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

We decided that the Plan has to pre-approve a 14-day Freestyle Libre sensor.
You asked the Plan to pre-approve a 14-day Freestyle Libre sensor. The Plan denied your request. The Plan
says that this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is 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 a 14-day Freestyle Libre sensor. Our
reviewer says that the requested items are considered medically reasonable and necessary in this case. Our
physician reviewer found that despite not requiring frequent insulin dosing, the Freestyle Libre sensor is
indicated due to frequent low blood sugars and morbidity associated with hypoglycemia, which can be life
threatening.
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 14-day Freestyle Libre sensor have been met. Therefore, we decided that the
Plan has to pre-approve a 14-day Freestyle Libre sensor.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (PCD) described by code E0652.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that a PCD coded as E0652 is not covered for the treatment of lymphedema of the extremities alone. 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 you do not meet the criteria for coverage. Our physician reviewer found the submitted records do not show that you have evidence of lymphedema of the chest, trunk, or abdomen on objective physical examination. There is no evidence of failure of a sufficient trial with an E0650 or E0651 PCD. The requested PCD is therefore 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 pneumatic compression device (PCD) described by code E0652.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve AVONEX, sterile liquid for intramuscular injection.
You asked the Plan to pre-approve AVONEX (Q3027). You say that you want the enrollee to be treated 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 selfadministered
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 AVONEX, sterile liquid for
intramuscular injection.
Benefits for AVONEX (Q3027) 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 Methylprednisolone oral.
You asked the Plan to pre-approve Methylprednisolone Tablet (J7509). You say that you want the enrollee
treated with this drug. The Plan denied your request. The Plan says this drug is not covered for the enrollee's
condition.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drug requested here is not among the types which are covered by
Medicare Part B for non-transplant related diagnoses. Therefore, we decided that the Plan does not have to preapprove
Methylprednisolone oral.
Benefits for Methylprednisolone Tablet (J7509) 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 Gelsyn-3 (J7328).
You asked the Plan to pre-approve the Gelsyn-3. You say that you would like reconsideration because the
Gelsyn-3 is medically necessary for treatment of the member's condition. The Plan denied your request. The
Plan says the member does not meet step therapy exception criteria.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the Gelsyn-3. Our reviewer says that
the health plan requires that other forms of hyaluronic acid injections be used first. There is no evidence that
the enrollee is allergic to or intolerant of these other forms of hyaluronic acid. Our physician reviewer found
there is no evidence that the enrollee has tried and not responded to these other forms of hyaluronic acid
injections. There is no documentation as to why these other forms of hyaluronic acid would not be expected to
be safe and effective 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 the Gelsyn-3 have not been met. Therefore, we decided that the Plan does not
have to pre-approve Gelsyn-3 (J7328).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for arthrocentesis (20606), a hand x-ray (73130), an office visit
(99213), triamcinolone acetonide injection (J3301) and syringe (A4209) provided on October 18, 2019.
You asked the Plan to pay for the outpatient services. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says there is a bilateral code for this diagnosis that
may be more appropriate for these procedures.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the outpatient services have not been met. Specifically, some diagnosis codes indicate laterality
and it is not appropriate to report unspecified, left, right or bilateral diagnosis codes when the procedure
modifier on the claim does not match the diagnosis code. Therefore, we decided that the Plan does not have to
pay for arthrocentesis (20606), a hand x-ray (73130), an office visit (99213), triamcinolone acetonide injection
(J3301) and syringe (A4209) provided on October 18, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Radiofrequency Ablation procedure (64636, 64635).
You asked the Plan to pre-approve the Radiofrequency Ablation. You say that the procedure is medically
necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that that two radiofrequency neurotomies per year may be
covered when 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 Radiofrequency Ablation. Our
reviewer says that the requested procedure is not medically necessary. Our physician reviewer found the
physical exam does not document the facet joints as the cause of back pain. Without this documentation, the
service is not supported.
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 Radiofrequency Ablation have not been met. Therefore, we decided that the
Plan does not have to pre-approve a Radiofrequency Ablation procedure (64636, 64635).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 11, 2020 by a
non-network provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were rendered by a non-network provider without prior authorization.
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 referring provider 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 laboratory services provided on February 11, 2020 by a non-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bilevel positive airway pressure (BiPAP) device
(E0470, E0562, A4604, A7036, A7046).
You asked the Plan to pre-approve a BiPAP device. You say that the items are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that a BiPAP device is covered when specific criteria is
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 a BiPAP device. Our reviewer says that
the items are not medically necessary. Our physician reviewer found in the case of this enrollee, the provided
records show that a follow-up visit with the sleep specialist to assess, calibrate, and possibly fix the BiPAP
machine was recommended many months ago, but never occurred. The enrollee thinks that his BiPAP is
malfunctioning, due to it making strange noises. Replacement of the existing and used device was not
supported as there was no completed follow-up consultation with the sleep specialist with a comment stating
that it cannot be repaired or calibrated anymore. Therefore, this request for replacement BiPAP will be
considered 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 a BiPAP device have not been met. Therefore, we decided that the Plan does
not have to pre-approve a bilevel positive airway pressure (BiPAP) device (E0470, E0562, A4604, A7036,
A7046).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the orthopedic office visits (99214) to be provided by an
out of network (OON) provider.
You asked the Plan to pre-approve orthopedic office visits. You say that this provider performed your treatment
before and you would like to continue seeing this provider. The Plan denied your request. The Plan says the
plan has network providers available that can render the services at issue. The services at issue are not
emergent or preauthorized.
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 the
orthopedic office visits (99214) to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit (99215) to be provided by an out of
network (OON) provider.
You asked the Plan to pre-approve an office visit to be provided by an OON provider. You say that the services
are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to
provide this service. Therefore, coverage criteria has not been met.
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
an office visit (99215) 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 an ultra-lightweight wheelchair with accessories.
You asked the Plan to pre-approve the ultra-lightweight wheelchair and accessories. You say that you would
like reconsideration because this wheelchair is necessary for safety and stability. The Plan denied your request.
The Plan says this wheelchair is 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 the ultra-lightweight wheelchair and
accessories. Our reviewer says that the requested items/services are not considered medically reasonable and
necessary in this case. Our physician reviewer found the member is not a full-time manual wheelchair user and
does not require individualized fitting and adjustments for one or more features such as, but not limited to, axle
configuration, wheel camber, or seat and back angles, and which cannot be accommodated by a K0001 through
K0004 manual wheelchair. The member did have a specialty evaluation that was performed by a
licensed/certified medical professional PT who has specific training and experience in rehabilitation wheelchair
evaluations but who states that the wheelchair and its features are not medically necessary. The documentation
is not clear of the wheelchair was to be provided by a RTS that employs a RESNA ATP who has direct, inperson
involvement in the wheelchair selection for the member.
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 ultra-lightweight wheelchair and accessories have not been met. Therefore,
we decided that the Plan does not have to pre-approve an ultra-lightweight wheelchair with accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the specialist office visit provided on January 17, 2020. 
 
You asked the Plan to waive the cost share for the specialist office visit. You say that that all you wanted was a new eye prescription and were told it would be completely covered. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $198 deductible that applies towards specialist office visits and 20% coinsurance for services obtained from a specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other no-physicians health care professionals in a specialist's office. The specialist office visit you asked the Plan to waive the cost share for falls within the "Physician/ Practitioner services, including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $198 deductible that applies towards specialist office visits and 20% coinsurance for services obtained from a specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other no-physicians health care professionals in a specialist's office. The record shows that you are enrolled in a SLMB program. See chart below. 
 
Date of Service Service Allowed Amount Deductible/Coinsurance Member Liability January 17, 2020 Specialist office visit $210.37 $198.00 $198.00 - This is where you met your 2020 deductible amount.   $12.37 - This is the remaining allowed amount. ($210.37 - 198) 20% $2.47 Total    $200.47 
 
This cost sharing is a contractual obligation that had not been met at the time the specialist office visit was received on January 17, 2020. Therefore, we decided that the Plan does not have to waive the cost share for the specialist office visit provided on January 17, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on January 8, 2020.
You asked the Plan to pay for drug tests. You say that you have submitted a valid physician laboratory requisition form. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not include a valid physician order for the tests billed.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a physician order or clear intent to order the specific lab services billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on January 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on March 12, 2020. 
 
You asked the Plan to pay for the pump assembly and operation. You say that you would like reconsideration because it takes 30 minutes to set up the machine and the perfusionist is required to remain in the operating room through the duration of the procedure. The Plan denied your request. The Plan says payment for this service is the responsibility of the facility to any vendor. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump assembly and operation have not been met. Specifically, payment for this service is included in the DRG payment to the facility and is the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on March 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visit services provided on January 15, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the rest home visit services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
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 rest home visit services provided on January 15, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on January 27, 2020.
You asked the Plan to pay for drug test. You say that you have submitted a valid physician laboratory requisition form. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the documentation submitted does not include a valid physician order, lab requisition, or medical records to support the billed test.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab service billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug test have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on January 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the inversion table purchased on January 27, 2020.
You asked the Plan to pay for the inversion table. You say that you saved the Plan money. The Plan denied your request. The Plan says there is no authorization on file.
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 rules say that no Medicare payment may be made to a beneficiary for items provided directly by a provider who is not eligible to take Medicare payment. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the item at issue in this appeal. The Plan did not pre-approve the item at issue. Durable medical equipment purchased privately through the internet are not eligible for coverage by your Medicare governed health plan. We found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does not have to pay for the inversion table purchased on January 27, 2020.