Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe requested external urine catheter system.You asked the Plan to pre-approvean external urine catheter system. You say that the requested supplies are medically necessary.The Plan denied your request. The Plan says disposable female external catheters do not meet the definition of durable medical equipment.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 an external urine catheter system. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records do not indicate that the enrollee meets the requirement for an external urine collection device or that the enrollee has permanent impairment of urination. As such, the requested external urine catheter system is not covered. The requested external urine catheter system is an alternative to an indwelling catheter for female adult patients suffering from permanent urinary incontinence. According to the manufacturer,  it is indicated for noninvasive urine output management in females and is contraindicated in patients with urinary retention.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an external urine catheter system have not been met.Therefore, we decided that the Plan does not have to pre-approvethe requested external urine catheter system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair lift 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair lift.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walk-in bathtub. 
 
You asked the Plan to pre-approve the bathtub. You say that the tub is medically necessary. The Plan denied 
your request. The Plan says the tub 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 a walk-in bathtub.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided by you on June 20, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 20, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on June 
20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a power seat elevation feature is non-covered. 
 
We looked at the file and Medicare rules. The item at issue is a power seat elevation system. This item is not 
covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation 
system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a reclining chair (A9270). 
 
You asked the Plan to pre-approve the recliner. You say that the chair is medically necessary due to back pain. 
The Plan denied your request. The Plan says the chair 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 a reclining chair (A9270).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an OON 
provider. 
 
You asked the Plan to pre-approve the medical services. You say that the second sleep study has not been 
completed. The Plan denied your request. The Plan says there are in-network providers that can provide 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 OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first 15 minutes of deep sedation/general anesthesia, 
additional 15 minute increment of deep sedation/general anesthesia, and therapeutic parenteral drug provided 
on March 20, 2020. 
 
You asked the Plan to pay for the deep sedation/general anesthesia services and therapeutic parenteral drug. 
You say that intravenous general anesthesia was provided to the enrollee to ensure a safe and predictable 
outcome of the surgery. The Plan denied your request. The Plan says the enrollee has reached their maximum 
allowed amount. 
 
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 Plan offers a $1,000 annual dental 
benefit maximum. The record shows that you met the annual maximum benefit while processing this claim 
from the March 20, 2020, date of service, and your annual maximum benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pay for the first 15 minutes of deep sedation/general anesthesia, 
additional 15 minute increment of deep sedation/general anesthesia, and therapeutic parenteral drug provided 
on March 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MOHS procedure to be performed by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the services. You say that there is no in-network provider that can provide 
the services. The Plan denied your request. The Plan says it is not medically necessary to get the member's care 
out-of-network except in cases where there is an urgent or emergency medical situation. The Plan states it 
might also be necessary to get the member's care out-of-network if there is no one in their network who can 
give the member the care they need. The Plan states the information does not show that the member has either 
of these situations. 
 
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 
MOHS procedure to be performed by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Engerix-B 20mcg/ml injection. 
 
You asked the Plan to pre-approve Engerix-B. You say that the vaccine is medically necessary. The Plan 
denied your request. The Plan says coverage is not available under the Part B medical benefit as the enrollee 
does not fit into a high or intermediate risk category as outlined in the coverage criteria. 
 
Records do not show that the enrollee has been injured or directly exposed to Hepatitis B. Insufficient clinical 
documentation was provided to show that the enrollee falls within a covered high or intermediate risk 
population as defined by Medicare rules. Therefore, we decided that the Plan does not have to pre-approve a 
Engerix-B 20mcg/ml injection.  
 
Benefits for Engerix-B 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided on July 7, 
2020. 
 
You asked the Plan to pay for foot orthotics. You say that you have foot pain. 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 pay for foot orthotics provided on July 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical studies have not proven that this device is helpful for treatment of the health 
problem. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee presents with persistent low back pain radiating into the left leg with signs/symptoms of 
neurogenic claudication. Functional limitations are noted in activities of daily living. There is imaging evidence 
of multilevel spinal stenosis from L2/3 through L5/S1. She has reportedly failed at least 6 months of reasonable 
and/or comprehensive conservative treatment. Under consideration is a request for the Vertiflex spacer at the 
L4/5 level. Current evidence based medical guideline and peer reviewed literature do not fully support the 
spinal decompression device procedure over the gold standard of lumbar laminectomy. There is a lack of 
large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's 
medical condition as discussed above. FDA indications include implantation of the Superion device at one or 
two adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated 
at no more than two levels, from L1 to L5. This enrollee has at least moderate spinal stenosis at the lumbar 
levels from L2/3 through L5/S1 with severe spinal stenosis at the L4/5 level, and would not meet FDA 
indications. FDA contraindications include scoliosis and osteoporosis, and have not been adequately addressed 
in the medical records. There is no discussion indicating that a DEXA scan has demonstrated no osteoporosis 
in this post-menopausal 74-year-old female. There is imaging evidence of degenerative scoliosis with no 
documentation that the Cobb angle is less than 10 degrees.  
 
Superion indirect lumbar decompression would not be considered the standard of care for the enrollee's 
medical condition. Therefore, this request does not meet Medicare criteria as medically reasonable and 
necessary for treatment of this enrollee's medical condition. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on May 
28, 2019 by an OON provider. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you were advised by 
the Plan that you are an in-network provider, and were told the treatment would be covered. The Plan denied 
your request. The Plan says the service was rendered by an OON provider. The Plan also says that no benefits 
are available for procedures performed by OON providers. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the problem 
focused limited oral evaluation provided on May 28, 2019 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit services provided to the enrollee on December 
19, 2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the primary carrier should be billed. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. The provider must first bill the primary 
carrier. The Plan cannot be held responsible for the services until the primary insurer has denied the claim for 
these services. Therefore, we decided that the Plan does not have to pay for office visit services provided to the 
enrollee on December 19, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that you need to stay in the hospital until you are better. 
 
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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for SNF services. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Belbuca 750MCG Film. 
 
You asked the Plan to pre-approve Belbuca. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug is not a covered benefit. 
 
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 Belbuca 750MCG Film.  
 
Benefits for Belbuca 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the cycling therapy system for the enrollee. 
 
You asked the Plan to pre-approve the system. You say that the enrollee is an excellent candidate for this 
equipment. The Plan denied your request. The Plan says this 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 system. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the requirements listed in the Social Security Act, Section 1862 (a)1(A) and the 42 CFR 411.15(k) for 
Medicare coverage for the cycling therapy system have not been met. There is insufficient evidence in the literature that reveal the impact of safety and effectiveness of this device for multiple sclerosis patients. The current evidence for FES on health-related quality of life is limited by studies recruiting small numbers of participants, investigating impact over the short-term, and lacking control comparators. 
 
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 system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the cycling therapy system for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve new patient outpatient office visit (99203) to be 
provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that you are requesting review of your case and 
grant you the opportunity to see a therapist in your vicinity. You have waited a long time to see a therapist and 
feel that this is impacting your physical health as well. The Plan denied your request. The Plan says enrollee's 
must receive their medical services from an in-network provider with the exception being urgent or emergent 
services. Non-emergent services with non-contracted providers require prior authorization before services 
being rendered. 
 
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 
new patient outpatient office visit (99203) to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for serum iron studies provided to the enrollee. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says nutritional deficiency, unspecified is not listed as an approved diagnosis for these services. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the diagnosis is inconsistent with the procedure. This should be billed with the appropriate code for these 
services. The review has determined that the documentation does not support that the services rendered were 
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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for serum iron studies provided to the enrollee.