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

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that the requested Euflexxa is medically necessary. The 
Plan denied your request. The Plan says the requested Euflexxa is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Euflexxa. Our reviewer says that the 
requested Euflexxa is not medically necessary. Our physician reviewer found the enrollee is diagnosed with 
arthritis of the left shoulder. Euflexxa is experimental for the treatment of shoulder degenerative joint disease. 
More research is needed to show the safety and efficacy of Euflexxa. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heel lift. 
 
You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary. The Plan denied 
your request. The Plan says the documentation received fails to indicate that the requested heel lift is on a shoe 
that is an integral part of a covered brace. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve a heel lift.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a transthoracic echocardiogram (TTE). 
 
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 that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the submitted records show that you have a 
history of aortic dilation and chronic high blood pressure. You have not had a repeat study in four years. Your 
condition requires monitoring for aortic root size and the requested TTE is reasonable and 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 been met. Therefore, we decided that the Plan has to pre-
approve a transthoracic echocardiogram (TTE).  
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an interlaminar process stabilization device 
(Vertiflex procedure). 
 
You asked the Plan to pre-approve Vertiflex. You say that you are appealing based on medical necessity. The 
Plan denied your request. The Plan says the denial of authorization for this service is correct, because there is a 
lack of long-term peer-reviewed studies to support the use of Vertiflex for the enrollee's medical condition. 
 
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 Vertiflex. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve insertion of an interlaminar process stabilization device (Vertiflex procedure).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture (97813). 
 
You asked the Plan to pre-approve acupuncture. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, you are requesting acupuncture for chronic neck pain. 
Acupuncture is only approved for low back pain. Therefore, we decided that the Plan does not have to pre-
approve acupuncture (97813).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cardiac Computed Tomography (75574). 
 
You asked the Plan to pre-approve the Cardiac Computed Tomography. You say that the Cardiac Computed 
Tomography is medically necessary. The Plan denied your request. The Plan says coverage criteria is not met. 
 
The Plan follows Medicare rules. Medicare rules say that Cardiac Computed Tomography is covered when 
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 Cardiac Computed Tomography. 
Our reviewer says that Cardiac Computed Tomography is not medically necessary. Our physician reviewer 
found there is no covered indication for the procedure and results are not expected to provide new additional 
information that would affect treatment. 
 
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 Cardiac Computed Tomography have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Cardiac Computed Tomography (75574).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says the plan does not cover durable medical equipment for enrollees residing in a 
facility not designated as their home by Medicare rules. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the wheelchair is being requested for use in a SNF or hospital. Therefore, we decided that 
the Plan does not have to pre-approve a group 3 power wheelchair.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve the medical services. You say that you were told that there were in-network 
providers, but the only other provider does not accept Medicare. The Plan denied your request. The Plan says 
there are other providers available in-network that you can seek treatment with that would be covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the medical services to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 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 A6530.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the custom ankle orthosis to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve these services. You say that the enrollee does not have anyone in network in 
her area. The Plan denied your request. The Plan says that they do not have a network deficiency. 
 
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 custom ankle orthosis to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar spinal fusion. 
 
You asked the Plan to pre-approve the lumbar spinal fusion. You say that you would like reconsideration 
because you are in pain and the surgery is necessary. The Plan denied your request. The Plan says this surgery 
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 lumbar spinal fusion. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documented spinal instability, fracture, or tumor. 
 
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 lumbar spinal fusion have not been met. Therefore, we decided that the Plan 
does not have to pre-approve lumbar spinal fusion.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup, including any pins when required 
(D2950). 
 
You asked the Plan to pre-approve the core buildup. You say that there was existing decay on tooth #11. You 
also say that the enrollee has sensitivity upon biting and chewing. The Plan denied your request. The Plan says 
this service is not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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-approve a 
core buildup, including any pins when required (D2950).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on June 3, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 did not pre-approve the 
physicians services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on June 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on January 20, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says prior 
authorization was not obtained as required under the Plan benefits. 
 
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 did not pre-approve the 
physicians services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on January 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance services provided out of network on 
February 5, 2020. 
 
You asked the Plan to pay for the periodontal maintenance services provided out of network. You say that the 
office staff of the provider should have known about the network status of the provider while submitting the 
claims. The Plan denied your request. The Plan says in order for dental benefits to be covered, they must be 
received from a network provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the benefits do not include coverage 
for services performed by an out of network dentist. The records show that the Therefore, we decided that the 
Plan does not have to pay for periodontal maintenance services provided out of network on February 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nurse practitioner services provided on April 23, 2020. 
 
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for nurse practitioner services provided on April 23, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office services provided from January 7, 2020 to February 
25, 2020. 
 
You asked the Plan to pay for office services. You say that you are requesting payment. The Plan denied your 
request. The Plan says the denial of payment for these services is correct, because this provider has opted out of 
the Medicare program and is not eligible for payment. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
office services provided from January 7, 2020 to February 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral x-ray (D0220) and extraction (D7210) provided 
on May 22, 2020. 
 
You asked the Plan to pay for the intraoral x-ray (D0220) and extraction (D7210). You say that there was no 
dentist at the hospital that could treat you. You say that you had to have this tooth extracted and couldn't find a 
network dentist. The Plan denied your request. The Plan says the services are not covered benefits. 
 
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 pay for the 
intraoral x-ray (D0220) and extraction (D7210) provided on May 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for wound debridement provided from 
November 7, 2019 to May 21, 2020. 
 
You asked the Plan to waive the copayments for wound debridement. You say that you feel that the charges are 
too high. The Plan denied your request. The Plan says the claims were processed correctly and you are being 
charged the correct amount. 
 
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 $310 
copayment for surgery services provided in an outpatient hospital facility. 
 
You received wound debridement from November 7, 2019 to May 21, 2020 for a total of 13 services. Wound 
debridement is considered an outpatient surgical procedure. Therefore, you are responsible to pay the total 
allowed amount of $4,024.09, which is less than the total copayment amount.   
 
You have been asked to pay the total copayment amount of $4,024.09 for wound debridement. Wound 
debridement falls within the outpatient surgery, including services provided at hospital outpatient facilities and 
ambulatory surgical centers benefit category. 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 copayments for wound 
debridement provided from November 7, 2019 to May 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head rendered on 
March 18, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim is a duplicate. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the 
Plan on a separate claim for the same date of service. 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 
pay for the computed tomography (CT) scan of the head rendered on March 18, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Mvasi, Carboplatin, Paclitaxel, Emend and Aloxi.

You asked the Plan to pre-approve Mvasi, Carboplatin, Paclitaxel, Emend and Aloxi. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drugs are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

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 Mvasi, Carboplatin, Paclitaxel, Emend and Aloxi. Our reviewer says that the documentation does not support that the requested drugs are medically reasonable or necessary. Our physician reviewer found you have recurrent  (metastatic) squamous cell carcinoma of  the anus. The requested drugs are not FDA-approved for your diagnosis. Just carboplatin and paclitaxel without Mvasi (bevacizumab) are FDA-approved for your diagnosis. The requested use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Therefore, you do not meet criteria for the requested drugs together.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Mvasi, Carboplatin, Paclitaxel, Emend and Aloxi have not been met. Therefore, we decided that the Plan does not have to pre-approve Mvasi, Carboplatin, Paclitaxel, Emend and Aloxi.