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

 
We decided that the Plan does not have to pre-approve the injection, aflibercept, (Eylea) 1 mg (J0178). 
 You asked the Plan to pre-approve Eylea injection. You say that please find attached more information required 
for this enrollee. The Plan denied your request. The Plan says there is no documentation that the enrollee has 
tried and failed Avastin.  
 
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 Eylea injection. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Plan requires a trial of drug Avastin before they will approve the requested drug. In this 
case, the enrollee has not tried and failed the required drug. There is no documentation provided indicating that 
the Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the injection, aflibercept, (Eylea) 1 mg (J0178).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an otolaryngology visit to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve an otolaryngology visit. You say that your son has seen this provider and 
they seem very good. The Plan denied your request. The Plan says there are numerous other in-network 
providers who are available within the Medicare mileage from your residence. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an otolaryngology visit to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an in-network high frequency chest wall 
oscillation system provided from December 26, 2022, to March 26, 2023. 
 
You asked the Plan to waive the coinsurance for an in-network high frequency chest wall oscillation system. 
You say that you have had multiple calls and letters about these charges. They are too costly and should 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 20% 
coinsurance for durable medical equipment (DME) and related services.  
 
You have a $574.52 total coinsurance ($111.02 (December) + $154.50 (January) + $154.50 (February) + 
$154.50 (March) = $574.52). You have been asked to pay a $574.52 coinsurance for an in-network high frequency chest wall oscillation 
system. This item/service falls within the durable medical equipment (DME) and related 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 an in-network high frequency chest wall 
oscillation system provided from December 26, 2022, to March 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for office visit provided on March 15, 2023. 
 
You asked the Plan to reduce the copayment for office visit. You say that you say that you should not have a 
copayment for injections performed in the office setting. 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 $30 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $30 copayment for office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to reduce the copayment for office visit provided on March 15, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rhopressa. 
 
You asked the Plan to pre-approve the medication. You say that this medication is medically necessary for the 
enrollee. 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 Rhopressa.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit, and knee x-rays provided on December 13, 
2022. 
 
You asked the Plan to pay for an office visit, and knee x-rays. You say that there is a referral for these services. 
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 an office visit, and knee 
x-rays provided on December 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99215 billed for date of service February 6, 2023. 
 
You asked the Plan to pay for code 99215. You say that the diagnosis codes billed are valid and appropriate. 
You have provided medical records to support payment. The Plan denied your request. The Plan says you 
billed incorrect diagnoses on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that when a condition exists bilaterally, and a 
bilateral diagnosis code exists, providers should be that bilateral diagnosis code. 
 
In this case, you billed diagnosis codes G56.01 (carpal tunnel syndrome, right upper limb) and G56.02 (carpal 
tunnel syndrome, left upper limb).  However, a bilateral diagnosis code exists for this scenario (i.e., G56.03, 
Carpal tunnel syndrome, bilateral upper limbs.)  Because a bilateral diagnosis exists, and because the records 
and the claim indicate that the condition existed bilaterally, this bilateral diagnosis should have been billed 
instead of the two unilateral diagnoses.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 99215 have not been met. Therefore, we decided that the Plan does not have to pay for code 
99215 billed for date of service February 6, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that you are requesting reconsideration of 
the denied authorization. The Plan denied your request. The Plan says the requested procedure is 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 pre-approve an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no magnetic resonance imaging showing only modic changes without 
facet degenerative joint disease or foraminal stenosis. The cause of the enrollee's back pain is not clear. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628, 64629).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on February 13, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on February 13, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nexletol. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee has an allergy to statin 
medications. You also say that the enrollee requires a cholesterol medication. 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 Nexletol.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cochlear device implantation (69930) provided on 
August 23, 2022. 
 
You asked the Plan to pay for the surgical service. You say that the procedure was medically necessary and 
should be reimbursed accordingly. The Plan denied your request. The Plan says it cannot be determined how 
the enrollee came to the servicing provider or whether the service was medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the surgical service have been met. 
There were no medical records provided to substantiate that the service should be paid. Therefore, we decided 
that the Plan does not have to pay for the cochlear device implantation (69930) provided on August 23, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a leuprolide acetate injection provided on 
February 07, 2023. 
 
You asked the Plan to waive the coinsurance for a leuprolide acetate injection. You say that you have never had 
a copay for this service. 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 Part B chemotherapy prescription drugs. 
 
You have been asked to pay 20% coinsurance for a leuprolide acetate injection. This item/service falls within 
the Medicare Part B chemotherapy prescription drugs 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 $113 ($564.99 allowed amount x 20% = 
$113 rounded up). Therefore, we decided that the Plan does not have to waive the coinsurance for a leuprolide 
acetate injection provided on February 07, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transurethral waterjet ablation of prostate (0421T) to be 
provided by an out-of-network provider.  
 
You asked the Plan to pre-approve the waterjet ablation procedure. You say that aquablation therapy is 
approved by the Food and Drug Administration (FDA). You say that you have been on Foley and the self-catheterization since leaving the emergency room on January 21, 2023. You say that this has had a detrimental 
impact on your quality of life. You also say that there are no network providers that offer this service. The Plan 
denied your request. The Plan says he provided documentation does not support why the requested service is 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that treatment for lower urinary tract symptoms 
(LUTS)/benign prostatic hyperplasia (BPH) treatment will be considered medically reasonable and necessary 
when performed once in patients who have met certain criteria. 
 
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 waterjet ablation procedure. Our 
reviewer says that the requested waterjet ablation procedure is not medically necessary. Our physician reviewer 
found the provided documentation indicates that you have a neurogenic bladder which is an exclusion to 
coverage. The reviewer also says that the documentation does not show that the prostate size is 30 to 150 cubic 
centimeters (cc) by transrectal ultrasound (TRUS). 
 
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 waterjet ablation procedure have not been met. Therefore, we decided that 
the Plan does not have to pre-approve transurethral waterjet ablation of prostate (0421T) to be provided by an 
out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for hospital observation services provided on 
April 17, 2023. 
 
You asked the Plan to reduce the copayment for hospital observation services. You say that you feel that this 
was an emergency room visit. 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 $280 
copayment for in-network outpatient hospital observation visits. 
 
You have been asked to pay a $280 copayment for hospital observation services. This item/service falls within 
the in-network outpatient hospital observation visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the 
copayment for hospital observation services provided on April 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for rest home visit provided on January 30, 2023. 
 
You asked the Plan to pay for rest home visit. You say that you are requesting reconsideration for the services 
provided. 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 rest home visit provided 
on January 30, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the diagnostic imaging of the pelvis artery 
provided by an in-network provider on February 22, 2022. 
 
You asked the Plan to waive the cost sharing for the diagnostic imaging. You say that you received the bill with 
no explanation. 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 in-network Medicare-covered radiological diagnostic services, not including x-rays, when 
performed in a hospital, outpatient facility, or a free-standing imaging facility or diagnostic center. 
 You have been asked to pay a $900.82 coinsurance for the diagnostic imaging because the Plan is only holding 
you responsible for this amount, which is less than the 20% coinsurance. 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. Therefore, we decided that the Plan does not have 
to waive the cost sharing for the diagnostic imaging of the pelvis artery provided by an in-network provider on 
February 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 01, 2022. 
 
You asked the Plan to pay for an office 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 an office visit provided 
on September 01, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87637 provided on January 17, 2023. 
 
You asked the Plan to pay for procedure code 87637. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the claim for this molecular pathology testing 
did not include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of procedure code 87637 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 87637 
provided on January 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on January 25, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the wound care supplies. You say that these supplies are a separately billable 
expense that do not require authorization. The Plan denied your request. The Plan says enrollees must receive 
their care from a network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
items/services 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 wound care supplies provided on January 25, 
2023, by an out-of-network (OON) provider.