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

 
We decided that the Plan does not have to waive the cost for an in-network injection procedure provided on 
December 15, 2023. 
 
You asked the Plan to waive the cost for an in-network injection procedure . You say that there was an issue 
the first time they did this test, so this one was supposed to be "free of charge". 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% 
coinsurance for Medicare Part B Prescription drugs, and a $250 copayment for outpatient surgery and other 
medical services provided at hospital outpatient facilities and ambulatory surgical centers. The allowed amount of this drug is $355.70, resulting in a coinsurance amount of $71.14 ($355.70 x 20% = 
$71.14). $250 + $71.14 = $321.14 total. 
  
You have been asked to pay a $321.14 cost for an in-network injection procedure. This item/service falls within 
the Medicare Part B Prescription drugs and outpatient surgery and other medical 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. Therefore, we decided that the Plan does not have to waive the 
cost for an in-network injection procedure provided on December 15, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 45385 billed for date of service May 3, 2023. 
 
You asked the Plan to pay for procedure code 45385. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 45385 is bundled into payment for code 45388.  
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 45385 
is a column II code to column I code 45388. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 45385 billed for date of service May 3, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the ambulance service provided on 
February 19, 2023. 
 
You asked the Plan to waive the coinsurance for the ambulance service. You say that this cost share is a 
hardship. 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 ambulance services. 
 
You have been asked to pay 20% coinsurance for the ambulance service. This item/service falls 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 coinsurance for the ambulance 
service provided on February 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation provided on  
April 24, 2023. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation. You say that the services were medically 
necessary. The Plan denied your request. The Plan says no medical necessity for an out-of-network provider, 
such as an urgent or emergency situation, has been documented. There is no network deficiency for these 
services and alternate network providers were found. 
 
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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a psychiatric diagnostic evaluation provided on April 24, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mammograms and breast ultrasounds provided from January 
28, 2022, to February 8, 2022. 
 
You asked the Plan to pay for the mammograms and breast ultrasounds. The Plan denied your request. The 
Plan says the primary payer will need to review the services for payment consideration before the Plan can 
consider the claim for payment consideration as secondary payer. The Plan contacted the provider and 
successfully relayed the information.  
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has contacted the 
provider and successfully relayed the information. As the secondary insurer, the Plan cannot be held 
responsible for the mammograms and breast ultrasounds until the primary insurer has denied the claim for 
these services. Therefore, we decided that the Plan does not have to pay for mammograms and breast 
ultrasounds provided from January 28, 2022, to February 8, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Hyalgan (J7321). 
 You asked the Plan to pre-approve Hyalgan. You say that Hyalgan is a medical necessity for the enrollee. The 
Plan denied your request. The Plan says step-therapy rules for coverage of Hyalgan 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 Hyalgan. Our reviewer says that 
treatment with Hyalgan is not medically reasonable and necessary in this case. Our physician reviewer found 
that the Plan requires a trial of drugs Monovisc, Orthovisc, Synvisc or Synvisc-One before they will approve 
the requested drug, Hyalgan. Based on the medical records provided, there is no indication that the enrollee has 
tried and failed the required drugs. Based on the medical records provided and the Medicare-approved major 
drug compendia, there is no indication 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 Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Hyalgan (J7321).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on March 07, 2023. 
 
You asked the Plan to pay for the home visit. You say that at the time of service the enrollee was residing in an 
assisted living facility. 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 home visit provided 
on March 07, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit, limited bilateral noninvasive physiologic 
studies of upper or lower extremity arteries, removal of noncancer thickened skin growth and nail debridement 
provided on March 1, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. 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 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 office visit, limited bilateral noninvasive 
physiologic studies of upper or lower extremity arteries, removal of noncancer thickened skin growth and nail 
debridement provided on March 1, 2023, by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medication assisted treatment, methadone provided on 
January 30, 2023. 
 
You asked the Plan to pay for medication assisted treatment, methadone. The Plan denied your request. The 
Plan says 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 Plan says that the Plan has also determined that these services 
are not urgent or emergent, nor were they approved in advance. 
 
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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for medication assisted treatment, methadone provided on  
January 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 15, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that this should be paid for. The 
Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 15, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 
You asked the Plan to pre-approve Feraheme. You say that the requested Feraheme is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Venofer first. 
 
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 Feraheme. 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(s). Based on the medical 
records provided and the Medicare-approved major drug compendia there is no indication that the plan's 
required drug(s) 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 Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 22, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that this should be paid for. The 
Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 4, 2022. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the primary 
payer will need to review the services for payment consideration before the Plan can consider the claim for 
payment consideration as secondary payer. The Plan contacted the provider and successfully relayed the 
information.  
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has contacted the 
provider and successfully relayed the information. As the secondary insurer, the Plan cannot be held 
responsible for the laboratory services until the primary insurer has denied the claim for these services. 
Therefore, we decided that the Plan does not have to pay for laboratory services provided on August 4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
December 10, 2022, to December 28, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you did not receive 
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 $325 
copayment each day, for days 1 to 5 and a $0 copayment for additional days for Medicare-covered hospital 
care. 
 
 You have been asked to pay a $325 copayment per day, for days 1 to 5 of the inpatient hospital stay. You have 
also been asked to pay a total of $1,625 ($325 copayment x 5 days = $1,625). You have not been charged for 
any additional days. This item/service falls within the inpatient hospital care benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the inpatient hospital stay provided from December 10, 2022, to 
December 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the VIA Disc procedure. 
 
You asked the Plan to pre-approve the VIA Disc procedure. You say that the procedure is to address the 
enrollee's current condition.  The Plan denied your request. The Plan says the VIA Disc procedure is not 
covered by Medicare.  
 
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 VIA Disc procedure. Our reviewer 
says that the VIA Disc procedure is not medically necessary. Our physician reviewer found that the VIA Disc 
procedure is still considered experimental and investigational. Therefore, the request is not medically 
reasonable and necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the VIA Disc procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the VIA Disc procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic testing provided on December 31, 2022, by an 
out-of-network (OON) provider.  
 
 You asked the Plan to pay for diagnostic testing. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says the enrollee must receive their care from a network provider (for more 
information about this, see Section 2 of Chapter 3). In most cases, care the enrollee receives from an out-of-
network provider (a provider who is not part of the plans network) will not be 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 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 diagnostic testing provided on December 31, 
2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on April 17, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you were 
not aware this service would not be covered, and you cannot afford the cost of $1,120.00 for this service. The 
Plan denied your request. The Plan says the medical records confirm that you refused transport on the date of 
service in question and no transport was done. The claim processed correctly according to the contract and 
Medicare guidelines and there was no plan error. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 17, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on April 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services provided on February 16, 2023. 
 
You asked the Plan to pay for the telehealth services. The Plan denied your request. The Plan says no benefit 
coverage is available for virtual services performed by an out-of-network provider. 
 
The Plan contract says that virtual care (also referred to as telehealth services, virtual check-ins or eVisits) is 
not covered out-of-network.  
 
We looked at the file and the Plans rules. The file shows that the Plan does not cover telehealth services out-
of-network. Based on this information, we decided that Plans rules for coverage of the telehealth services have 
not been met. Therefore, we decided that the Plan does not have to pay for telehealth services provided on 
February 16, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for echocardiography (EKG) on March 17, 
2023. 
 
You asked the Plan to waive the deductible for EKG. 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. Your 
contract with the Plan says that there is a $1,250 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies.  
 
The item or service you asked the Plan to waive the deductible for falls within the outpatient diagnostic tests 
and therapeutic services and supplies benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $1,250 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time 
EKG was received on March 17, 2023. Therefore, we decided that the Plan does not have to waive the 
deductible for echocardiography (EKG) on March 17, 2023.