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

We decided that the Plan does not have to pay for IUD. 
 
You asked the Plan to pay for IUD. You say that you have been on birth control for 30 years and do not want to 
continue that route. The Plan denied your request. The Plan says the requested services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that items/services for the purposes of preventing 
conception (contraception) are not considered medically reasonable and necessary.  
 
Records show that the requested service is primarily for the purpose of contraception. The documentation does 
not show that this service is being requested to treat a specific illness/injury. As such, the Medicare rules for 
coverage of this item/service have not been met. Therefore, we decided that the Plan does not have to pay for 
IUD.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of
network (OON) provider.
You asked the Plan to pre-approve the orthoses. You say that you didn't know you had to get the supplies from
an in-network provider. The Plan denied your request. The Plan says there are in-network alternatives available
for the 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 medical 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 pay for the orthoses defined by codes L1970 and L2200 on February
24, 2020.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your
request. The Plan says the enrollee has previously received the same supplies within the 5-year RUL.
The plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of durable
medical equipment is no less than five years. Replacement equipment may be granted when irreparable wear or
irreparable damage is demonstrated or there has been a change in the enrollee's medical condition.
We looked at the file and Medicare rules. In this instance, the submitted documentation indicates that the
enrollee has received the same durable medical equipment on January 29, 2020. These orthoses are still within
the 5-year RUL and the documentation submitted does not show that the orthoses are irreparably worn,
irreparably damaged, or that the enrollee had a change in medical condition to warrant the orthoses at issue.
Based on this information, we decided that Medicare rules for coverage of the orthoses have not been met.
Therefore, we decided that the Plan does not have to pay for the orthoses defined by codes L1970 and L2200
on February 24, 2020.
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 this is medically necessary to prevent back pain. 
The Plan denied your request. The Plan says the heel lift is not attached to a brace. 
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an injection of an anesthetic and/or steroid drug into 
upper or middle spine nerve root using imaging guidance to be provided by the requested facility. 
 
You asked the Plan to pre-approve the injection. You say that this is the only surgery center capable of 
providing the cervical injection. The Plan denied your request. The Plan says there are many in-network 
surgical centers within 25 miles of the enrollee that can provide this procedure. In addition, the enrollee has not 
had any procedures done by this provider in the past, which would support continuity of care. 
 
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 an 
injection of an anesthetic and/or steroid drug into upper or middle spine nerve root using imaging guidance to 
be provided by the requested facility.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office consultation to be provided by an out of 
network (OON) cardiothoracic surgeon. 
 
You asked the Plan to pre-approve an out-of-network office consultation. You say that you would like the Plan 
to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither 
emergent nor urgent to seek out-of-network care. The Plan says that there are equally qualified in-network 
cardiothoracic surgeons available to you that can provide the services being requested. 
 
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 consultation to be provided by an out of network (OON) cardiothoracic surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gradient compression stockings (30-40mmhg). 
 
You asked the Plan to pre-approve the compression stockings. You say that you need the zipper stockings 
because you have swollen feet which prevent you from using the standard stocking. The Plan denied your 
request. The Plan says these stockings are non-covered under the surgical dressing benefit because they do not 
meet the statutory definition of a dressing. 
 
The Plan must follow Medicare rules. The rules say that compression stockings are noncovered because they 
do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve gradient 
compression stockings (30-40mmhg).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 8 additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional trips. You say that you have no other way of transportation to 
get to your scheduled appointments. The Plan denied your request. The Plan says this request exceeds the 
benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 24 one way trips.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 8 additional routine transportation trips.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Computed Tomography (CT) scan of the lower 
extremity. 
 
You asked the Plan to pre-approve CT scan. You say that the enrollee needs these tests. The Plan denied your 
request. The Plan says the denial of authorization for this CT scan is correct. 
 
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 CT scan. Our reviewer says that the 
enrollee does not meet the Medicare criteria for this CT scan. Our physician reviewer found the enrollee has 
been authorized for a Magnetic Resonance Imaging (MRI) test which can evaluate the joints of the right foot 
and ankle and demonstrate swelling/inflammation. The presence of gout crystals within a joint can also be 
evaluated by joint aspiration, or blood tests. A CT scan will demonstrate similar findings to the MRI, and joint 
aspiration is more simple and straightforward compared to a CT scan for diagnosing joint gout. Therefore, the 
requested CT scan is not medically reasonable and necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Computed Tomography (CT) scan of the lower extremity.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a Posturpedic mattress. 
 
You asked the Plan to pay for a Posturpedic mattress. 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 only certain replacement mattresses are covered. 
 
We looked at the file and Medicare rules. Review of the file shows that Medicare will cover certain innerspring 
mattresses or foam rubber mattresses when replacement is required for an approved hospital bed. The requested 
Posturpedic mattress is not one of the covered mattresses. Based on this information, we decided that Medicare 
rules for coverage of a Posturpedic mattress have not been met. Therefore, we decided that the Plan does not 
have to pay for a Posturpedic mattress.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc injections (20610, J7325). 
 
You asked the Plan to pre-approve Synvisc injections. You say that this is necessary because the previous 
injection did not work. The Plan denied your request. The Plan says this cannot be covered because the 
previous injection did not work. 
 
The Plan must follow Medicare rules. Medicare rules say that Viscosupplementation is considered not 
medically reasonable and necessary and will not be covered when a repeat series of injections is administered 
when there was no symptomatic/functional improvement evidenced from the previous series of injections. 
 
We looked at the file and Medicare rules. The record shows that the enrollee received Gel-One in August 
without improvement. Based on this information, we decided that Medicare rules for coverage of Synvisc 
injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc 
injections (20610, J7325).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an exercise pulley set (A2970). 
 
You asked the Plan to pre-approve the exercise pulley set. You say that the exercise pulley equipment is 
medically necessary. The Plan denied your request. The Plan says this is not a covered item. 
 
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 an exercise pulley set (A2970).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network lab services provided to the enrollee on April 
9, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 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 out of network lab services 
provided to the enrollee on April 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the arthrodesis services coded 25805 and the arthroplasty 
services coded 25447 provided on January 8, 2020. 
 
You asked the Plan to pay for the arthrodesis services and the arthroplasty services. You say that you would 
like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not 
supported by the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 25805 and 25447 are not supported in the medical record. Specifically, the operative 
report did not include documentation of a wrist arthrodesis, with sliding graft; therefore, code 25805 cannot be 
verified. The operative report did not include documentation of an interposition arthroplasty of the intercarpal 
or carpometacarpal joints; therefore, code 25447 cannot be verified. Based on this information, we decided that 
Medicare rules for coverage of the arthrodesis services and the arthroplasty services have not been met. 
Therefore, we decided that the Plan does not have to pay for the arthrodesis services coded 25805 and the 
arthroplasty services coded 25447 provided on January 8, 2020.
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 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 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 the enrollee does not require skilled nursing or 
therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria 
for an inpatient basis in a skilled nursing facility setting. 
 
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 stereotactic body radiation therapy (SBRT). 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee does not have low or medium risk of recurrence. 
 
The Plan follows Medicare rules. Medicare rules say that stereotactic body radiation therapy is only covered 
under certain medical indications.  
 
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 requested services. Our physician 
reviewer found that arguably SBRT is more cost-effective, and perhaps equivalent to conventionally 
fractionated IMRT/IGRT.  However, the coverage criteria require that prostate cancer is only medically 
necessary for low and intermediate risk prostate cancer. Therefore, the requested services are not considered 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve stereotactic body radiation therapy (SBRT).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased March 9, 2020
You asked the Plan to pay for the hearing aids. You say that you contacted member services prior to scheduling any medical appointments to confirm your policy's coverage for hearing aids. The Plan denied your request. The Plan says this is not covered under the plan benefits.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when purchased through the plan. Hearing aids ordered through providers other than the plan are not covered. We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids purchased March 9, 2020
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for somatosensory testing, electroencephalogram, and continuous intraoperative neurophysiology monitoring provided on April 17, 2019.
You asked the Plan to pay for somatosensory testing (95938), electroencephalogram (95955), and continuous intraoperative neurophysiology monitoring (G0453). You say that the claim was received by the plan within the timely filing guidelines. The Plan denied your request. The Plan says the claim was untimely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that a claim for somatosensory testing (95938), electroencephalogram (95955), and continuous intraoperative neurophysiology monitoring (G0453) was not filed until April 22, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for somatosensory testing, electroencephalogram, and continuous intraoperative neurophysiology monitoring provided on April 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for routine eyewear provided on March 7, 2020.
You asked the Plan to pay for the eyewear. You say that your benefits summary only shows the benefits
available but does not say anything about any limitations. The Plan denied your request. The Plan says the
service obtained by the member was rendered by a provider who is not under contract with the health plan. As
per the member's plan, he has no out-of-network benefits.
Medicare generally does not cover eyewear services. However, the Plan offers a routine eyewear benefit that
exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these
services when provided by a Plan provider.
We looked at the file and the Plan's rules. The file shows that you purchased the eyewear from a provider that
is not a network provider with the Plan. Based on this information, we decided that the Plan's rules for coverage
of the eyewear have not been met. Therefore, we decided that the Plan does not have to pay for routine eyewear
provided on March 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 17, 2020 by an
out of network (OON) provider.
You asked the Plan to pay for Wrist-hand-finger orthosis (L3809). You say that the claim should be paid. The
Plan denied your request. The Plan says there is no medical necessity for 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 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 medical services provided on February 17,
2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse the enrollee for hearing aids provided on February 19, 2020.
You asked the Plan to reimburse you for the hearing aids. The Plan denied your request. The Plan says there is no coverage for hearing aids when received from a provider other than the Plan provider.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when provided by the Plan hearing aid provider. We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by the Plan's hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse the enrollee for hearing aids provided on February 19, 2020.