Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of lateral exostosis (D7471). 
 
You asked the Plan to pre-approve the dental services. You say please review the attached for processing. The 
Plan denied your request. The Plan says this service is not listed as covered under the plan benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The health plan contract 
specifically says that any service not listed under the list of covered dental procedures is not covered by the 
plan. 
 
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 pre-approve 
removal of lateral exostosis (D7471).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 power wheelchair. 
 
You asked the Plan to pre-approve the group 2 power wheelchair. You say that you would like reconsideration 
because this wheelchair is medically necessary. The Plan denied your request. The Plan says you do not meet 
LCD criteria for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 group 2 power wheelchair. Our 
reviewer says that the documentation does not show that a home evaluation has been performed to ensure safe 
access in the home. No trial or demonstration of safe use of power wheelchair is documented. The prescriber 
answered "YES" to whether you are able to maneuver a manual wheelchair in/out of home independently. Our 
physician reviewer found the medical notes give no detail of your current functional or ambulatory status. 
 
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 group 2 power wheelchair have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a group 2 power wheelchair.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the upper gastrointestinal endoscopy (43235). 
 
You asked the Plan to pre-approve the upper gastrointestinal endoscopy. You say that you are appealing for the 
upper endoscopy. The enrollee is currently using Gaviscon for intractable GERD symptoms. She has recurrent 
reflux. The Plan denied your request. The Plan says the Medicare medical necessity criteria has not been met. 
 
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 upper gastrointestinal endoscopy. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee meets none of the LCD coverage criteria above. 
Specifically, available records do not support that the enrollee had at the time intractable upper abdominal 
distress which persisted despite an appropriate trial of optimally-dosed PPI therapy. As such, Medicare medical 
necessity criteria has not been met. 
 
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 upper gastrointestinal endoscopy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the upper gastrointestinal endoscopy (43235).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Medical nutrition therapy 
 
You asked the Plan to pre-approve Medical nutrition therapy. You say that you agree with the wound care 
center that seeing a nutritionist would be beneficial to assist with her management of malnutrition and low 
protein levels. The Plan denied your request. The Plan says this service is not covered under the plan benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the 
Plan does not have to pre-approve Medical nutrition therapy
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eyeglasses.
You asked the Plan to pre-approve eyeglasses. You say that because of a medical condition you need new eyeglasses now. The Plan denied your request. The Plan says you received eyeglasses on September 20, 2019 and are not eligible for eyeglasses until September 1, 2021.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pre-approve are considered routine vision services or eyewear. Therefore, we decided that the Plan does not have to pre-approve eyeglasses.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift chair. 
 
You asked the Plan to pre-approve the chair. You say that the seat lift chair is medically necessary.  The Plan 
denied your request. The Plan says that the lift mechanism will be approved, but payment is limited to the lift 
mechanism and the chair is not covered. 
 
The Plan must follow Medicare rules. The rules say that payment is limited to the lift mechanism itself and not 
the chair component. 
 
We looked at the file and Medicare rules. Payment is limited to lift mechanism only. Therefore, we decided 
that the Plan does not have to pre-approve the chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bath/shower chair. 
 
You asked the Plan to pre-approve the bath/shower chair. You say that the shower chair is medically necessary. 
The Plan denied your request. The Plan says the shower chair is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve bath/shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shoe insert (L3000). 
 
You asked the Plan to pre-approve a shoe insert. You say that this was previously approved. The Plan denied 
your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that inserts and other shoe modifications are covered 
if they are on a shoe that is an integral part of a covered brace and if they are medically necessary for the proper 
functioning of the brace. 
 
We looked at the file and Medicare rules. The record does not show that the requested insert is for a shoe that is 
an integral part of a brace. Based on this information, we decided that Medicare rules for coverage of a shoe 
insert have not been met. Therefore, we decided that the Plan does not have to pre-approve a shoe insert 
(L3000).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you have a leg length discrepancy and do not 
want future problems with your knees or hip. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre CGM. 
 
You asked the Plan to pre-approve the CGM. You say that you would like reconsideration because the member 
is using a glucometer but has been when using the lancets. The Plan denied your request. The Plan says the 
member is not insulin treated with multiple daily injections of insulin or using a Medicare covered continuous 
subcutaneous insulin fusion pump. 
 
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 the CGM. Our reviewer says that based 
on the medical records provided there is no documentation that the enrollee meets the Local Coverage 
Determination (LCD): Glucose Monitors (L33822) criteria for the requested Freestyle Libre 14 day glucose 
monitor device. Our physician reviewer found the enrollee is not insulin treated with multiple daily injections 
of insulin or using a Medicare covered continuous subcutaneous insulin fusion pump. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Freestyle Libre CGM.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that the enrollee needs this shower chair to keep her 
safe from harm. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Xolair. 
 
You asked the Plan to pre-approve the Xolair. You say that you would like reconsideration because this drug is 
medically necessary. The Plan denied your request. The Plan says that the FDA has not approved this drug for 
the member's condition. 
 
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 the Xolair. Our reviewer says that the 
requested use of Xolair is supported by clinical research. Our physician reviewer found the requested use of 
Xolair is not listed as not indicated, not supported or not recommended in any of the Medicare compendia. 
 
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 Xolair have been met. Therefore, we decided that the Plan has to pre-
approve Xolair.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Guided Tissue Generation (D4266) and a Removal of 
Lateral Exostosis (D7471). 
 
You asked the Plan to pre-approve the dental procedures. You say that the services are medically necessary. 
The Plan denied your request. The Plan says the requested dental procedures are not covered under your dental 
benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s 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 pre-approve a 
Guided Tissue Generation (D4266) and a Removal of Lateral Exostosis (D7471).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve an office visit (99213) with the out of network provider.
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's
denial. The Plan denied your request. The Plan says that in-network providers are available to provide the
requested service.
Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is
considered accessible to an enrollee if contract providers are available within reasonable distance and travel
time from the enrollee's home. The Plan says that enrollees must use contract providers.
The provider is a non-contract provider. We were able to confirm that the Plan does not have contract providers
located within reasonable distance and travel time from your home who can provide this service. The time and
distance noted by the plan for indicated contract providers could not be confirmed. The actual time and
distance were beyond what is considered accessible. Under Medicare rules, this means that contract providers
are not accessible to you. Therefore, we decided that the Plan has to pre-approve an office visit (99213) with
the out of network provider.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator for the enrollee. 
 
You asked the Plan to pre-approve a home ventilator. You say that this is medically necessary for the enrollee. 
The Plan denied your request. The Plan says that the records show that the member has sleep apnea, which 
disqualifies the member for a home ventilator for chronic respiratory failure. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that a home ventilator is not medically reasonable and necessary for the enrollee in this case. There is no 
documentation of increased pCO2. The treating physician indicates the patient is on BiPAP. Medicare does not 
cover a home ventilator when used as BiPAP. A home ventilator is not needed or indicated for the treatment of 
obstructive sleep apnea. It appears the patient's needs could be met with BiPAP. Our physician reviewer found 
that the enrollee's condition does not meet Medicare criteria for a home ventilator. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental extraction with an out-of-network dentist. 
 
You asked the Plan to pre-approve the extraction. The Plan denied your request. The Plan says out-of-network 
services are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit when provider by an out-of-network dentist. The Plan contract states that 
dental services are not covered from out-of-network providers. Therefore, we decided that the Plan does not 
have to pre-approve a dental extraction with an out-of-network dentist.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve six physical therapy (PT) visits. 
 
You asked the Plan to pre-approve these services. You say that you need physical therapy. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 these services. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the submitted records show that you were seen by your doctor on July 
7, 2020 via telehealth and were referred to physical therapy for your left hip pain. There is no documentation 
by a physical therapist with evaluation, a plan of care, or goals. There is no documentation to support that the 
requested therapy is generally accepted as specific and effective therapy for your condition or required to safely 
and effectively provide treatment. The PT is not reasonable or medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve six physical therapy (PT) visits.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MAZE cardiac ablation procedure.
You asked the Plan to pre-approve the MAZE cardiac ablation procedure. You say that you suffer with
persistent unremitting atrial fibrillation. You say that you feel short-of-breath, dizzy, and unable to tolerate
normal physical exertion. You say that your condition is getting progressively worse. You say that your
medical records show that you have exhausted conservative medical management. You say that your heart
could stop at any moment and that the treatment cannot be postponed any longer. The Plan denied your request.
The Plan says the requested surgery is considered investigational.
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 MAZE cardiac ablation procedure.
Our reviewer says that the requested services are not considered medically reasonable and necessary in this
case. Our physician reviewer found, based on the records, the enrollee has atrial fibrillation. In this
circumstance, if a rhythm control strategy is preferred then a trial of antiarrhythmic medication is the preferred
initial approach. If that fails, then consideration of catheter based endocardial ablation is made. Surgical
ablation (VATS Cox maze) has not been adequately studied compared to endocardial ablation and is generally
not recommended as a stand-alone procedure. It is considered appropriate only when additional heart surgery
is required such as CABG or valve replacement.
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 MAZE cardiac ablation procedure have not been met. Therefore, we decided
that the Plan does not have to pre-approve a MAZE cardiac ablation procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics (L3216). You say that you need the orthotics. The Plan denied 
your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the orthotics are not an integral part of a brace. Although orthotics may be appropriate for 
you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided 
that the Plan does not have to pre-approve foot orthotics.
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 the Euflexxa. You say that you would like reconsideration because this drug 
is medically necessary. The Plan denied your request. The Plan says the member does not meet step therapy 
exception criteria. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Euflexxa. Our reviewer says that the 
enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as 
outlined by the plan, requires these be trialed first. Our physician reviewer found the documentation does not 
outline contraindications or reasons these medications were not considered. 
 
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 Euflexxa have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Euflexxa (J7323).