Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Victoza. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee has been on this medication since 
2020, and a change in treatment would not be appropriate. 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 Victoza.  
 
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 pre-approve an RFA. 
 
You asked the Plan to pre-approve an RFA. You say that the requested procedure is medically necessary. The 
Plan denied your request. The Plan says the requested procedure does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that an RFA is not medically necessary.  
 
We looked at the file and Medicare rules. Specifically, that the requested RFA procedure is not considered 
medically necessary. Based on this information, we decided that Medicare rules for coverage of an RFA have 
not been met. Therefore, we decided that the Plan does not have to pre-approve an RFA.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on July 18, 2023. 
 
You asked the Plan to pay for the ambulance services. You did not provide a specific argument with your 
appeal request. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim 
and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on August 4, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for the ambulance services have not been met. 
Therefore, we decided that the Plan does not have to pay for ambulance services provided on July 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a primary care provider visit provided on 
September 21, 2023. 
 
You asked the Plan to waive the copayment for a primary care provider visit. You say that this was an annual 
wellness visit and should not have a 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 $15 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $15 copayment for a primary care provider 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 waive the copayment for a primary care provider visit provided on September 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for coverage. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the cause of pain is not clear. There is no imaging showing only Modic changes 
without facet degrative joint disease (DJD) or stenosis. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on May 
13, 2023, to May 17, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that the enrollee was under 
observation status. 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 $335 
copayment for inpatient hospital care. 
 
You have been asked to pay a $335 copayment for the inpatient hospital stay. 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. The medical records show the enrollee was admitted as an inpatient on May 15, 2023. The 
enrollee has been asked to pay $670, which is a $335 copayment for days one to two of the inpatient stay ($335 
copayment x 2 days = $670). Therefore, we decided that the Plan does not have to waive the copayment for the 
inpatient hospital stay provided on May 13, 2023, to May 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on July 27, 2023, billed with 
procedure code 99442. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim is billed with an inappropriate diagnosis 
code. 
 
The Plan must follow Medicare rules. Medicare rules say that it is not appropriate to bill a left and right sided 
diagnosis code when a bilateral code is available. 
 We looked at the file and Medicare rules. The claim was reported with a right and left side diagnosis which is 
inappropriate as a bilateral diagnosis is available. Based on this information, we decided that Medicare rules for 
coverage of the practitioner services provided have not been met. Therefore, we decided that the Plan does not 
have to pay for practitioner services provided on July 27, 2023, billed with procedure code 99442.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve the office visit. You say that the services are medically necessary. The Plan 
denied your request. The Plan says there are available providers within the network who can provide the care 
needed. 
 
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 office visit to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray provided on October 11, 2023. 
 
You asked the Plan to waive the copayment for an x-ray. You say that you say that you already met you out-of-
pocket maximum. 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 $15 
copayment for outpatient hospital services. 
 
You have been asked to pay a $15 copayment for an x-ray. This item/service falls within the outpatient hospital 
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 an x-ray provided on 
October 11, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Procrit (J0885). 
 
You asked the Plan to pre-approve Procrit. You say that the patient has to have this injection. You also say that 
it is crucial. The Plan denied your request. The Plan says the clinical value and effectiveness of Procrit for your 
condition has not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Procrit. Our reviewer says that the 
requested use of Procrit is not medically necessary. Our physician reviewer found the requested use of this drug 
is not indicated by the Food and Drug Administration (FDA) for the enrollee's condition. The reviewer also 
found that the requested use is not supported by one of the major drug compendia or by clinical research that 
appears in a CMS-approved medical journal. Therefore, the reviewer found that the requested use of Procrit is not medically reasonable or 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 Procrit have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Procrit (J0885).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the endodontic therapy, of a premolar tooth (excluding 
final restoration) (D3330) provided on August 24, 2023. 
 
You asked the Plan to pay more for this dental service. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider.  
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for the endodontic therapy, of a premolar tooth 
(excluding final restoration) (D3330) provided on August 24, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the debridement of a wound provided on 
August 31, 2023. 
 
You asked the Plan to waive the copayment for the debridement of a wound. You say that you were never told 
this was considered to be outpatient surgery. 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 $295 
copayment for each Medicare-covered outpatient hospital facility visit. 
 
You have been asked to pay a $295 copayment for the debridement of a wound. This item/service falls within 
the each Medicare-covered outpatient hospital facility visit 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 debridement of a wound provided on August 31, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a neck ultrasound provided on July 31, 
2023. 
 
You asked the Plan to waive the copayment for a neck ultrasound. You say that this test should not have a 
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 $110 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $110 copayment for a neck ultrasound. 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 $95.24. Therefore, we decided that the Plan does not have to waive the 
copayment for a neck ultrasound provided on July 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special height arms for wheelchair (E1227), and special 
wheelchair seat height from floor (E1296). 
 
You asked the Plan to pre-approve the wheelchair features. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says these items are unbundled and cannot be covered 
separately. 
 
The Plan must follow Medicare rules. Medicare rules say that codes E0968, E0969, E0970, E0980, E0994, 
E1227, E1228, E1296, E1297, E1298, and E2340, E2341, E2342, E2343 are not valid for claim submission. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the wheelchair features have not been met. Therefore, we decided that the Plan does not have to 
pre-approve special height arms for wheelchair (E1227), and special wheelchair seat height from floor (E1296).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for outpatient practitioner services provided 
on July 28, 2023, to August 29, 2023. 
 
You asked the Plan to waive the coinsurance for outpatient practitioner services. You say that you are 
requesting reconsideration for the denied claim. 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 physician/practitioner services, including doctors office visits. 
 
You have been asked to pay 40% coinsurance for outpatient practitioner services. 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 waive the coinsurance for outpatient practitioner services provided on July 28, 2023, to August 29, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Myrbetriq. 
 
You asked the Plan to pre-approve Myrbetriq. 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 Myrbetriq.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management of an established patient 
provided on October 23, 2023. 
 
You asked the Plan to pay for evaluation and management of an established patient. You say that you are 
requesting reconsideration for the denied claim. 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 evaluation and 
management of an established patient provided on October 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (80307, G0480) provided on September 19, 
2023. 
 
You asked the Plan to pay for drug testing (80307, G0480). You say that the services at issue were a necessity 
for the enrollees care. 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 drug testing (80307, 
G0480) provided on September 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second-opinion consultation to be provided by an out-
of-network (OON) provider.  
 
You asked the Plan to pre-approve a second-opinion consultation. You say that the requested services are a 
necessity for your care. The Plan denied your request. The Plan says rules for coverage for OON services have 
not been met. 
 
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 
a second-opinion consultation to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant at surgery services provided on July 31, 2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the service is 
outside the scope of the provider. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
 
 
 In this case, the record does not show that the provider of the surgical assistant service was a physician, PA, 
NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types 
of practitioners. Therefore, we decided that the Plan does not have to pay for the assistant at surgery services 
provided on July 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on August 9, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
available in-network. 
 
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 services at issue in this appeal. 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 the services provided on August 9, 2023, by an out-of-network 
(OON) provider.