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

 
We decided that the Plan does not have to pay for podiatry services provided on July 15, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for podiatry services. You say that you would like this appeal reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The 
Plan says that there are in-network providers available for 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 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 podiatry services provided on July 15, 2020 by an 
out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that the hospitalization has been complicated. The Plan 
denied your request. The Plan says care can be provided at an alternate setting such as SNF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does 
not currently require intensive physician and nursing oversight only in an IRF. You may benefit from multiple 
therapies such as physical and occupational therapy but the documentation does not support that your 
functional status requires an intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to an inpatient rehabilitation facility (IRF).
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. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee has not met step therapy requirements. 
 
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. Our reviewer says that the 
criteria for coverage of Prolia have not been met. Our physician reviewer found the Plan requires a trial of an 
oral bisphosphonate and zoledronic acid (generic Reclast) before they will approve the requested drug. In this 
case, that patient has not tried and failed the required drugs. There is no documentation provided indicating that 
the Plan?s required drugs would likely be less effective or 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 have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network laboratory. 
 
You asked the Plan to pre-approve these services. You say that this is your preferred laboratory. The Plan 
denied your request. The Plan says the services are available from network providers. 
 
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 laboratory.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the lumbar spine to be provided by the 
requested facility. 
 
You asked the Plan to pre-approve the MRI of the lumbar spine. You say that the MRI equipment at the in-
network facility is old and always breaks down.  The Plan denied your request. The Plan says you must receive 
care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out 
of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior 
authorization from the plan. 
 
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 this service. Therefore, we decided that the Plan does not have to pre-approve an MRI of 
the lumbar spine to be provided by the requested facility.
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 you have a foot condition and need this to walk 
correctly. 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 foot orthotics.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve biceps tenodesis and distal claviculectomy. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee presents with persistent 
right shoulder pain status post a fall in April 2020. She reports on-going positional and activity-related pain. 
Clinical exam findings have documented positive impingement signs consistent with imaging evidence of a full 
thickness supraspinatus tear. She has failed to adequately improve with conservative treatment, including 
activity modification, medications, physical therapy, home exercise program, and subacromial injection. Biceps 
tendon clinical exam findings are not reported. A specific indication for the inclusion of these procedures has 
not been provided by the requesting orthopedic physician. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request. Therefore, the requested 
biceps tenodesis and distal claviculectomy would not be considered the standard of care or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve biceps tenodesis and distal claviculectomy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CPAP cleaning device (A9270). 
 
You asked the Plan to pre-approve the cleaning device. You say that the device is medically necessary and will 
improve your health and reduce the amount of CPAP equipment you need to replace. The Plan denied your 
request. The Plan says this item is considered cleaning equipment and is not covered. 
 
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 CPAP cleaning device (A9270).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Reclast (J3489). 
 
You asked the Plan to pre-approve Reclast. You say that the Reclast is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Reclast. Our reviewer says that the 
requested Reclast infusion is not medically necessary. Our physician reviewer found the patient's bone density 
scan shows a T-score of no worse than -2.1 which is in the osteopenia range. The patient has no documented 
history of fracture, androgen-deprivation therapy, or corticosteroid history in the available records. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Reclast have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Reclast (J3489).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea bone graft in conjunction with periradicular surgery (D3428), removable prosthodontic procedure (D5899), and core buildup, including any pins when required (D2950).You asked the Plan to pre-approvethe bone graft, removable prosthodontic procedure, and core buildup. You say that this treatment is for a medical cause, and not cosmetic. You also say that you are on a low income, and this treatment is necessary for your health.The Plan denied your request. The Plan says bone graft and removable prosthodontic procedure are not covered under your benefit package. The Plan also says that the core buildup exceeds the maximum count allowed per period.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, bone graft in conjunction with periradicular surgery and unspecified removable prosthodontic procedure are not among those covered under this benefit. The contract also clearly states that core buildup, including any pins when required (D2950) is limited to one procedure per tooth every five plan years. The record shows that you last received a core buildup on tooth #11 onTherefore, we decided that the Plan does not have to pre-approvea bone graft in conjunction with periradicular surgery (D3428), removable prosthodontic procedure (D5899), and core buildup, including any pins when required (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(S9986). 
 
You asked the Plan to pre-approve special supplemental benefits for the chronically ill. You say that the 
benefits are medically necessary. The Plan denied your request. The Plan says the enrollee does not have a 
condition for which this benefit is provided. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the plan contract, the file, and Medicare rules. The enrollee does not have a covered condition 
that qualifies them for the supplemental benefits. Based on this information, we decided that Medicare rules for 
coverage of special supplemental benefits for the chronically ill have not been met. Therefore, we decided that 
the Plan does not have to pre-approve special supplemental benefits for the chronically ill (S9986).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve Magnetic Resonance Imaging (MRI) of the lumbar spine (72148). 
 
You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary. The Plan denied 
your request. The Plan says that coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 the MRI. Our reviewer says that the 
MRI is medically necessary. Our physician reviewer found the enrollee has known cervical canal stenosis. A 
Neurosurgical consultation has been requested. The MRI is medically appropriate in order to evaluate and plan 
surgical intervention. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
Magnetic Resonance Imaging (MRI) of the lumbar spine (72148).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro upper extremity assist orthosis. 
 
You asked the Plan to pre-approve the MyoPro orthosis. You say that the enrollee requires this to assist with 
daily living activities. The Plan denied your request. The Plan says there is no fee for this item on the fee 
schedule and medical necessity is not established. 
 
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 MyoPro orthosis. Our reviewer says 
that the requested device is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is a 65-year-old woman with a diagnosis of left-sided hemiplegia and hemiparesis 
following a right thalamic stroke in 2007. The enrollee has significant left upper extremity weakness with 1-2/5 
strength, despite sustained traditional therapies. The documentation does not support that the enrollee's needs 
cannot be met with a standard body-powered orthosis. 
 
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 MyoPro orthosis have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the MyoPro upper extremity assist orthosis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not haveto pre-approvea transport wheelchair.You asked the Plan to pre-approvethe transport chair. You say that the chair is medically necessary.The Plan denied your request. The Plan says the documentation shows the item is for use outside the home.The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home.Therefore, we decided that the Plan does not have to pre-approvea transport wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) for a power 
mobility device. 
 
You asked the Plan to pre-approve the power seat elevation feature. You say that the elevation feature is 
necessary for you to reach items and avoid pressure sores. The Plan denied your request. The Plan says this 
item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) is non-
covered.  
 
We looked at the file and Medicare rules. While the item may be beneficial, it is not covered under your 
Medicare benefit. Based on this information, we decided that Medicare rules for coverage of the power seat 
elevation feature have not been met. Therefore, we decided that the Plan does not have to pre-approve a power 
seat elevation feature (E2300) for a power mobility device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea chondrolaryngoplasty as part of gender transition.You asked the Plan to pre-approvethe chondrolaryngoplasty. You say that you believe that this treatment is medically necessary and should be covered by the Plan.The Plan denied your request. The Plan says per peer-reviewed literature, the requested gender reassignment male-to-female procedure associated with feminization for voice modification is considered cosmetic in nature, as this is not considered medically necessary for gender affirming surgery.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 chondrolaryngoplasty. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a 31-year-old transgender female with dysphonia, who recently started hormonal therapy. The documentation does not support that female to male chondrolaryngoplasty is medically reasonable and necessary for the enrollee in this case. As of 4/16/19, the enrollee was a smoker, and had recently started hormone therapy. The enrollee had not been evaluated by speech therapy. The case file does not contain additional updated medical records. overage determinations for transgender surgery are made on a case by case basis with particular consideration of the World Professional Association for Transgender Health (WPATH) Standards of Care as interpreted through the various Medicare statutes, rules, regulations, and Manual instructions. The WPATH Standards of Care do not address chondrolaryngoplasty. We looked atthis physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the chondrolaryngoplasty have not been met.Therefore, we decided that the Plan does not have to pre-approvea chondrolaryngoplasty as part of gender transition.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe oral surgery consultation.You asked the Plan to pre-approvethe oral surgery consultation. You say that the enrollee has a periapical abscess and needs surgery.The Plan denied your request. The Plan says the service is not a covered benefit.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-approvethe oral surgery consultation
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine chiropractic services. 
 
You asked the Plan to pre-approve these services. You say that you need the services due to low back pain. The 
Plan denied your request. The Plan says you have exhausted the supplemental benefit limit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The Plan covers routine chiropractic visits for up to 
six visits per year. 
 
The services at issue are routine chiropractic visits. The file shows that you have used all six of the 
supplemental routine chiropractic visits allowed by the Plan. Further routine chiropractic visits are not covered 
by Medicare or your supplemental benefit. Therefore, we decided that the Plan does not have to pre-approve 
routine chiropractic services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
 
 
We decided that the Plan does not have to pre-approvea cough stimulating device interface (A7020).You asked the Plan to pre-approvethe cough stimulating device interface. You say that the items are medically necessary.The Plan denied your request. The Plan says code A7020 can only be billed for a replacement device interface, and not for a new device.The Plan must follow Medicare rules. Medicare rules say that CPT code A7020, interface, should be billed for replacement only. We looked at the file and Medicare rules. The record shows the cough stimulating device is newly approved and the requested interface is not a replacement item. Based on this information, we decided that Medicare rules for coverage of the cough stimulating device interface have not been met.Therefore, we decided that the Plan does not have to pre-approvea cough stimulating device interface (A7020).