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

 
We decided that the Plan does not have to pre-approve the office visit (99204) to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that the services are medically necessary. The Plan 
denied your request. The Plan says there are network providers available that can provide 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 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 office 
visit (99204) 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 Prolia. 
 
You asked the Plan to pre-approve Prolia (J0897). You say that you want the enrollee treated with this drug. 
The Plan denied your request. The Plan says the enrollee does not have a history of osteoporosis related 
fracture and has not first tried and had a contraindication or intolerance to zoledronic acid. 
 
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 Prolia (J0897). Our reviewer says that 
the drug is not medically reasonable and necessary. Our physician reviewer found the enrollee has not tried and 
failed zoledronic acid. The enrollee does not have a history of an osteoporosis related fracture. There is no 
documentation provided indicating that the Plan's required drug 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 Prolia (J0897) have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265) and low air loss 
mattress (E0277). 
 
You asked the Plan to pre-approve a total electric hospital bed and low air loss mattress. You say that the 
services 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 group 2 support surface is covered when specific 
criteria is met and a total electric hospital bed is not covered; the height adjustment feature is a convenience 
feature. 
 
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 total electric hospital bed and low air 
loss mattress. Our reviewer says that the items are not medically necessary. Our physician reviewer found the 
documentation does not indicate that you have multiple stage II pressure ulcers located on the trunk or pelvis 
which have failed to improve over the past month, during which time you have been on a comprehensive ulcer 
treatment program. The documentation does not indicate that you have large or multiple stage III or IV 
pressure ulcer(s) on the trunk or pelvis or had a myocutaneous flap or skin graft for a pressure ulcer on the 
trunk or pelvis within the past 60 days. A total electric hospital bed is not medically necessary as the height 
adjustment feature is a convenience feature. 
 
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 total electric hospital bed and low air loss mattress have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed (E0265) and low 
air loss mattress (E0277).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient mental health services. 
 
You asked the Plan to pre-approve inpatient mental health services. You say that the services are necessary. 
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve inpatient mental health services. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found based upon review of the records provided, you do not meet the criteria for 
treatment in an acute inpatient mental health treatment beyond the date in question of November 16, 2020 
forward and could have been treated in a lesser restrictive setting. You were not showing any suicidal or 
homicidal ideation, auditory or visual hallucinations, delusions and you were not showing any behaviors or 
aggression. You were being cooperative and compliant while not showing any acute threats to the safety of 
yourself or others. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient mental health services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve inpatient mental health services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve osseous surgery (D4260) for all 4 quadrants, 4 bone 
replacement grafts for the first tooth in the quadrant (D4263), and 4 bone replacement grafts for an additional 
tooth in the quadrant. 
 
You asked the Plan to pre-approve the dental services. You say that you have loss of bone in your gums and 
tartar. You say that your dentist advised that after the procedure you will need cleanings every 2 to 3 months. 
You also say that oral health has an impact on physical and emotional health. The Plan denied your request. 
The Plan says osseous surgery is not listed as a covered service. The Plan says that bone replacement grafts for 
the first tooth in the quadrant are not listed as covered service. The Plan also says bone replacement grafts for 
an additional tooth in the quadrant are not listed as covered services. 
 
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 
osseous surgery (D4260) for all 4 quadrants, 4 bone replacement grafts for the first tooth in the quadrant 
(D4263), and 4 bone replacement grafts for an additional tooth in the quadrant.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve RFA. You say that the services 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 there are limitations of coverage for RF ablations. 
 
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 RFA. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found cooled RFA is considered 
experimental/investigation in the performance of any RFA. Genicular RFA by any method after total knee 
arthroplasty (TKR) is considered experimental/investigational and is the subject of on-going clinical trials. You 
are not in a clinical trial. Therefore, the request is considered not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of RFA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve radiofrequency ablation (RFA).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up (D2950) for teeth # 3, 20, and 32. 
 
You asked the Plan to pre-approve the dental services. You say that core build up and a full coverage 
restoration is necessary to restore your teeth to the optimum strength and function. You also say that core build 
up is needed for the retention of the crown. The Plan denied your request. The Plan says core build up is not 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 core build up is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core 
build up (D2950) for teeth # 3, 20, and 32.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total knee arthroscopy. 
 
You asked the Plan to pre-approve a total knee arthroscopy. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has 
not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a total knee arthroscopy. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found criteria for a total knee surgery have not been met. There is no documentation of 
smoking cessation. 
 
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 total knee arthroscopy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a total knee arthroscopy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric admission. 
 
You asked the Plan to pre-approve inpatient psychiatric admission. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve inpatient psychiatric admission. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found based upon review of the records provided, this enrollee does not meet 
criteria for acute inpatient mental health treatment. This enrollee was not shown to be a danger to herself or 
others and was not experiencing auditory or visual hallucinations. She is noted to be cooperative and compliant 
with treatment while not showing any aggressive behaviors. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric admission have not been met. Therefore, we decided that 
the Plan does not have to pre-approve inpatient psychiatric admission.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for a respiratory viral panel provided on March 
26, 2020. 
 
You asked the Plan to waive the deductible for a respiratory viral panel. You say that you had to return to the 
provider to have another respiratory panel done because the provider failed to do so when you were COVID-19 
tested. You state that because it was related to COVID-19 testing you should not owe the charges. The Plan 
denied your request. The Plan says the claims were processed correctly and you are being charged the correct 
amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1,250 deductible for out-of-network outpatient diagnostic tests and 
therapeutic services and supplies.  
 
You received a respiratory viral panel on March 26, 2020 from an out-of-network provider. The record shows 
that you had paid $207.28 toward the deductible prior to receiving the services. Therefore, you are responsible 
to pay the total allowed amount of $416.78. Please note that you were not charged for COVID-19 testing.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient 
diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $1,250 deductible for out-of-network outpatient diagnostic tests and 
therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time 
a respiratory viral panel was received on March 26, 2020. Therefore, we decided that the Plan does not have to 
waive the deductible for a respiratory viral panel provided on March 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a synergy seating frame (K0108). 
 
You asked the Plan to pre-approve a synergy seating frame. You say that the item is necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that wheelchair seat and back cushion codes are all-
inclusive.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a synergy seating frame have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a synergy seating frame (K0108).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Breztri Aerosphere. 
 
You asked the Plan to pre-approve Breztri Aerosphere. You say that the enrollee has COPD and Breztri is an 
important key in their health with the pandemic. The Plan denied your request. The Plan says this drug is not 
covered for the enrollee's condition by Medicare Part B. 
 
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 Breztri Aerosphere.  
 
Benefits for Breztri Aerosphere 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet Medicare criteria for coverage of SNF care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. There are identifiable skilled therapy service needs but they do not need to be provided on a 
daily basis or in a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit (99203, 99204) to be provided by an out 
of network (OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that the services you are requesting are medically 
necessary. The Plan denied your request. The Plan says there are multiple in-network providers that can 
perform the required 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 
the office visit (99203, 99204) to be provided by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care provided from March 18, 2020, to June 9, 
2020. 
 
You asked the Plan to pay for home health care. You say that this care was medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria were not met. 
 
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 pay for home health care. 
Our reviewer says that Medicare coverage criteria were not met. Our physician reviewer found the records do 
not show that skilled nursing services are required to effectively provide treatment, care, and/or services in 
order to improve the patient's condition, or to establish/perform a maintenance program to maintain the 
patient's condition and/or prevent deterioration. There are no complex wounds, new enteral feedings or other 
skilled nursing needs.  
 
 
The records do not show that skilled therapy is needed to effectively provide treatment, care, and/or services in 
order to improve the patient's level of function, or to establish/perform a maintenance program to maintain the 
patient's level of function and/or prevent deterioration. As the enrollee did not require skilled therapy or skilled 
nursing services the enrollee did not meet the definition of home health aide services per Section 50.2 and the 
request for  home health aide services were not reasonable and necessary to the treatment of the enrollees 
illness or injury by the skilled professional staff.  
 
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 care have not been met. Therefore, we decided that the Plan does 
not have to pay for home health care provided from March 18, 2020, to June 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit 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 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 shower chair and hoyer lift sling. 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the DME is not necessary. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a shower chair and hoyer lift sling.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transurethral waterjet ablation of prostate (0421T). 
 
You asked the Plan to pre-approve transurethral waterjet ablation of prostate. You say that it is your clinical 
judgement that the enrollee is an ideal candidate for transurethral waterjet ablation. You are seeking 
preauthorization. The Plan denied your request. The Plan says medical studies have not proven that the service 
or procedure is helpful for the treatment of an enlarged prostate. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of transurethral waterjet ablation of prostate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve transurethral waterjet ablation of prostate (0421T).