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

 
We decided that the Plan does not have to pre-approve a ViaDisc procedure (0627T) and related anesthesia 
services (00630). 
 
You asked the Plan to pre-approve a ViaDisc procedure and anesthesia services. You say that you are 
requesting reconsideration of the denied authorization. The Plan denied your request. The Plan says this 
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 a ViaDisc procedure and anesthesia 
services. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that this is an experimental therapy. 
 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 ViaDisc procedure and anesthesia services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a ViaDisc procedure (0627T) and related anesthesia services 
(00630).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient office visit, and related services provided on 
December 13, 2022, to December 21, 2022. 
 
You asked the Plan to pay for a new patient office visit, and related services. You say that these services were 
medically necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a new patient office 
visit, and related services provided on December 13, 2022, to December 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the aquatic fitness instructor certification 
program (99199) purchased on January 17, 2023. 
 
You asked the Plan to issue reimbursement for this service. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the service provided in this case 
is not a covered benefit.  
  
 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.   
 
The Plans rules for coverage of gym benefits have not been met because the service purchased in this case is 
not a covered benefit. Specifically, the Plans contract states that the wellness allowance benefit reimburses you 
up to $150 per calendar year towards your cost for membership in a qualified health club or fitness facility, 
covered instructional fitness classes, or for participation in specific wellness programs. Therefore, we decided 
that the Plan does not have to issue reimbursement for the aquatic fitness instructor certification program 
(99199) purchased on January 17, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa (J7323). 
 
You asked the Plan to pre-approve Euflexxa. You say that you are requesting reconsideration of the denied 
authorization. The Plan denied your request. The Plan says the coverage criteria has not been met. 
 
We reviewed the Local Coverage Determination (LCD) cited by the Plan and found it was not applicable to the 
state the services would be provided in. The Plan must follow Medicare rules. The rules say that Medicare pays 
for a drug or biological only if it is safe and effective and otherwise reasonable and necessary.  
 
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 Euflexxa. Our reviewer says that 
Euflexxa is not medically necessary. Our physician reviewer found that there is no documentation of the degree 
of relief with a knee steroid injection. Also, there is no documentation of a recent trial of physical therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa (J7323).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the 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 you feel that there is no provider in-network to 
treat your condition. The Plan denied your request. The Plan says you must receive your 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 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 item/service at issue in this appeal. We found no exception that would require 
the Plan to pre-approve this item/service. Therefore, we decided that the Plan does not have to pre-approve the 
office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each primary care provider telehealth visit 
provided from October 31, 2022, to January 31, 2023. 
 
You asked the Plan to waive the copayment for each primary care provider telehealth visit. You say that the 
provider could not explain what occurred during these visits. 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). The enrollees 2022 contract with the Plan clearly says that enrollees must pay a $25 copayment for each in-network primary care provider telehealth visit. The enrollees 
2023 contract with the Plan clearly says that enrollees must pay a $25 copayment for each in-network primary 
care provider telehealth visit 
 
The enrollee has been asked to pay a $25 copayment for each primary care provider telehealth visit. This 
item/service falls within the physician/practitioner services benefit category. This means that the enrollee has 
been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for each primary care provider telehealth visit provided from October 31, 2022, to 
January 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telephone evaluation and management service provided on 
February 07, 2023. 
 
You asked the Plan to pay for telephone evaluation and management service. You say that the services were 
medically necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for telephone evaluation and 
management service provided on February 07, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient stay provided on March 13, 2023. 
 
You asked the Plan to pay for an inpatient stay. 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 inpatient stay 
provided on March 13, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an in-network emergency room (ER) visit provided on 
January 13, 2022. 
 
You asked the Plan to pay for an in-network emergency room (ER) 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 in-network 
emergency room (ER) visit provided on January 13, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Supartz FX (J7321). 
 You asked the Plan to pre-approve Supartz FX. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 Supartz FX. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found in this case, you have not tried and failed 
the required drugs. There is no documentation provided indicating that the plan's required drugs would likely 
be less effective and/or likely have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Supartz FX have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Supartz FX (J7321).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services (90837) provided on March 14, 2023, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for the telehealth services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the out-of-network service was not pre-authorized or emergent. 
 
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 telehealth services (90837) provided on March 14, 
2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unspecified preventive procedure (D1999), resin-based 
composite - one surface, posterior (D2391) and resin-based composite - one surface, anterior (D2330) provided 
on January 5, 2023. 
 
You asked the Plan to pay for these dental services. You say that this should be covered. The Plan denied your 
request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for unspecified preventive procedure (D1999), resin-based composite - one surface, posterior (D2391) and resin-
based composite - one surface, anterior (D2330) provided on January 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the endodontic therapy (D3320) for tooth #13 provided 
on February 23, 2023. 
 
You asked the Plan to pay more for the dental service. You say that there were no in-network providers in your 
service area. The Plan denied your request. The Plan says your annual dental benefit maximum for the year has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows on January 30, 2023, the Plan paid $120 for dental services. On February 23, 2023, the Plan paid $1,138 
for dental services. On March 15, 2023, which was processed prior to the date of service of February 23, 2023, 
the Plan paid $742 for dental services. For the year of 2023 the Plan paid $2,000 ($120 paid + $1,138 paid + 
$742 paid) for dental services; therefore, your annual dental benefit for the year of 2023 was exhausted on the 
date of service of February 23, 2023. Therefore, we decided that the Plan does not have to pay more for the 
endodontic therapy (D3320) for tooth #13 provided on February 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the deductible for the specialist office visit provided on 
March 6, 2023. 
 
You asked the Plan to reduce the deductible for the specialist office visit. You say that you were unaware that 
the provider was out-of-network. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible which applies to the out-of-network specialist office 
visit.  
 
 You have been asked to pay $154.61 towards your deductible for the specialist office visit. The item or service 
you asked the Plan to reduce the deductible for falls within the physician/practitioner services, including 
doctors office visits benefit category. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $750 deductible which applies to physician/practitioner services, including doctors 
office visits. This cost sharing is a contractual obligation that had not been met at the time the specialist office 
visit was received on March 6, 2023. Therefore, we decided that the Plan does not have to reduce the 
deductible for the specialist office visit provided on March 6, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation 
is necessary.  The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage 
criteria have not been met. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 36 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the intraoral radiographic images (D0220 and D0230) 
and to pay for the limited oral evaluation (D0140) and the pulp vitality test (D0460) provided by an out-of-
network provider on December 7, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you were referred to the provider and you 
did not know they were an out-of-network provider. 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. Also, the denial of payment for the pulp vitality test is correct because it is 
not covered by the Plan. Your benefit for the limited oral evaluation has already been exhausted. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the limited oral evaluation was exhausted on the date of service of October 06, 2022. 
The pulp vitality test is not covered under the Plans dental benefit. For the intraoral radiographic image 
(D0220) the total amount billed was $36 and the allowed amount was $22 leaving a difference of $14 ($36 
billed - $22 allowed). For the intraoral radiographic image (D0230) the total amount billed was $31 and the 
total allowed amount was $15 leaving a difference of $16 ($31 billed - $15 allowed). 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 intraoral radiographic images (D0220 and D0230) and to pay for the limited 
oral evaluation (D0140) and the pulp vitality test (D0460) provided by an out-of-network provider on 
December 7, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided March 7, 2022, to March 17, 
2022. 
 
You asked the Plan to pay for home health services. You say that the home health services were medically 
necessary. 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 March 7, 2022. The NOA was not received by the Plan until May 5, 2022. 
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 home health services provided March 
7, 2022, to March 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a therapeutic continuous glucose monitor (CGM) and 
supplies. 
 
You asked the Plan to pay for the CGM and supplies. You say that you are appealing for procedure code 
K0553 and have submitted the medical records for review. The Plan denied your request. The Plan says proof 
of delivery is required, the documentation submitted does not include valid proof of delivery, therefore 
payment is not supported at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that for any items that do not have proof of delivery 
from the supplier, such claimed items shall be denied. We looked at the file and Medicare rules. Proof of delivery is required, the documentation submitted does not 
include valid proof of delivery, therefore payment is not supported at this time. Based on this information, we 
decided that Medicare rules for coverage of the CGM and supplies have not been met. Therefore, we decided 
that the Plan does not have to pay for a therapeutic continuous glucose monitor (CGM) and supplies.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an in-network genetic testing provided on 
September 18, 2022. 
 
You asked the Plan to waive the coinsurance for an in-network genetic testing. You say that you have had 
bloodwork done before and it never cost this much. 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 outpatient diagnostic tests and therapeutic services and supplies.  
The allowed amount of this genetic laboratory test is $2,911.58, resulting in a coinsurance amount of $583.92 
($2,911.58 x 20% = $583.92). 
 You have been asked to pay a $583.92 coinsurance for an in-network genetic testing. 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 coinsurance for an in-network genetic testing provided on September 18, 2022.