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

 
We decided that the Plan does not have to pre-approve Procrit (J0885). 
 
You asked the Plan to pre-approve Procrit (J0885). You say that you want the enrollee treated with this drug. 
The Plan denied your request. The Plan says the enrollee has not first tried and had a contraindication or 
intolerance to Epoetin Alfa (Retacrit). 
 
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 Procrit (J0885). Our reviewer says that 
the drug is not medically reasonable and necessary. Our physician reviewer found there is no documentation 
that the enrollee has failed Retacrit nor is there documentation that Retacrit would not be medically appropriate 
for this enrollee. In summary, neither step therapy or step therapy exception criteria are 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 Procrit (J0885) have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Procrit (J0885).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve orthopedic shoes. 
 
You asked the Plan to pre-approve the orthopedic shoes. You say that you are having problems with your 
arches of your feet and are not able to wear other shoes. You feel this is medically necessary. 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 orthopedic shoes.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture. 
 
You asked the Plan to pre-approve the maxillary partial denture. You say that you currently do not have any 
dentures because they were stolen. You also say that it is difficult to eat, and not having your denture causes 
discomfort. The Plan denied your request. The Plan says this service exceeds the benefit allowance. 
 
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, dentures are limited to one set every 5 
years. The record shows that you received a maxillary partial denture on January 23, 2019 and your maxillary 
dentures benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a 
maxillary partial denture.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections (64493, 64494). 
 
You asked the Plan to pre-approve facet joint injections. You say that this is medically necessary. 
 The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint injections are covered when the indications 
listed above are 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 facet joint injections. Our reviewer says 
that the criteria for coverage of the requested injections has not been met. Our physician reviewer found the 
requested procedure is supported when diagnostic tests during the physical examination show that the source of 
pain is suspected to originate in the facet joint between C2-3 and L5-S1. In this case, the clinical information 
provided does not describe positive facet joint examination results between these levels and, therefore, the 
requested procedure is not indicated 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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections (64493, 64494).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement power scooter (K0801). 
 
You asked the Plan to pre-approve the replacement scooter. You say that you would like reconsideration 
because you were not given the correct scooter for your size. The Plan denied your request. The Plan says the 
weigh cap of the scooter you have and the requested scooter is 350lbs. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have Phoenix HD 4 wheel Scooter. Phoenix HD 4 wheel Scooter serves the same 
purpose as the replacement scooter. The record does not show any documentation to suggest malicious damage, 
culpable neglect, or wrongful disposition of equipment. Therefore, we decided that the Plan does not have to 
pre-approve a replacement power scooter (K0801).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoCycle home functional electrical stimulation 
(FES) device. 
 
You asked the Plan to pre-approve the Myocycle FES device. You say that this device is necessary for the 
enrollee to help with her condition. The Plan denied your request. The Plan says the enrollee does not have a 
Medicare-covered indication for this device. 
 
The Plan must follow Medicare rules. Medicare rules say that FES systems are covered only for SCI patients in 
order to achieve the ability to walk.  
 
In this case, the enrollee does not have an SCI and the goal of the use of this device is not to assist with 
walking, but to help with muscle atrophy. Therefore, we decided that the Plan does not have to pre-approve a 
MyoCycle home functional electrical stimulation (FES) device.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to waive the coinsurance for DME and related supplies provided by "the provider", on August 9, 2019.You asked the Plan to waive the coinsurance for DME and related supplies. You say that the services were never requested nor received.The Plan denied your request. The Plan says that the claims were processed correctly and you are being charged the correct amount.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan did not provide medical records nor any other documentation showing that services were requested and received.Therefore, we decided that the Plan has to waive the coinsurance for DME and related supplies provided by "the provider" on August 9, 2019.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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network provider for wound care 
supplies. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services can be received from a participating provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a referral to an out-of-network provider for wound care supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns (D6740) for tooth #'s 19 & 21 and a 
pontic (D6245) for tooth #20. 
 
You asked the Plan to pre-approve the retainer crowns and pontic. You say that the enrollee is in a lot of pain. 
The Plan denied your request. The Plan says the documentation fails to demonstrate a specific medical 
condition (physical or neurological) that would preclude the use of a removable partial denture. 
 
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. The Plan covers the retainer 
crowns and pontic when the services are medically necessary and reasonable.  
 
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 retainer crowns and pontic. Our 
reviewer says that the criteria have not been met for the service of a three unit posterior bridge. Our physician 
reviewer found there is no periapical x-ray supplied to assess the periapical status of the tooth, and no 
indication of pulp testing of #20 that would indicate a necrotic pulp which might necessitate removal. Our 
reviewer found that there is no indication that endodontics was a consideration, or why it would not be a 
treatment option. Our physician reviewer also found that a periapical radiograph is necessary of all abutment 
teeth to be able to consider the stability of the units in question. 
 
 
 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the retainer crowns and pontic have not been met. Therefore, we decided that 
the Plan does not have to pre-approve retainer crowns (D6740) for tooth #'s 19 & 21 and a pontic (D6245) for 
tooth #20.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve the bed. You say that the enrollee is too heavy for the caregivers to crank 
the semi-electric hospital bed. The Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that you have lymphedema and require 
the stockings. The Plan denied your request. The Plan says compression stockings are noncovered for all 
indications because they do not meet the definition of a surgical dressing. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 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 compression 
stockings identified with code A6549.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation of the left genicular nerves. 
 
You asked the Plan to pre-approve radiofrequency ablation. You say that you are appealing with records. The 
Plan denied your request. The Plan says the denial of authorization for this service is correct, because this 
procedure is not covered for pain caused by osteoarthritis or degenerative joint disease. 
 
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 radiofrequency ablation. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is considered an experimental/investigational procedure which is the subject of 
ongoing clinical trials. The enrollee is not enrolled in a clinical trial. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation of the left genicular nerves.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the extraction to be provided by an oral surgeon. 
 
You asked the Plan to pre-approve the extraction. You say that there is a lot of bone underneath the tooth that 
you are concerned about. You say that you were referred to an oral surgeon. The Plan denied your request. The 
Plan says the Plan only covers dental services provided by a participating general dentist. 
 
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 item is not among those 
covered under this benefit when received from an oral surgeon. Therefore, we decided that the Plan does not 
have to pre-approve the extraction to be provided by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to waive the copayment of $298 for the dental services and the enrollee has to
pay the correct copayment of $100 provided September 10, 2019 to October 23, 2019.
You asked the Plan to waive the copayment of $298 for the dental services. You say that you are appealing the
cost share that was applied The Plan denied your request. The Plan says that this claim processed and paid
correctly and the correct copayment was applied.
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 enrollees must pay $50 copayment for Medicare covered comprehensive dental.
The Plan says you must pay $298 for the dental services. Based on the Plan contract, however, you cannot be
asked to pay more than $50 copayment for Medicare covered comprehensive dental. Therefore, the correct
amount of the copay is $100. Which is $50 for the September 10, 2019 date of service and $50 for the October
23, 2019 date of service. Therefore, we decided that the Plan has to waive the copayment of $298 and the
enrollee has to pay the correct copayment of $100 for the dental services provided September 10, 2019 to
October 23, 2019.
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: Favorable

We decided that the Plan has to pre-approve power wheelchair replacement batteries.
You asked the Plan to pre-approve power wheelchair replacement batteries. You say that the requested power
wheelchair replacement batteries are medically necessary. The Plan denied your request. The Plan says that the
requested power wheelchair replacement batteries were improperly coded on the prior authorization request
form.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. Specifically, it is the plan's responsibility to show that its decision to deny
coverage is correct. Records from a plan provider are considered to be within the control of the plan. In cases
where the plan has not supplied records from a plan provider that are critical to its decision, we may properly
find that the denial is not medically appropriate or justifiable. Enrollees should not be penalized for a plan's
failure to obtain records that are within the plan's control. Furthermore, the Plan is denying the requested
batteries due to improper coding. This is a prior authorization request and Medicare criteria must still be met.
The Plan did not request medical records for review to determine if the enrollee meets Medicare criteria for the
requested batteries, regardless of how they were coded on the request form. Therefore, we decided that the Plan
has to pre-approve power wheelchair replacement batteries.
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: Surgery
Decision: Partially Favorable

We decided that the Plan has to reduce the copayment for a cystourethroscopy. We decided that the Plan does
not have to reduce the copayment for a cystourethroscopy to the amount you requested.
You asked the Plan to reduce the copayment for a cystourethroscopy. You say that you paid a $175 copayment
in the past. The Plan says that the claims were processed correctly and you are being charged the correct
amount.
We decided that the Plan has to reduce the copayment for a cystourethroscopy from $250 to $40.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The record shows that the provider is a clinic, not an outpatient hospital facility. The plan did not provide a
claim, nor any evidence that the provider billed services as an outpatient hospital facility. Therefore, we
decided that the Plan has to reduce the copayment for a cystourethroscopy from a $250 copayment to a $40
copayment.
We also decided that the Plan does not have to waive the copayment for a cystourethroscopy.
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 surgery services provided by a specialist. Therefore, we decided that the Plan does not have to
waive the $40 copayment for a cystourethroscopy.
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: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the coinsurance for the medical services provided on July 26, 2018.
You asked the Plan to waive the coinsurance for the medical services. You say that you would like the Plan to cover these charges because this is the only provider that can treat the enrollee. The Plan denied your request. The Plan says that you have been charged the correct cost sharing amount.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. There was no explanation of benefit or claim form submitted with the code at issue to verify the billed services. Therefore, we decided that the Plan has to waive the coinsurance for the medical services provided on July 26, 2018.
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: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pre-approve 2 units of epidural steroid injections. We decided that the Plan does not have to pre-approve 4 units of epidural steroid injections.
You asked the Plan to pre-approve 6 units of epidural steroid injections. You say that you would like reconsideration as the member has not had 3 injections in 2019. The Plan says that the requested service is not medically reasonable and necessary.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve7 additional skilled nursing home visits.You asked the Plan to pre-approvehome health services. You say that the records provided should support the necessity of the services.The Plan denied your request. The Plan says that the records do not support the need for additional skilled nursing visits.The Plan must follow Medicare rules. The rules say that a NOMNC must be issued prior to discontinuing coverage of home care services. There is no evidence that a NOMNC has been issued saying that coverage is ending for the home care services at issue in this appeal.Therefore, we decided that the Plan has to pre-approve7 additional skilled nursing home visits.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.