320.43) for the outpatient surgeries. You are being asked to pay $14.03 ($70.13 
allowed amount x 20% = $14.13) for the office visit. 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 cost share for 
out-of-network inpatient hospital care, out-of-network Medicare Part B drugs, out-of-network x-ray services, 
out-of-network laboratory services, out-of-network outpatient surgeries and out-of-network office visits 
provided on December 4, 2022, to February 3, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prednisone. 
 
You asked the Plan to pre-approve the medication. You say that this should be covered. The Plan denied your 
request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve prednisone.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane. 
 You asked the Plan to pre-approve Durolane. The Plan denied your request. The Plan says the enrollee has not 
tried one of the preferred products.  
 
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 Durolane. Our physician reviewer 
found that the enrollee has osteoarthritis of the left knee. The Plan requires a trial of Monovisc, Orthovisc, 
Synvisc, or Synvisc-One before they will approve the requested drug. In this case, the enrollee has not tried and 
failed the required drugs. There is no documentation provided indicating that the Plans required drugs would 
likely be less effective 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 Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durolane.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the application of caries arresting medicament (D1354) 
provided on November 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
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 
application of caries arresting medicament (D1354) provided on November 29, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3. 
 You asked the Plan to pre-approve Gelsyn-3. The Plan denied your request. The Plan says the enrollee has not 
tried the preferred agents.  
 
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 Gelsyn-3. Our physician reviewer 
found that the enrollee has osteoarthritis of the knee. The Plan requires a trial of Orthovisc or Supartz FX 
before they will approve the requested drug. In this case, the enrollee has not tried and failed the required 
drugs. There is no documentation provided indicating that the Plans required drugs would likely be less 
effective 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 Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gelsyn-3.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 9, 2023, by an out-of-
network (OON) provider.  
 You asked the Plan to pay for the physician service. You say that this has been a recurring problem with 
services being denied. You say that this should be covered. The Plan denied your request. The Plan says prior 
authorization was not 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 provider in this case is not a network provider with the Plan. The Plan did not pre-approve the service at 
issue. We found no exception that would require the Plan to pay for these services. Additionally, there was no 
documentation provided to support that the service was medically necessary. Therefore, we decided that the 
Plan does not have to pay for the office visit provided on January 9, 2023, by an out-of-network (OON) 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve APOS shoes, foot orthotics.  
 
You asked the Plan to pre-approve foot orthotics. You say that you would like reconsideration because the 
requested foot orthotics are medically necessary. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve APOS 
shoes, foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglasses provided on December 28, 2022. 
 
You asked the Plan to pay for the eyeglasses. The Plan denied your request. The Plan says you have exceeded 
the eyewear benefit limit. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services every year. 
 
We looked at the file and the Plan's rules. The file shows you have exceeded the eyewear benefit limit. Based 
on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. 
Therefore, we decided that the Plan does not have to pay for eyeglasses provided on December 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the work out bicycle purchased on February 8, 2023. 
 
You asked the Plan to pay for the work out bicycle. You say that with COVID-19 you did not feel comfortable 
in person, and did not want to use the same equipment after someone. You also say that they are not sanitizing 
the equipment like they are supposed to. The Plan denied your request. The Plan says bicycles are not a 
covered benefit. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan reimburses you up to 
$350 per calendar year towards your cost for membership in a qualified health club or fitness facility. 
 The Plans rules for coverage of gym benefits have not been met because a bicycle is not listed as a covered 
benefit. Therefore, we decided that the Plan does not have to pay for the work out bicycle purchased on 
February 8, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to waive the deductible for laboratory services provided on February 7, 2023. 
 
You asked the Plan to waive the deductible for laboratory services. You say that you had bloodwork taken 
during your yearly visit and do not feel a cost share should be applied. The Plan denied your request. The Plan 
says that 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 does not say in clear and accurate terms 
how much you should expect to pay for laboratory services performed during an annual wellness visit.  
 
We looked at your contract with the Plan. The Plan contract states a separate copayment may apply if a non-
preventive screening laboratory test or other non-preventive services are provided at the time of an annual 
wellness visit; However, we did not see where the contract specifies which laboratory services performed 
during an annual wellness visit are considered preventive. This means that the Plan did not follow Medicare 
rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the deductible 
for laboratory services provided during an annual wellness visit on February 7, 2023.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Abiraterone. 
 
You asked the Plan to pre-approve the medication. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Abiraterone.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc One (J7325) and the arthrocentesis (20611). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says this treatment is only allowed for osteoarthritis of the knee or shoulder; the 
enrollee does have osteoarthritis of the knee or shoulder. The Plan states medical studies have not proven that 
these injections are helpful in joints other than the knee or shoulder. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our physician reviewer 
found the literature states that intra-articular injections of sodium hyaluronate are unproven and not medically 
necessary for treating any other indication due to insufficient evidence of efficacy including but not limited to 
the following:  Hip osteoarthritis, temporomandibular joint osteoarthritis, and temporomandibular joint disc displacement. The review has determined that the requested use of Synvisc-one is not FDA-approved for the 
enrollee's diagnosis. Its use is not supported by one of the major drug compendia (as in Micromedex/DrugDex) 
or by clinical research that appear in a Centers for Medicare & Medicaid Services (CMS)-approved medical 
journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc One (J7325) and the arthrocentesis (20611).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on  
January 18, 2022. 
 
You asked the Plan to pay for the emergency department visit. The Plan denied your request. The Plan says 
According to Medicare guidelines an original claim submission must be filed to the appropriate Medicare 
claims processing contractor no later than 12 months, or 1 calendar year, after the date the services were 
furnished. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the emergency department visit was not filed until March 9, 2023. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for an emergency department visit provided on 
January 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics.  
 
You asked the Plan to pre-approve foot orthotics. You say that you would like reconsideration because the 
requested foot orthotics are medically necessary. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot 
orthotics.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service January 29, 
2023 to February 25, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that this should be paid for. The Plan denied 
your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service January 29, 2023 to February 25, 2023.