Persius/hicric huggingface dataset:
Appeal type: Drugs
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 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 Botox. 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 a past medical history of bladder cancer and overactive bladder. The 
documentation does not support that the enrollee has tried and failed two muscarinic receptor antagonists (e.g. 
oxybutynin and trospium). The documentation does not support that muscarinic receptor antagonists 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 Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zoledronic Acid. 
 
You asked the Plan to pre-approve Zoledronic Acid. You say that the requested Zoledronic Acid is medically 
necessary. The Plan denied your request. The Plan says the requested Zoledronic Acid is not medically 
necessary. 
 
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 Zoledronic Acid. Our reviewer says 
that the requested Zoledronic Acid is not medically necessary. Our physician reviewer found the enrollee is 
with a diagnosis of osteoporosis. Based on the medical records provided there is no documentation that 
supports that the zoledronic acid injection is medically reasonable and necessary for the enrollee. No bone 
density scan (DEXA scan) results are included in the records; the records indicate that the enrollee has not had 
an osteoporotic fracture and her renal function appears to be borderline for use of bisphosphonates. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zoledronic Acid have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Zoledronic Acid.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the outpatient evaluation (99214) to be provided by an 
out of network (OON) provider. 
 
You asked the Plan to pre-approve the outpatient evaluation. You say that you need to have this appointment 
approved because you need to know the results after the MRI. The Plan denied your request. The Plan says 
enrollees must receive their medical services from an in-network provider. If an enrollee requires medical care 
that Medicare requires the plan to cover and there are no in-network providers who can provide the care then 
the enrollee can receive the care from an out-of-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 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 outpatient evaluation (99214) to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monovisc. 
 
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 not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has pain related to 
osteoarthritis of the left knee. The diagnosis is confirmed with imaging studies. The Plan has authorized 
Synvisc. The documentation does not support that Monovisc is reasonable and medically necessary for the 
enrollee in addition to the approved Synvisc. 
 
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 Monovisc.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve echocardiography (93306) and vascular studies (93880, 
93978). 
 
You asked the Plan to pre-approve echocardiography and vascular studies. You say that this should be 
approved based on the enrollee's history. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal, echocardiography and vascular studies, is being requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pre-approve echocardiography (93306) and vascular studies (93880, 93978).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LINX procedure. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says benefits are not available for this service. 
 
The Plan must follow Medicare rules. Medicare rules say that the LINX procedure is not a covered service. 
 
The requested procedure is statutorily not covered. Based on this information, we decided that Medicare rules 
for coverage of the procedure have not been met. Therefore, we decided that the Plan does not have to pre-
approve the LINX procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continued referral to an out-of-network dermatology 
provider 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says the COVID-19 public health emergency and clinical backlogs make this out-of-network 
request for only one visit medically necessary in order to obtain the adequate frequency of skin cancer follow-
up. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 referral. Our reviewer says that the 
requested referral is not medically reasonable or necessary. Our physician reviewer found there is no medical 
necessity to continuing care with out-of-network dermatology provider beyond one visit as long as there is no 
backlog within the in-network to allow regular skin exams. 
 
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 referral have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continued referral to an out-of-network dermatology provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and complete 
mandibular denture (D5120). 
 
You asked the Plan to pre-approve the complete maxillary and complete mandibular dentures. You say that the 
enrollee's previous dentures have broken. You also say that without dentures, the enrollee is unable to obtain 
proper nutrition. The Plan denied your request. The Plan says the benefits for these services have been 
exhausted. 
 
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, complete maxillary denture (D5110) 
and complete mandibular denture (D5120) are each limited to one procedure every five plan years. The record 
shows that the enrollee received a complete maxillary denture (D5110) and complete mandibular denture 
(D5120) on May 29, 2018, and the enrollee's complete maxillary denture (D5110) and complete mandibular 
denture (D5120) benefits have been exhausted. Therefore, we decided that the Plan does not have to pre-
approve a complete maxillary denture (D5110) and complete mandibular denture (D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve supplies for a continuous glucose 
monitor. 
 
You asked the Plan to pre-approve continuous glucose monitor. You say that in order to achieve optimal blood 
glucose control, these items are a medical necessity. The Plan denied your request. The Plan says the denial of 
authorization for these items is correct, because Medicare only covers therapeutic continuous glucose monitors. 
 
The Plan must follow Medicare rules. Medicare rules say that a continuous glucose monitor which does not 
replace a blood glucose monitor for making diabetes treatment decisions is not covered.  
 
We looked at the file and Medicare rules. The is not intended to replace a blood glucose 
monitor for making diabetes treatment decisions; therefore, this non-therapeutic CGM and associated supplies 
are not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve supplies for a 
Medtronic 670G continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transfer bench for tub or toilet. 
 
You asked the Plan to pre-approve a transfer bench. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that transfer benches 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 transfer bench for tub or toilet.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve DUROLANE 1mg injection for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not covered under Medicare Part B, although there may be coverage under 
Medicare Part D. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve DUROLANE 1mg injection for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 pressure reducing mattress. 
 
You asked the Plan to pre-approve pressure reducing mattress. You say that the enrollee has an unstageable 
pressure ulcer location on the back-center of her spine. The Plan denied your request. The Plan says the denial 
of authorization for this item is correct, because the enrollee does not meet the Medicare criteria for this 
mattress. 
 
The Plan follows Medicare rules. Medicare rules say that group 2 pressure reducing support surfaces are 
covered when the above listed clinical criteria have been met. 
 
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 pressure reducing mattress. Our 
reviewer says that the enrollee does not meet the Medicare criteria for the requested group 2 pressure reducing 
mattress. Our physician reviewer found the enrollee does not have multiple or large pressure ulcers noted on 
the trunk or pelvis. Without the support of the documentation, medical necessity cannot be determined. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of pressure reducing mattress have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a group 2 pressure reducing mattress.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the rest home visit services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve these OON services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services can be provided by 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 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 rest home visit services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
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 not medically necessary. 
 
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 patients 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 these services. Our reviewer says that 
the enrollee does not meet the criteria for coverage. Our physician reviewer found the submitted records 
support that you have a mobility deficit that interferes with the ability to perform mobility-related activities of 
daily living (MRADLs) in the home but the records do not support that the mobility deficit cannot be helped by 
the use of a manual wheelchair or walker. Given that the manual wheelchair or walker would be appropriate to 
meet your needs, a power scooter is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your 
request. The Plan says the LCD requires that the enrollee must take insulin three or more times daily. 
 
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 monitor. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found based on the medical records provided there is no documentation that the enrollee is using insulin 
multiple times (3 or more) a day. There is no documentation that the enrollee requires frequent adjustment of 
the insulin dose on the basis of testing results. There is documentation in the records that the Lantus dose is 
titrated on a weekly basis. 
 
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 monitor have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continuous glucose monitor.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Genvisc for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested agent is subject to step therapy. 
 
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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the enrollee has not 
trialed viscosupplemental treatments such as Orthovisc and Monovisc.  Step therapy, as outlined by the plan, 
requires these be trialed first. The documentation does not outline contraindications or reasons these 
medications were not considered. Without the support of the documentation, Genvisc is not approved as step 
criteria is not 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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Genvisc for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex interspinous and/or interlaminar device 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 medical 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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this device remains experimental at this time. More research is needed to show safety and efficacy. 
 
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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex interspinous and/or interlaminar device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high strength lightweight wheelchair (K0004). 
 
You asked the Plan to pre-approve the wheelchair. You say that you would like reconsideration because this 
wheelchair is medically necessary. The Plan denied your request. The Plan says there is no record that the 
member's home provides adequate access and maneuvering space for the requested manual wheelchair, and 
there is no documentation that the member is unable to propel a standard wheelchair. 
 
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 wheelchair. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not indicate that the member's mobility deficit cannot be alleviated 
with a manual wheelchair or walker or that her home provides adequate access and space to maneuver the 
wheelchair.  The documentation does not support that the member requires the K0004 to perform frequent 
activities in the home that cannot be performed in a standard or lightweight wheelchair or needs the K004 as 
the member requires a seat width, depth, or height that cannot be accommodated in a standard, lightweight or 
hemi-wheelchair, and spends at least two hours per day in the wheelchair. 
 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high strength lightweight wheelchair (K0004).