Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing visits 7 days a week. 
 
You asked the Plan to pre-approve home health skilled nursing visits 7 days a week. You say that the additional 
visits are medically necessary. The Plan denied your request. The Plan says skilled nursing visits have been 
approved twice a week. The request for 7 days a week exceeds the enrollee's needs. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health skilled nursing visits 7 
days a week. Our reviewer says that the requested services are not medically necessary. Our physician reviewer 
found the documentation doesn?t support that the enrollee requires skilled nursing services to provide treatment 
that is medically necessary 7 days a week. The enrollee does not require skilled nursing services more than the 
2 days a week that has been authorized by the health plan. The enrollee has been medically stable without any 
 
 
recent exacerbations of chronic medical problems or hospitalizations. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health skilled nursing visits 7 days a week have not been met. Therefore, 
we decided that the Plan does not have to pre-approve home health skilled nursing visits 7 days a week.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve MRI, abdomen; without contrast material(s), followed by with 
contrast material(s) and further sequences (CPT Code 74183). 
 
You asked the Plan to pre-approve the MRI. You say that the MRI is necessary. The Plan denied your request. 
The Plan says that the MRI is not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when 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 MRI. Our physician reviewer found 
the patient with high risk for hepatocellular carcinoma and now with elevated AFP. The MRI has been ordered 
and is medically reasonable and necessary in the management of this patient. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
MRI, abdomen; without contrast material(s), followed by with contrast material(s) and further sequences (CPT 
Code 74183).  
 
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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are available from network providers. 
 
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 referral to an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ubrelvy Tab. 
 
You asked the Plan to pre-approve Ubrelvy Tab. You say that the enrollee has had relief with this drug. The 
Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B benefit. 
 
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 Ubrelvy Tab.  
 
Benefits for Ubrelvy Tab 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan. 
 
You asked the Plan to pre-approve Hyalgan. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug does not meet step therapy 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 Hyalgan. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee pain related to osteoarthritis of the right knee, diagnosis confirmed with imaging 
studies. The enrollee has failed conservative treatment. The documentation does not support that the enrollee 
has tried and failed Orthovisc and Monovisc. The documentation does not support any indication that the plan's 
required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hyalgan.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gelsyn 3. 
 
You asked the Plan to pre-approve Gelsyn 3. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug does not meet step therapy 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 Gelsyn 3. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has pain related to osteoarthritis of the right knee. She has failed conservative 
treatment and prior treatment with Orthovisc and Euflexxa. The documentation does not support that the 
enrollee has had a trial and failure of Monovisc. The documentation does not include any indication that 
Monovisc would likely be less effective and/or likely have adverse effects for the enrollee. 

Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gelsyn 3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gelsyn 3.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor sensor as identified by 
code A9276. 
 
You asked the Plan to pre-approve the requested sensor. The Plan denied your request. The Plan says Medicare 
only covers the requested device when using certain code numbers. 
 
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 find that CPT code A9276 is not used to bill for supplies used with a therapeutic continuous glucose 
monitor. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a continuous glucose monitor sensor as identified by 
code A9276.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair upgraded electronics. 
 
You asked the Plan to pre-approve the power wheelchair Electronic connection (E2311), Expandable controller 
harness (E2313), and Expandable controller (E2377). You say that you need a new power wheelchair, 
accessories and upgraded electronics. The Plan denied your request. The Plan says the notes do not show a 
medical need to control power options through the joystick. 
 
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.  
 
 
 
The documentation indicates you have sufficient functional ability in the upper extremities to control the power 
features through their own individual switches. This means that Medicare rules for coverage of power 
wheelchair upgraded electronics have not been met. Therefore, we decided that the Plan does not have to pre-
approve power wheelchair upgraded electronics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6545. 
 
You asked the Plan to pre-approve compression stockings. You say that you need this because it will go higher 
on your leg. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6545 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code 
A6545.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain crown (D2740), core build up (D2950), and 
a pulp cap (D3120). 
 
You asked the Plan to pre-approve the dental services. You say that you need these services. You say that your 
health will be at risk if you do not get them. You also say that you cannot eat well. The Plan denied your 
request. The Plan says porcelain crown is not listed as a covered service. The Plan says that core build up is not 
listed as a covered service. The Plan also says that pulp cap is not listed as 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 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 
porcelain crown (D2740), core build up (D2950), and a pulp cap (D3120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and appliance (E0673). 
 
You asked the Plan to pay for a pneumatic compression device and appliance. You say that you would like the 
Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0675 to treat PAD is not eligible for 
reimbursement. A PCD coded as E0675 is used only for peripheral artery disease. Other PCD codes are not 
used for this condition. PCD related accessories are eligible for reimbursement only when the appropriate, 
related base PCD meets coverage criteria for that type of PCD. The file shows CPT code E0675 was billed 
along with E0673 (x2). As E0675 is not eligible for payment, E0673 is also not payable in this case. Therefore, 
we decided that the Plan does not have to pay for a pneumatic compression device (E0675) and appliance (E0673).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (PWC). 
 
You asked the Plan to pre-approve these services. You say that you need the PWC to go to doctor 
appointments. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a power wheelchair (PWC).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services (99203 & 97110) provided. 
 
You asked the Plan to pay for the chiropractic services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says these services were not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for chiropractic services (99203 & 97110) provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core build up (D2950). 
 
You asked the Plan to pre-approve the core build up. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the requested dental service is not a covered 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 
core build up (D2950).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a visit with an out-of-network physician at the in-
network rate. 
 
You asked the Plan to pre-approve the visit with an out-of-network physician. You say that this provider is the 
best provider to treat your condition. The Plan denied your request. The Plan says you may see the out-of-
network provider, however the in-network rate can only be applied when the plan does not have in-network 
providers available. The plan has in-network providers available. 
 
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 provide care from out-of-network providers at the in-network rate only in cases 
involving emergencies, out of area urgent care and care that cannot be provided by network providers. Utilizing 
out-of-network providers otherwise may result in higher costs. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to apply the in-network rate in this case. Therefore, we decided that the Plan does not have to pre-approve 
a visit with an out-of-network physician at the in-network rate.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prefabricated post and core in addition to a crown 
(D2954) for tooth # 30. 
 
You asked the Plan to pre-approve the dental service. You say that the prefabricated post and core in addition 
to a crown is medically necessary. The Plan denied your request. The Plan says prefabricated post and core in 
addition to a crown is not listed as a covered service. The Plan also says that any service not listed is 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. The Customer Handbook clearly states that if a dental item or service 
is not listed in the benefit chart or listed with NC, then it is not covered. Therefore, we decided that the Plan 
does not have to pre-approve a prefabricated post and core in addition to a crown (D2954) for tooth # 30.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mammography services (77061) provided May 18, 2020. 
 
You asked the Plan to pay for the mammography services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says this CPT code is not payable under Medicare. 
 
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 find that CPT code 77061 is not supported. Specifically, this CPT code is marked with a status code of "I" 
per the 2020 National Physician Fee Schedule and is not eligible for Medicare payment. Based on this 
information, we decided that Medicare rules for coverage of the mammography services have not been met. 
Therefore, we decided that the Plan does not have to pay for mammography services (77061) provided May 18, 
2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for surgical repair of a hip fracture after a fall. 
The patient was discharged home where she is receiving home health services but remains weak. Medical 
conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing 
or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
documents a need for physical and occupational therapy, it does not document a need for an intensive 
rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox to be provided by an out of network (OON) 
provider. 
 
You asked the Plan to pre-approve Botox. You say that you would like approval for these services. The Plan 
denied your request. The Plan says they have redirected care to an in-network pharmacy for these services. 
 
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 
Botox to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services you received on July 17, 2020, from an 
OON provider. 
 
You asked the Plan to pay for the medical services. You say that you were not aware that you had to use 
network providers and that you cannot afford to pay this bill. The Plan denied your request. The Plan says 
unauthorized, non-plan care is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this appeal were not provided in an emergency or urgent care situation. These services 
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not 
have to pay for these medical services.  Please note that under the terms of your contract, if you receive out-of-
network care that isn't covered by the Plan, then those services are covered by Original Medicare.  You will be 
responsible for Original Medicare cost sharing amounts.