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

 
We decided that the Plan does not have to waive the copayment for the abdominal paracentesis (49083) 
provided on June 5, 2020, to July 27, 2020. 
 
You asked the Plan to waive the copayment for the abdominal paracentesis. You say that you do not agree with 
the service being billed as surgery. The Plan denied your request. The Plan says the copayment applied 
correctly in this case. 
 
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 $295 
copayment for outpatient surgery.  
 
You have been asked to pay a $295 copayment for the abdominal paracentesis. The service provided falls 
within the outpatient surgery 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 
abdominal paracentesis (49083) provided on June 5, 2020, to July 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided 
on July 30, 2020. 
 
You asked the Plan to pay for the dental service. You say that you have been in pain for 5 months. You also say 
that you have seen many doctors. The Plan denied your request. The Plan says comprehensive periodontal 
evaluation 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
comprehensive periodontal evaluation (D0180) provided on July 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom continuous glucose monitor. 
 
You asked the Plan to pre-approve a Dexcom continuous glucose monitor. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the 
requested device. 
 
The Plan must follow Medicare rules. Medicare rules say that continuous glucose monitors are only covered for 
enrollees that are insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-covered 
continuous subcutaneous insulin infusion (CSII) pump. 
 
 
 
 
 
 
We looked at the file and Medicare rules. Review of the file does not support that you are insulin-treated with 
multiple (three or more) daily injections of insulin. Based on this information, we decided that Medicare rules 
for coverage of a Dexcom continuous glucose monitor have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Dexcom continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a continuous glucose monitor. You say that the enrollee needs a CGM. The 
Plan denied your request. The Plan says the records show the enrollee is on single dose insulin and checking 
glucose only once daily. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The enrollee is not insulin treated by injection three or more times a 
day so the Medicare coverage criteria for a CGM is not met.  Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 additional fillings (D2393). 
 
You asked the Plan to pre-approve the dental services. You say that your teeth are sensitive. You say that you 
want to be able to drink hot and cold beverages again. You say that you have not used your dental benefits 
since 2014 and therefore the fillings should be covered. The Plan denied your request. The Plan says 1 filling 
per year is covered. The Plan also says that the frequency limit has been reached. 
 
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 frequency limit of 1 filling per year 
has been reached. The record shows that the Plan already approved a filling for 1 tooth, thus reaching the 
frequency limit. Therefore, we decided that the Plan does not have to pre-approve 4 additional fillings (D2393).
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're in tremendous amount of pain and unable 
to walk. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Vertiflex decompression device 
(22869, 22870). 
 
You asked the Plan to pre-approve the insertion of a Vertiflex decompression device. You say that this is 
medically necessary. The Plan denied your request. The Plan says this is experimental. 
 
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 insertion of a Vertiflex 
decompression device. Our reviewer says that the requested services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found current evidence based medical guideline and peer 
reviewed literature do not fully support the spinal decompression device procedure over the gold standard of 
lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the 
use of this device for your medical condition. FDA contraindications include scoliosis and osteoporosis. The 
submitted medical records include imaging evidence of a 14-degree lumbar scoliosis, which is an FDA 
contraindication for the Vertiflex procedure. There is no discussion indicating that a DEXA scan has 
demonstrated no osteoporosis. The Vertiflex decompression procedure would not be considered the standard of 
care for your condition. Therefore, this request does not meet Medicare criteria as medically reasonable and 
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 the insertion of a Vertiflex decompression device have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the insertion of a Vertiflex decompression device 
(22869, 22870).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and 
pelvis with contrast (74177). 
 
You asked the Plan to pre-approve this service. You say that a CT scan of the abdomen and pelvis is medically 
necessary. The Plan denied your request. The Plan says the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 this service. Our reviewer says that a 
CT scan of the abdomen and pelvis is not medically necessary. Our physician reviewer found that you have 
reported an unintentional weight loss of fifteen pounds over three months, with a normal appetite, daily life the 
same, and mild overall weakness. There are no abnormalities noted on physical exam. Your provider has 
requested a CT scan of the abdomen and pelvis. There is no specific clinical rationale for the requested CT 
scan. Whole body CT imaging may be a useful investigation for the noninvasive workup of patients with 
unexplained weight loss. Patients with additional symptoms, abnormal physical examination, anemia and raised 
tumor markers are significantly more likely to have positive findings on a CT scan. This group of patients may 
derive the most diagnostic value from whole body CT imaging. In this case, there are no reported physical 
exam findings or abnormal laboratory results. The review has determined that the requested CT scan is not 
medically reasonable or 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 this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the abdomen and pelvis with contrast (74177).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient surgery for bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that the medical records provided support 
the necessity of the services in dispute. The Plan denied your request. The Plan says the Plan does not cover the 
use of bone marrow aspirate for this procedure. Medical studies haven't proven that this procedure is helpful for 
the treatment of the enrollee's 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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspiration remains experimental. 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 bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve inpatient surgery for bone marrow aspirate (20939).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the remote physiologic monitoring 
treatment management services (99454, 99457) provided. 
 
You asked the Plan to waive the copayment for the remote physiologic monitoring treatment management 
services. You say that you disagree with the copayment as charged for the services rendered. The Plan denied 
your request. The Plan says the copayment applied correctly in this case. 
 
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 $40 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay a $40 copayment for the remote physiologic monitoring treatment management 
services. The services provided fall 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 the remote physiologic 
monitoring treatment management services (99454, 99457) provided.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy visits. 
 
You asked the Plan to pre-approve physical therapy. You say that you are bed bound and need 20 visits to get 
you back to where you were before. The Plan denied your request. The Plan says the denial of authorization for 
these services is correct, because you appear to be at a new baseline and even after a lot of therapy you do not 
appear to have the capability to improve function. 
 
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 physical therapy. 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 there is no documentation that the requested therapy is generally 
accepted as a specific and effective therapy for your condition. Based on the available records, you appear to 
have plateaued with therapy, further therapy does not appear likely to achieve any significant improvement in 
your functional status. There is no documentation that the unique skills of a professional therapist are required 
to safely and effectively provide treatment or that the services can be safely and effectively performed only by 
a therapist or under the supervision of a therapist. The specialized skill, knowledge, and judgment of a qualified 
therapist is not required to establish, design, and/or deliver a program to maintain your current condition or to 
prevent/slow further deterioration.  
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve additional physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the P-C IOL. 
 
You asked the Plan to pre-approve the P-C IOL. You say that you would like reconsideration because you have 
been wearing glasses since you were 9 years old and currently need a magnified glass to read. The Plan denied 
your request. The Plan says this specialty lens is not a covered benefit under Medicare. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives a P-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the P-C IOL and a 
conventional IOL.  
 
While a P-C IOL may be appropriate for you, neither the Plan nor Medicare covers the presbyopia-correcting 
feature of a P-C IOL. Therefore, we decided that the Plan does not have to pre-approve the P-C IOL.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xgeva 120 mg/1.7 ml subcutaneous solution given as 
120 mg every 28 days. 
 
You asked the Plan to pre-approve Xgeva. 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 Xgeva. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the documentation does not support a history of treatment, contraindication, or intolerance to 
zoledronic acid. Step therapy, as outlined by the plan, requires this documentation.  Without the support of the 
documentation, Xgeva 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 Xgeva have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Xgeva 120 mg/1.7 ml subcutaneous solution given as 120 mg every 28 days.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair glide. 
 
You asked the Plan to pre-approve a stair glide. You say that your knee gives out making it dangerous to get 
down stairs. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift 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 stair glide.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-
network provider. 
 
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says you 
must receive care from in-network providers with the exception of emergency or urgent care or if the care 
cannot be provided with an in-network provider, which requires prior authorization from the plan.  
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea shower/bath chair.You asked the Plan to pre-approvea shower/bath chair. You say that a shower/bath chair is medically necessary.The Plan denied your request. ThePlan says this item is not covered by Medicare.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/bathchair 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-approvea shower/bath chair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint injections. 
 
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. 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 services are not medically necessary. Our physician reviewer found the enrollee has been receiving 
quarterly injections since 2010. She received previous injections on March 26, 2020 and June 25, 2020. The 
records do not support that the repeat SI injections are 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 sacroiliac (SI) joint injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous laminotomy/laminectomy for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says this will only be covered when provided in a clinical study. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered an experimental/investigational procedure that is the subject of on-going 
clinical trials. The enrollee is not enrolled in a clinical trial. Therefore, the request is considered not medically 
reasonable or 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 the procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous laminotomy/laminectomy for the enrollee.