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

 
We decided that the Plan does not have to pre-approve treatment with Gel-One (J7326). 
 You asked the Plan to pre-approve Gel-One. You say that Gel-One is a medical necessity for the enrollee. The 
Plan denied your request. The Plan says step-therapy rules for coverage of Gel-One have not been 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 Gel-One. Our reviewer says that 
treatment with Gel-One is not medically reasonable and necessary in this case. Our physician reviewer found 
that the Plan requires a trial of drugs Durolane, Monovisc 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 Plan's required drugs 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 Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Gel-One (J7326).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intracept intraosseous nerve ablation system. 
 
You asked the Plan to pre-approve intracept intraosseous nerve ablation system. You say that the requested 
procedure is medically necessary. The Plan denied your request. The Plan says the procedure requested does 
not meet the requirements for approval. 
 
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 intracept intraosseous nerve ablation 
system. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the available data regarding the requested procedure is 
inconsistent and suggest that, compared with placebo, radiofrequency denervation may modestly reduce pain in 
the short-term; however, there does not appear to be clear long-term benefit.  When added to a treatment regimen that includes a regular exercise program and psychologic support, 
radiofrequency denervation provides little additional benefit. In addition, provided records document spinal 
stenosis, facet arthrosis and other degenerative changes on spinal imaging which may be the cause of the 
enrollee's back pain. Provided records in this case do not document the Intracept procedure meets Medicare 
criteria for safe, effective, reasonable, and necessary as required by the Social Security Act, Section 1862 
(a)1(A) and the 42 CFR Section 411.15(k). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intracept intraosseous nerve ablation system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve intracept intraosseous nerve ablation system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for venipuncture provided on March 22, 2023. 
 
You asked the Plan to pay for venipuncture. You say that the services were medically necessary. 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 venipuncture provided 
on March 22, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for myocardial perfusion imaging provided on 
June 20, 2023. 
 
You asked the Plan to waive the copayment for myocardial perfusion imaging. You say that you were told that 
this service would be covered. 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 $160 
copayment for in-network Medicare-covered diagnostic radiology services. 
 
You have been asked to pay a $160 copayment for myocardial perfusion imaging. This item/service falls within 
the in-network Medicare-covered diagnostic radiology 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 myocardial perfusion imaging provided on June 20, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for a total hip replacement surgery provided 
on March 14, 2023. 
 
You asked the Plan to reduce the coinsurance for a total hip replacement surgery. You say that you were 
informed that the provider was in-network. 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 40% 
coinsurance for out-of-network outpatient surgery at a hospital. 
 
You have been asked to pay 40% coinsurance for a total hip replacement surgery. This item/service falls within 
the out-of-network outpatient surgery at a hospital 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. The total you owe is $6,153.68 ($15,384.21 allowed amount x 
40% = $6,153.68). Therefore, we decided that the Plan does not have to reduce the coinsurance for a total hip 
replacement surgery provided on March 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a complete mandibular denture (D5120) provided on 
April 12, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the dentures are over five years old. You 
also say the dentist is on the Plan's provider list. 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. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 12, 2023. 
Therefore, we decided that the Plan does not have to pay more for a complete mandibular denture (D5120) 
provided on April 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on May 15, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says this service is not covered when received by an OON 
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 a POS option to use either network providers or out-of-network providers for certain 
covered services. The Plan contract also says that out-of-network physician services are not covered. 
 
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 service at issue in this appeal. The Plan did not pre-approve the service 
at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that 
the Plan does not have to pay for the office visit provided on May 15, 2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for radiologic examination, chest; 3 views provided on April 10, 2023. 
 
You asked the Plan to pay for the radiologic examination, chest; 3 views. You say that this claim is not a 
duplicate. The Plan denied your request. The Plan says that the claim is a duplicate of a paid claim. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not provided a remittance of the paid claim to substantiate their 
denial. Therefore, we decided that the Plan has to pay for radiologic examination, chest; 3 views provided on 
April 10, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive urine drug testing (UDT) billed with procedure 
code G0482 provided on March 30, 2023. 
 
You asked the Plan to pay for procedure code G0482. You say that the definitive UDT testing (G0482) was 
medically necessary. The Plan denied your request. The Plan says the definitive UDT testing (G0482) was not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for procedure code G0482. Our reviewer says 
that the definitive UDT testing (G0482) was not medically necessary. Our physician reviewer found the 
number of definitive urine drug classes tested was not medically necessary and the enrollee did not meet the 
stated LCD criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code G0482 have not been met. Therefore, we decided that the Plan 
does not have to pay for the definitive urine drug testing (UDT) billed with procedure code G0482 provided on 
March 30, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for admission to an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee with debility does not meet the coverage criteria for IRF admission. 
There are no acute rehab nursing needs documented. At the current functional level, the enrollee needs routine 
physical and occupational therapy and does not need intensive therapies. The enrollees rehab needs can be 
safely provided in an alternate and low intensity setting such as in a skilled nursing facility.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
August 1, 2023, and billed with codes 87481, and 87798. 
 
You asked the Plan to pay for the urine PCR panel. You say that  this testing was medically necessary. The 
Plan denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel have not been met. 
Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
provided on August 1, 2023, and billed with codes 87481, and 87798.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an emergency room visit provided on 
April 22, 2023. 
 
You asked the Plan to reduce the copayment for an emergency room visit. You say that you think that the 
copayment should be lower. 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 $90 
copayment for in and out-of-network emergency care services. 
 
You have been asked to pay a $90 copayment for an emergency room visit. This item/service falls within the in 
and out-of-network emergency care 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 reduce the copayment 
for an emergency room visit provided on April 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
May 25, 2023, and billed with codes 87481, and 87798. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel have not been met. 
Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
provided on May 25, 2023, and billed with codes 87481, and 87798.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network wound care procedure 
provided on May 15, 2023, to May 19, 2023. 
 
You asked the Plan to waive the copayment for an in-network wound care procedure. You say that when you 
go to the hospital, you are still being charged 20%. It is too expensive and you are not getting proper care. 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 for Medicare-covered observation services provided to you at an outpatient hospital, including but 
not limited to hospital or other facility charges and physician or surgical charges.  
You have been asked to pay a $360 copayment for an in-network wound care procedure. This item/service falls 
within the Medicare-covered observation services provided to you at an outpatient hospital, including but not 
limited to hospital or other facility charges and physician or surgical charges 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. However, since the allowed amount is 
less than the standard copayment for each procedure, you owe a total of $310.60 ($284.80 + $25.80 = $284.80). 
Therefore, we decided that the Plan does not have to waive the copayment for an in-network wound care 
procedure provided on May 15, 2023, to May 19, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medication assisted treatment, and a take home supply of 
methadone provided on June 05, 2023. 
 
You asked the Plan to pay for medication assisted treatment, and a take home supply of methadone. You say 
that a referral or authorization is not required. 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 medication assisted 
treatment, and a take home supply of methadone provided on June 05, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist visit provided on February 20, 2023. 
 
You asked the Plan to pay for a specialist visit. You say that this was medically necessary and should be 
covered. 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 a specialist visit 
provided on February 20, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medication assisted treatment provided on May 22, 2023. 
 
You asked the Plan to pay for medication assisted treatment. You say that a referral or authorization is not 
required. 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 medication assisted 
treatment provided on May 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87798, 87801, 97150, 87481, 87653, 87641, 
and 87500 for date of service June 22, 2022. 
 
You asked the Plan to pay for procedure codes 87798, 87801, 97150, 87481, 87653, 87641, and 87500. You 
say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the services are not 
payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components regardless of the fact that the test reports multiple individual pathogens and/or targets. 
 
We looked at the file and Medicare rules. Review of the file shows that the services at issue were a panel that 
was billed as unbundled. Based on this information, we decided that Medicare rules for coverage of procedure 
codes 87798, 87801, 97150, 87481, 87653, 87641, and 87500 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 87798, 87801, 97150, 87481, 87653, 87641, and 87500 for 
date of service June 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep sedation/general anesthesia (D9222, D9223). 
 
You asked the Plan to pre-approve 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 pre-approve deep 
sedation/general anesthesia (D9222, D9223).