Persius/hicric huggingface dataset:
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 you need the stockings for 
neuropathy. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code  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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided from November 12, 2020, to 
November 18, 2020. 
 
You asked the Plan to pay for the electrical stimulation and hot/cold packs. You say that the Plan gave you a 
list of in-network providers but did not tell you about the limitations of your benefit. The Plan denied your 
request. The Plan says electrical stimulation and hot/cold packs are not covered by Medicare or the Plan. 
 
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 records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for electrical stimulation and hot/cold packs provided from November 12, 
2020, to November 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exam rendered on August 20, 2019. 
 
You asked the Plan to waive the copayment for these services. You say that the copayment is a financial 
hardship. The Plan denied your request. The Plan says the copayment was applied correctly. 
 
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 $50 
copayment for each Medicare-covered eye exam to diagnose and treat diseases and conditions of the eye.  
 
Review of the file shows that you received an eye exam on August 20, 2019. You have been asked to pay a $50 
copayment for these services. These services fall within the Medicare-covered eye exam to diagnose and treat 
diseases and conditions of the eye 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 copayment for 
the eye exam rendered on August 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2300, 
E2311, E2313, E2377) for the enrollee. 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that for equipment to 
be covered, it must primarily serve a medical purpose. 
 
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 accessories. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not reveal that the enrollee requires other types of proportional input 
devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-
proportional input devices (e.g., sip and puff, head array, etc.) The enrollee does not need to operate 3 or more 
powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other 
electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive 
control), or an attendant control. The enrollee's upper extremity strength and function would allow the enrollee 
to control any power options through their own individual switches. 
 
We looked at this physician's review, the file, and Medicare rules. Our reviewer found that E2311, E2313, and 
E2377 are not considered medically reasonable or necessary. Additionally, E2300 is not needed for a primarily 
medical purpose. Based on this information, we decided that Medicare rules for coverage of the accessories 
have not been met. Therefore, we decided that the Plan does not have to pre-approve additional power 
wheelchair accessories (E2300, E2311, E2313, E2377) for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve myocardial perfusion imaging. 
 
You asked the Plan to pre-approve myocardial perfusion imaging. You say that the Plan denied your 
request. The Plan says that the requested 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 myocardial perfusion imaging. Our 
reviewer says that the requested services are considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee has no symptoms, but a left bundle branch block on EKG is 
suggestive of underlying heart disease possibly due to ischemia or prior silent myocardial infarction. An 
ischemic assessment, even in the absence of symptoms, is reasonable and medically necessary in this elderly 
woman. The enrollee has a significant abnormality on cardiac testing (specifically a left bundle branch block on 
electrocardiography) and this study would not be considered screening, and is therefore appropriate and 
covered by Medicare. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of myocardial perfusion imaging have been met. Therefore, we decided that the 
Plan has to pre-approve myocardial perfusion imaging.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Gelsyn-3 injection (J7328). 
 
You asked the Plan to pre-approve Gelsyn-3. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says rules for pre-approval have not been met because preferred drug Monovisc 
has not been trialed. 
 
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 Gelsyn-3. Our reviewer says that this 
drug is not medically necessary. Our physician reviewer found that the enrollee has a diagnosis of unilateral 
primary osteoarthritis of the right knee and has received 3 Orthovisc injections in the right knee in December 
2019. The enrollee has not tried and failed treatment with Monovisc. The documentation does not support that 
Monovisc (Hyaluronic acid) would likely be less effective, and/or would likely have adverse effects for the 
enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Gelsyn-3 injection (J7328).
Appeal type: Practitioner Services
Decision: Unfavorable

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

 
We decided that the Plan does not have to pre-approve bone replacement graft (D7953), crown (D2750), filling 
(D2950), nerve treatment (D3310), partial upper denture (D5213), and partial lower denture (D5214).  
 
You asked the Plan to pre-approve bone replacement graft, crown, filling, nerve treatment, partial upper 
denture, and partial lower denture. You say that the services should be covered. The Plan denied your request. 
The Plan says the services are not covered under your benefit plan. 
 
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-approve bone 
replacement graft (D7953), crown (D2750), filling (D2950), nerve treatment (D3310), partial upper denture 
(D5213), and partial lower denture (D5214).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Invokana tab 100mg. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the medical benefit covers those drugs covered under traditional Medicare Part A and 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 Invokana tab 100mg.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 1 Synvisc injection (J7325) per week for 3 weeks. 
 
You asked the Plan to pre-approve the Synvisc injections. You say that the requested drug is medically 
necessary. The Plan denied your request. The Plan says the benefit provides coverage for the requested 
viscosupplement, Synvisc, when medically necessary. The Plan also says that the enrollee has not tried and 
cannot use Monovisc. 
 
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 injections. Our reviewer says 
that the requested drug is not medically necessary. Our physician reviewer found in the documentation that was 
provided, there is no evidence that the enrollee tried and failed the first line viscosupplementation such as 
Monovisc. Therefore, the reviewer found that the criteria for Synvisc has not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc injections have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 1 Synvisc injection (J7325) per week for 3 weeks.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Cephalexin and Ondansetron provided on September 16, 
2020. 
 
You asked the Plan to pay for Cephalexin and Ondansetron. You say that the items were medically necessary. 
The Plan denied your request. The Plan says drugs and biologicals which you can give yourself ("self-
administered drugs") are not covered. 
 
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 pay for Cephalexin and Ondansetron 
provided on September 16, 2020.  
 
Benefits for Cephalexin and Ondansetron 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 a vacuum erection system. 
 
You asked the Plan to pre-approve a vacuum erection system. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that vacuum erection devices are non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a vacuum erection system have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a vacuum erection system.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the additional mammography view 
provided on September 17, 2020. 
 
You asked the Plan to waive the coinsurance for the additional mammography view. You say that you had to 
have an additional screening/view from the mammogram you had done. The Plan denied your request. The 
Plan says you were charged the coinsurance correctly. 
 
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 0 -20% 
coinsurance for Outpatient Diagnostic Tests.  
 
You have been asked to pay $16.73 coinsurance, 20% of the allowed amount, for the additional mammography 
view. The additional mammography view falls within the Outpatient Diagnostic Tests 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 coinsurance for the additional mammography view provided on September 
17, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Cologuard Test. 
 
You asked the Plan to pre-approve the Cologuard test. You say that you would like reconsideration because 
this testing is medically necessary. The Plan denied your request. The Plan says the member does not meet 
Medicare coverage criteria for this testing. 
 
The Plan must follow Medicare rules. Medicare rules say that The CologuardTM test is covered once every 
three years for Medicare beneficiaries that are between 50 and 85 years old. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Cologuard test have not been met. Specifically, this member is over 85 years old and therefore 
does not meet Medicare's NCD criteria. Therefore, we decided that the Plan does not have to pre-approve the 
Cologuard Test.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two localized deliveries of antimicrobial agents. 
 
You asked the Plan to pre-approve the localized deliveries of antimicrobial agents. You say that you need the 
medication for the treatment. 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 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-approve two 
localized deliveries of antimicrobial agents.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two crowns and two core buildups, including any pins 
when required. 
 
You asked the Plan to pre-approve the crowns and core buildups. The Plan denied your request. The Plan says 
these services are not covered under the enrollee's benefit plan. 
 
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-approve two 
crowns and two core buildups, including any pins when required.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oxygen concentrator and portable oxygen. 
 
You asked the Plan to pre-approve an oxygen concentrator and portable oxygen. You say that this is medically 
necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that for patients with arterial PO2 at or above 60 mm Hg or 
arterial O2 saturation at or above 90%, there is a rebuttable presumption of non-coverage for home oxygen.   
 
We looked at the file and Medicare rules. The record shows that testing on October 13, 2020, shows the 
enrollee's blood oxygen levels were above 90%. Although the certificate of medical necessity states it was at 
88% percent, no specifics are documented and this contradicts the medical records submitted. Based on this 
information, we decided that Medicare rules for coverage of an oxygen concentrator and portable oxygen have 
not been met. Therefore, we decided that the Plan does not have to pre-approve an oxygen concentrator and 
portable oxygen.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide an intermittent limb compression device and garments. 
 
You asked the Plan to provide intermittent limb compression device (E0651) and garments (E0667). You say 
that criteria are met for the intermittent limb compression device. The Plan denied your request. The Plan says 
the clinical notes showed improvement after leg elevation and knee-high compression stockings. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show clear documentation of failure of therapy interventions, exercise or leg elevation. The 
enrollee's trial was with a different device in January 2020. Therefore, we decided that the Plan does not have 
to provide an intermittent limb compression device and garments.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lift chair. 
 
You asked the Plan to pre-approve the chair. You say that you have difficulty getting up and out of a chair. The 
Plan denied your request. The Plan says possible alternatives may include treatment for enrollee's 
radiculopathy. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed above are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the chair. Our reviewer says that the 
requested services are not medically reasonable and necessary. Our physician reviewer found the 
documentation does not reveal objective findings of severe arthritis of the hip on imaging studies or a 
neuromuscular disease. The seat lift is not likely to effect improvement in your condition, or arrest or retard 
deterioration in your condition. The records do not show that you are completely incapable or standing from a 
chair in the home. You have the ability to ambulate. 
 
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 chair have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a lift chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Dexcom G6 transmitter for the enrollee. 
 
You asked the Plan to pre-approve the transmitter. You say that this is medically necessary. 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 transmitter. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case, the documentation indicates that the enrollee has been non-compliant with using a 
BGM and does not perform frequent (four or more times a day) testing. The enrollee has been using insulin 
multiple times (3 or more) a day and the treatment has not required frequent adjustment on the basis of testing 
results. 
 
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 transmitter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Dexcom G6 transmitter for the enrollee.