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

 
We decided that the Plan does not have to pre-approve a gastrointestinal transit capsule. 
 
You asked the Plan to pre-approve a capsule endoscopy. You say that the enrollee has stomach pain and 
belching. The Plan denied your request. The Plan says that this kind of test is unproven for the enrollee's issues. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a capsule endoscopy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that capsule endoscopy is not indicated in this clinical scenario and the enrollee's 
history does not meet criteria for this service. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a capsule endoscopy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a gastrointestinal transit capsule.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray provided on May 16, 2023. 
 
You asked the Plan to waive the copayment for an x-ray. You say that this service should be covered under the 
global period for the knee replacement. 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 $35 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $35 copayment for an x-ray. This item/service 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. However, since the allowed amount is less than the standard 
copayment, you only owe $34.67. Therefore, we decided that the Plan does not have to waive the copayment 
for an x-ray provided on May 16, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 19, 2023, to 
February 17, 2023. 
 You asked the Plan to pay for the home health services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the NOA was not received timely. As 
such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 19, 2023. The NOA was not received by the Plan until March 6, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
provided from January 19, 2023, to February 17, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lexapro. 
 
You asked the Plan to pre-approve Lexapro. The Plan denied your request. The Plan says that self-administered 
drugs do not fall under Medicare Part B coverage. 
 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 Lexapro.  
 
Benefits for Lexapro 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for diabetic shoes, and custom inserts 
provided on May 16, 2023. 
 
You asked the Plan to waive the coinsurance for diabetic shoes, and custom inserts. You say that you do not 
agree with the cost sharing. 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 20% 
coinsurance for Medicare-covered diabetic therapeutic custom-molded shoes or inserts. 
 
You have been asked to pay 20% coinsurance for diabetic shoes, and custom inserts. This item/service falls 
within the Medicare-covered diabetic therapeutic custom-molded shoes or inserts 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 $66.92 ($334.58 
allowed amount x 20% = $66.92 rounded up). Therefore, we decided that the Plan does not have to waive the 
coinsurance for diabetic shoes, and custom inserts provided on May 16, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on May 15, 2023. 
 
You asked the Plan to pay for nursing facility care. 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 nursing facility care 
provided on May 15, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health provided on October 04, 2022. 
 
You asked the Plan to pay for outpatient mental health. You say that you say that this procedure does not 
require a precertification or reauthorization. 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 outpatient mental health 
provided on October 04, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on March 15, 2023. 
 
You asked the Plan to pay for the nursing facility care. You say that the service was 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 the nursing facility care 
provided on March 15, 2023.
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 you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has osteoporosis. The documentation does not support that the enrollee has a history of 
osteoporotic fracture or has tried or cannot use zoledronic acid. The documentation does not support that 
zoledronic acid would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the 
enrollee does not meet criteria for the requested drug. 
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zilretta. 
 You asked the Plan to pre-approve Zilretta. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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 Zilretta. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the documentation does not support that the enrollee has tried and failed Triamcinolone Acetonide intra-
articular Injection. The documentation does not support that Triamcinolone Acetonide intra-articular Injection 
would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the enrollee does 
not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zilretta have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Zilretta.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on May 18, 2023. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration based on the federal 
guidelines due to covid you are requesting that the claim be reprocessed and paid. 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 lab testing provided on 
May 18, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an unclassified drug provided on August 
26, 2022. 
 
You asked the Plan to waive the coinsurance for an unclassified drug. You say that you were never told in 
advance that the service would not 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 50% 
coinsurance for all other out-of-network Medicare-covered Part B drugs, besides Medicare-covered Part B 
allergy antigens.  
You have been asked to pay 50% coinsurance for an unclassified drug. This item/service falls within the all 
other out-of-network Medicare-covered Part B drugs, besides Medicare-covered Part B allergy antigens 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 $1314 ($2628 allowed amount x 50% = $1314). Therefore, we decided that the Plan does not have to 
waive the coinsurance for an unclassified drug provided on August 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for extracapsular cataract removal provided on 
August 17, 2022, to September 21, 2022. 
 
You asked the Plan to waive the copayment for extracapsular cataract removal. You say that you disagree with 
the copayment. 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 $350 
copayment for outpatient surgery. 
 
You have been asked to pay a $350 copayment for extracapsular cataract removal. This item/service falls 
within the outpatient surgery 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 amount you are being asked to pay is $700 ($350 x 2 = $700). Therefore, we 
decided that the Plan does not have to waive the copayment for extracapsular cataract removal provided on 
August 17, 2022, to September 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each outpatient surgery provided on 
February 27, 2023, to March 07, 2023. 
 
You asked the Plan to waive the copayment for each outpatient surgery. You say that you want to appeal the 
amount being charged. 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 $120 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. 
 
You have been asked to pay a $120 copayment for each outpatient surgery. This item/service falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The 
total you owe is $240 ($120 copayment x 2 visits = $240). Therefore, we decided that the Plan does not have to 
waive the copayment for each outpatient surgery provided on February 27, 2023, to March 07, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device. 
 
You asked the Plan to pre-approve the Vertiflex device. You say that this device would provide significant 
clinical and quality of life benefits for the enrollee. The Plan denied your request. The Plan says this service is 
not considered to be the accepted standard of medical practice as there is unclear guidance and minimal support 
for the use of this technology. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the Vertiflex device is experimental. More research is needed. 
 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 Vertiflex device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex device.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99284 for date of service March 17, 2023. 
 
You asked the Plan to pay for procedure code 99284. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says that the services billed are not supported. 
 
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, the CPT Code Manual definition of 
code 99284 is emergency department visit for the evaluation and management of a patient, which requires a 
medically appropriate history and/or examination and moderate level of medical decision making. 
 
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 99284. Our reviewer says 
that the documentation supports that the code billed is supported. Our reviewer found the enrollee presented to 
Emergency Department after a mechanical fall and right knee and foot pain sustained nine days earlier. The 
enrollee had a second fall and presented with left leg pain. X-rays and left leg ultrasound were negative. The 
enrollee was discharged home on over-the-counter analgesics. Due to two mechanical falls in a short period of 
time the enrollee would have been considered a high-risk patient therefore, code 99284 was reasonable and 
appropriate. 
 
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 99284 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 99284 for date of service March 17, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for X-ray services provided on May 07, 2023. 
 
You asked the Plan to waive the copayment for X-ray services. You say that you disagree with the copayment. 
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 $20 
copayment for outpatient diagnostic test/X-ray services. 
 
You have been asked to pay a $20 copayment for X-ray services. This item/service falls within the outpatient 
diagnostic test/X-ray 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 X-ray 
services provided on May 07, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the portable abdominal x-ray provided on April 17, 2023, by 
an OON provider.  
 
You asked the Plan to pay for the portable x-ray. You say that you are appealing the denial with supporting 
documentation. The Plan denied your request. The Plan says this service was not authorized. 
 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 portable abdominal x-ray provided on April 
17, 2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on March 
13, 2023. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you disagree with the 
copayment. 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 $300 
copayment for outpatient surgery. 
 
You have been asked to pay a $300 copayment for an outpatient surgery. This item/service falls within the 
outpatient surgery 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, you are only being asked to pay $140.16 which is less than the required amount. 
Therefore, we decided that the Plan does not have to waive the copayment for an outpatient surgery provided 
on March 13, 2023.