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

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says there is no agreement that the requested medication can effectively relieve 
the symptoms and improve the results of gastric emptying study in patients with gastroparesis. 
 
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 Botox. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the enrollee has a diagnosis of 
Gastroparesis with Nausea and vomiting, unspecified. The enrollee has a large hiatal hernia. The unlabeled use 
of the requested FDA-approved drug is not medically accepted as safe and effective or appropriate for the 
particular use being requested. There is conflicting data in the current medical literature regarding the efficacy 
of Botox for the treatment of refractory gastroparesis. Based on current evidence, the use of Botox for the 
management of gastroparesis has not been sufficiently demonstrated to be safe and effective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 1200 units of tape, waterproof, per 18 square inches 
(A4452) per 90 days for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that  The Plan denied your request. The Plan says 
that the amount of supplies requested is more than what is reasonable and 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 these services. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. The 
explanation for use of a greater quantity of supplies than the amounts listed must be clearly documented in the 
beneficiarys medical record. If adequate documentation is not provided when requested, the excess quantities 
will be denied as not reasonable and necessary. In this case, the member is requesting beyond the listed 
maximum amount to meet their personal demands as the member likes to swim. Our physician reviewer found 
that the enrollee's condition does not meet Medicare criteria for these services. 
 
 
 
 
 
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 1200 units of tape, waterproof, per 18 square inches (A4452) per 90 days for the enrollee.  
 
Please note, the Plan has approved 240 units of tape, waterproof, per 18 square inches (A4452) per 90 days.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen concentrator provided by 
an out of network (OON) provider. 
 
You asked the Plan to pay for oxygen concentrator. You say that you were told by this provider that they 
accepted insurance, but you would have to request reimbursement yourself. The Plan denied your request. The 
Plan says the denial of payment for this item is correct, because this provider is out-of-network with the Plan, 
this item could have been obtained from an in-network supplier, and this item is only covered as a rental. 
 
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 has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the oxygen concentrator provided on November 
26, 2019 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 DME provided on June 10, 2020. 
 
You asked the Plan to waive the coinsurance for DME. You say that you were not informed of the charges and 
already had a device at home. The Plan denied your request. The Plan says the claims were processed correctly 
and you are being charged the correct amount. 
 
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 DME and related supplies.  
 
You received DME on June 10, 2020. The allowed amount is $1,187.35 and 20% of that is $237.47.  
 
You have been asked to pay the total coinsurance amount of $237.47 for DME. DME falls within the DME and 
related 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 DME provided on June 
10, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spine surgery with allograft and autograft for the 
enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are no physical exam findings or documented neurologic deficit. 
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found more details are needed to justify the surgery. There is no documentation of exam findings. The surgery 
is not justified. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve spine surgery with allograft and autograft for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a Computed Tomography (CT) scan 
provided. 
 
You asked the Plan to waive the copayment for CT scan. You say that this copayment is too high and you 
cannot afford to pay it. The Plan denied your request. The Plan says the copayment amount you are being 
charged is correct. 
 
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 $110 
copayment for in-network CT scan.  
 
You have been asked to pay $110 copayment for CT scan. CT scan 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 copayment 
for a Computed Tomography (CT) scan provided.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ultrasound ethanol ablation services to be provided 
by an out of network (OON) provider. 
 
You asked the Plan to pre-approve the ultrasound ethanol ablation services. You say that you would like the 
Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither 
emergent nor urgent to seek out-of-network care. The Plan says there are equally qualified in-network 
providers available to the enrollee that can provide the ultrasound ethanol ablation services being requested. 
 
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 
the ultrasound ethanol ablation services to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Coflex device (22867). 
 
You asked the Plan to pre-approve a Coflex device. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage 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 a Coflex device. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Coflex device is experimental. More research is needed to show safety and efficacy. There 
is no spinal instability documented. 
 
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 Coflex device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Coflex device (22867).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fluoride application (D1206), a pulp cap (D3120), 
antimicrobial agents (D4381), periodontal maintenance (D4910). gingival irrigation (D4921), and other dental 
drugs (D9630). 
 
You asked the Plan to pre-approve fluoride application, a pulp cap, antimicrobial agents, periodontal 
maintenance, gingival irrigation, and other dental drugs. You say that these services are medically necessary. 
The Plan denied your request. The Plan says these 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
fluoride application (D1206), a pulp cap (D3120), antimicrobial agents (D4381), periodontal maintenance 
(D4910). gingival irrigation (D4921), and other dental drugs (D9630).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvethe Optimizer Smart implantable pulse generatorYou asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysmedical studies have not proven that this device is helpful for treatment of the health problem.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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this circumstance treatment with the Optimizer System (CPT0408T) device has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. Moreover, the trial was very small (only 160 patients) and the results for the composite endpoint barely reached statistical difference (p=0.048). Therefore the efficacy of the Optimizer System (CPT0408T) is still uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure.  Medicare coverage criteria are not met since the device should still be considered experimental or investigational.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 services have not been met.Therefore, we decided that the Plandoes not haveto pre-approvethe Optimizer Smart implantable pulse generator.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee was discharged from skilled 
therapies before being ready. The Plan denied your request. The Plan says the enrollee's needs are custodial in 
nature. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 SNF services. Our physician reviewer 
found that the enrollee does not have any parental medication, complex wound care, or nutrition given via a 
feeding tube. She is medically stable, without any acute exacerbations of chronic medical problems. Her 
physical function is at or near her baseline. She does not require skilled nursing or skilled therapy services on a 
daily basis.  Therefore an admission to a SNF for inpatient skilled rehab services is not medically 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on June 
13, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you feel you should not 
be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan 
denied your request. The Plan says you received ambulance services on the date of service at issue in this 
appeal. The Plan says that the correct copayment has applied per your contract with the Plan. 
 
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 $220 
copayment for Ambulance services.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received ambulance 
services on June 13, 2020. You have been asked to pay a $220 copayment for the ambulance services. The 
ambulance services fall within the Ambulance services benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for the ambulance services provided on June 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the needle electromyography (EMG) testing and 
neuromuscular junction (NMJ) testing provided as part of intraoperative monitoring billed 
with codes 95870 and 95937. 
 
You asked the Plan to pay for the EMG/NMJ testing. You say that the services provided were billed correctly. 
The Plan denied your request. The Plan says the codes at issue are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our coding 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 pay for the EMG/NMJ testing. Our reviewer says 
that the billed codes are not supported in the records provided. Our coding reviewer found code 95870 is 
defined as Needle electromyography; limited study of muscles in 1 extremity or non-limb (axial) muscles 
(unilateral or bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters. The 
medical records provided do not include sufficient documentation to support two units of a Needle 
electromyography. Code 95937 is defined as Neuromuscular junction testing (repetitive stimulation, paired 
stimuli), each nerve, any 1 method. The medical records indicate that Train of Four testing was performed 
which does not meet CMS description of CPT 95937. There is no specific CPT code that is used for Train of 
Four Testing. 
 
 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the EMG/NMJ testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the needle electromyography (EMG) testing and neuromuscular junction (NMJ) 
testing provided as part of intraoperative monitoring billed with codes 95870 and 95937.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided 
from July 15, 2020 to July 17, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you feel you 
should not be responsible for this cost share amount and you would like the Plan to reconsider your request. 
The Plan denied your request. The Plan says you received inpatient hospital care on the dates of service at issue 
in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan. 
 
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 $370 
copayment per day for days 1-5 for Inpatient hospital care.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received inpatient 
hospital care from July 15, 2020 to July 17, 2020. You have been asked to pay a $370 copayment per day for 
days 1-2 for the inpatient hospital services, totaling $740. The inpatient hospital services fall within the 
Inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient 
hospital services provided from July 15, 2020 to July 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided 
that the Plan does not have to pre-approve a pneumatic compression device (E0676).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a CPAP device and humidifier for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the plan has no contractual obligation to cover services that are not medically 
necessary, or that do not meet Medicare criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if they are medically 
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 device. Our reviewer says that the 
requested device is considered medically reasonable and necessary in this case. Our physician reviewer found 
another 3-month trial of CPAP is considered reasonable and medically necessary. The enrollee was prescribed 
CPAP for moderate to severe obstructive sleep apnea, in January 2020. She has not been able to tolerate the 
interface. A followup telehealth visit took place to address this on 8/26/2020. A plan is in place to try to 
achieve compliance with the device. It is in the enrollee's best interests to try it again. 
 
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 device have been met. Therefore, we decided that the Plan has to pre-
approve a CPAP device and humidifier for the enrollee.  
 
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.