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

 
We decided that the Plan does not have to pre-approve advanced prosthetic features (L5976, L5782, L5962). 
 
You asked the Plan to pre-approve the advanced prosthetic features. You say that these features are medically 
necessary. The Plan denied your request. The Plan says the items do not meet coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that these advanced features are covered for enrollees that 
are level 3 ambulators. 
 
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 advanced prosthetic features. Our 
reviewer says that the advanced features requested are not medically necessary. Our physician reviewer found 
the documentation from the physician progress notes do not indicate the patient is a Level 3 ambulator. 
 
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 advanced prosthetic features have not been met. Therefore, we decided that 
the Plan does not have to pre-approve advanced prosthetic features (L5976, L5782, L5962).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-One (J7325). 
 
You asked the Plan to pre-approve Synvisc-One. The Plan denied your request. The Plan says the information 
submitted does not meet the Plan's medical necessity guidelines for coverage. 
 
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 Synvisc-One. Our reviewer says that 
Synvisc-One is not medically reasonable and necessary for the enrollee. Our physician reviewer found the 
enrollee has not tried and failed the required drug(s). Our reviewer also found that there is no indication that the 
Plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
 
 
Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc-One (J7325).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Epidural Steroid Injection. 
 
You asked the Plan to pre-approve Epidural Steroid Injection. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Epidural Steroid Injections are only covered for 
certain 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 Epidural Steroid Injection. Our 
reviewer says that the documentation does not support that the requested injection services are medically 
reasonable or necessary. Our physician reviewer found you have diagnoses of other intervertebral disc 
 displacement, lumbar region and spondylosis without myelopathy or radiculopathy, lumbosacral region. The 
documentation does not support that you have had failure of four weeks of non-surgical, non-injection care. 
The documentation states that you were prescribed Gabapentin but are not taking the prescribed medication. 
The record also states that you would benefit from a brace. However, dates of physical therapy trials, use of 
nonsteroidal anti-inflammatory drugs, use of the brace or other conservative measures were not documented in 
the provided record. Therefore, you do not meet criteria for the requested 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 Epidural Steroid Injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Epidural Steroid Injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Osteogen ultrasound stimulator (E0760). 
 
You asked the Plan to pre-approve a Osteogen ultrasound stimulator. You say that the item is necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that an ultrasonic osteogenesis stimulator is covered when 
specific criteria is 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 a Osteogen ultrasound stimulator. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based on the medical 
records provided there is no documentation that you meet the coverage criteria. The following criteria are not 
met: demonstration of nonunion of a fracture documented by a minimum of two sets of radiographs obtained 
prior to starting treatment with the osteogenesis stimulator, separated by a minimum of 90 days. Each 
radiograph set must include multiple views of the fracture site accompanied by a written interpretation by a 
treating practitioner stating that there has been no clinically significant evidence of fracture healing between the 
two sets of radiographs; and the fracture is not tumor related. 
 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Osteogen ultrasound stimulator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Osteogen ultrasound stimulator (E0760).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve leg lifts for your power wheelchair. 
 
You asked the Plan to pre-approve leg lifts. You say that you need leg lifts. The Plan denied your request. The 
Plan says that your power wheelchair already has leg lifts. 
 
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 your power wheelchair has leg lifts. The leg lifts you are requesting serve the same purpose 
as leg lifts you already have. Therefore, we decided that the Plan does not have to pre-approve leg lifts for your 
power wheelchair.  
 
Please note, the Plan has approved repairs to the leg lifts your already have on your power wheelchair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp (J0881). 
 
You asked the Plan to pre-approve Aranesp. You say that the enrollee needs the requested drug. The Plan 
denied your request. The Plan says there is no evidence that the enrollee had an inadequate response to 
Retacrit. The Plan says that the criteria has not been met. 
 
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 Aranesp. Our reviewer says that the 
requested drug is not medically necessary. Our physician reviewer found based on the medical records 
provided the enrollee has not tried and failed the required drug, Retacrit. The reviewer found that the medical 
records provided do not indicate that the plan's required drug would likely be less effective or likely have 
adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp (J0881).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Testosterone 1.62% Gel Pump. 
 
You asked the Plan to pre-approve the Testosterone 1.62% Gel Pump. You say that the enrollee has been on 
this therapy for 3 years. You also say this prescription is working well, and the enrollee's labs for testosterone 
have improved over the past few years. The Plan denied your request. The Plan says this drug is not covered 
for the enrollee's condition by Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve a Testosterone 1.62% Gel 
Pump.  
 
Benefits for the Testosterone 1.62% Gel Pump 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the outpatient surgery services provided 
on December 16, 2019, by an in-network provider. 
 
You asked the Plan to waive the coinsurance for the outpatient surgery services. You say that you thought the 
Plan should have to pay the bill. The Plan denied your request. The Plan says the claim was processed 
accordingly with your 2019 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that you received outpatient surgery services provided on December 16, 2019, by an 
in-network provider. You are asked to pay 20% coinsurance for the services. Your EOC states that enrollees 
must pay 0% to 20% coinsurance for each in-network Medicare-covered outpatient hospital facility. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the coinsurance for the outpatient surgery services provided on December 16, 
2019, by an in-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.The rules say that Medicare will cover a Power Mobility Device (PMD) (i.e., power wheelchair or scooter) for a person who meets the following criteria: 1.The person must have a personal mobility deficit; 2.The deficit must impair their participation in mobility related activities of daily living (MRADLs) such as toileting, feeding, grooming and bathing in customary locations within the home; 3.The person's condition must not be able to be ameliorated by a walker, cane or manual wheelchair; and4.The person must be capable of safely operating the PMD. You can find this rule in the Medicare National Coverage Determinations Manual, Section 280.3(B).If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuous glucose monitor (CGM) sensors. 
 
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 a therapeutic CGM and supplies are covered 
when specific criteria 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of Type 2 
diabetes. A progress note dated July 20, 2020 states she has had multiple issues with medications, compliance, 
motivation, and blood glucose checking. The records do not support that the enrollee has been using a blood 
glucose monitor and performing frequent testing of at least four or more times a day. The requested CGM 
sensors are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continuous glucose monitor (CGM) sensors.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on March 28, 
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 claim was submitted with an incorrect place of service code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case the claim cannot be paid due to an issue 
with the POS code. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to 
pay for physician services provided to the enrollee on March 28, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xifaxan for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xifaxan for the enrollee.  
 
Benefits for this drug 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MRI of a lower extremity (73721). 
 
You asked the Plan to pre-approve the MRI. You say that you would like reconsideration because the MRI is 
medically necessary. The Plan denied your request. The Plan says there is no supporting clinical information 
that indicates these guidelines have 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 based 
on the medical records provided there is no documentation that an MRI of the left hip is medically reasonable 
and necessary in this case. Our physician reviewer found records do not document a recent plain x-ray of the 
left hip or document a trial of six weeks of physician-directed conservative treatment prior to the request for the 
MRI. 
 
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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve MRI of a lower extremity (73721).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a robotic surgical system (S2900). 
 
You asked the Plan to pre-approve the robotic surgical system. You say that you would like reconsideration 
because this service is medically necessary. The Plan denied your request. The Plan says this service is not a 
Medicare covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that [insert custom text from glossary].  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the robotic surgical system have not been met. Specifically, CPT code S2900 represents a robotic 
surgical system and this is not a Medicare covered benefit. Therefore, we decided that the Plan does not have to 
pre-approve a robotic surgical system (S2900).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (01610) provided on January 23, 2020. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the documentation does not support the service 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 01610 is anesthesia for all procedures on nerves, muscles, 
tendons, fascia, and bursae of shoulder and axilla. 
 
We asked our coder 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 anesthesia services. Our reviewer says that CPT code 
01610 does not meet criteria for billing or reimbursement consideration. Our reviewer found the documentation 
does not include an anesthesia report, therefore, CPT 01610 cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan 
does not have to pay for anesthesia services (01610) provided on January 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a manual high strength lightweight wheelchair the enrollee 
purchased on July 18, 2020. 
 
You asked the Plan to pay for this equipment. You say that this manual wheelchair was medically necessary. 
The Plan denied your request. The Plan says the medical records do not indicate the enrollee tried and failed a 
standard wheelchair in the home or that the enrollee met the required criteria for this type of manual 
wheelchair. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The rules say deluxe or specialize equipment must meet specific criteria and is not covered 
for use outside of the home.  
 
Your appeal states the enrollee required this manual wheelchair for home use and for appointments outside the 
home. There was no face to face evaluation, where was no home evaluation, there were now measurements to 
show the home could accommodate the purchased wheelchair. Insufficient medical records were provided to 
show the enrollee required the manual wheelchair purchased. Therefore, we decided that the Plan does not have 
to pay for a manual high strength lightweight wheelchair the enrollee purchased on July 18, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the chest x-ray performed, by an in-network
 provider. 
 
You asked the Plan to waive the copayment for the chest x-ray. You say that this was a procedure that was part 
of your annual preventive exam. The Plan denied your request. The Plan says your annual wellness visit does 
not include lab tests. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that you had a chest x-ray, by an in-network provider. You are asked 
to pay a $20 copayment for the x-ray. Your EOC states, "enrollees must pay a $20 copayment per day, per 
provider, for in-network Medicare-covered x-ray services" and "the annual preventive physical exam DOES 
NOT include lab tests and immunizations." This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the chest x-
ray performed, by an in-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for eyeglasses provided on April 6, 2020. 
 
You asked the Plan to reimburse you for the eyeglasses. The Plan denied your request. The Plan says this 
provider is not a preferred provider with our vision network that provides the supplemental benefit for your 
plan. 
 
Medicare generally does not cover routine 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 preferred vision provider. 
 
We looked at the file and the Plan's rules. The eyewear provider at issue in this case is not a Plan preferred 
vision provider. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have 
not been met. Therefore, we decided that the Plan does not have to reimburse you for eyeglasses provided on 
April 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the CT scan of the abdomen provided on 
July 7, 2020. 
 
You asked the Plan to waive the copayment for the CT scan. You say that this was preventative. The Plan 
denied your request. The Plan says they contacted your provider's office and were told that this study was to 
follow up on a liver abscess seen on a CT scan in January 2020. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that you received a CT scan of the abdomen on July 7, 2020. You are asked to pay a 
$100 copayment for the CT scan. Your EOC states that enrollees must pay a $100 copayment for advanced 
imaging services performed at a freestanding radiological facility. This means that you have been asked to pay 
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for the CT scan of the abdomen provided on July 7, 2020.