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

 
We decided that the Plan does not have to pre-approve the eye and medical examination for diagnosis and 
treatment (92014) to be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve the eye and medical examination for diagnosis and treatment. You say that 
you have been working with this out of network doctor to help your condition. The Plan denied your request. 
The Plan says they have ophthalmology specialists that can evaluate and treat your condition. 
 
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 eye and medical examination for diagnosis and treatment (92014) to be provided by an out of network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the new patient office or other outpatient visit (99204) 
to be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve the new patient office or other outpatient visit. You say that you were told 
no one in network is able to do the procedure. The Plan denied your request. The Plan says the care is available 
in network and they have approved you to see an in-network 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 
the new patient office or other outpatient visit (99204) to be provided by an out of network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sodium hyaluronate. 
 
You asked the Plan to pre-approve sodium hyaluronate. 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. 
 
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 sodium hyaluronate. Our reviewer says 
that the medication is not medically necessary. Our physician reviewer found based on the medical records 
provided there is no indication that the plan's required drugs 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 sodium hyaluronate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve sodium hyaluronate.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gradient compression sleeve, gradient pressure 
aid/gauntlet, and a Sigvaris full radial chip pad. 
 
You asked the Plan to pre-approve gradient compression sleeve, gradient pressure aid/gauntlet, and a Sigvaris 
full radial chip pad. You say that you would like the plan to reconsider their denial. The Plan denied your 
request. The Plan says the requested items are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that wound care items identified with code A6549 is 
non-covered. 
 
We looked at the file and Medicare rules. Gradient compression sleeves identified with code A6549 is non-
covered. Review of the file shows that the requested Gradient pressure aid (gauntlet) identified with code 
S8428 has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. 
Medicare uses another code for reporting of, and payment of these services. Also, the requested Sigvaris full 
radial chip pad does not have a billing code and the requested provider does not bill insurance claims for this 
item. Based on this information, we decided that Medicare rules for coverage of gradient compression sleeve, 
gradient pressure aid/gauntlet, and a Sigvaris full radial chip pad have not been met. Therefore, we decided that 
the Plan does not have to pre-approve gradient compression sleeve, gradient pressure aid/gauntlet, and a 
Sigvaris full radial chip pad.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the orthopedic office visit to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the orthopedic office visit. You say that you would like to see the doctor 
who performed your hip replacement. The Plan denied your request. The Plan says the requested service can be 
provided in-network. 
 
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 orthopedic office visit to be provided by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional transportation. You say that it is critical that the enrollee attends 
dialysis treatment three times weekly. The Plan denied your request. The Plan says the enrollee's benefit only 
allows 60 trips for this service. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this 
case. The Plan covers a maximum of 60 one-way trips per year.  
 
The file shows that at the time of request, 57 trips have been used. We looked at your request, the records in the 
case file, and the rules. Once the enrollee has used 60 one-way trips, she will have exhausted the Plan 
maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to 
pre-approve additional routine transportation.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve the PET scan. You say that the requested PET scan should be authorized to 
evaluate whether the enrollee's symptoms are Alzheimer's or a type of dementia. The Plan denied your request. 
The Plan says the clinical information provided does not show that the criteria for coverage of the requested 
PET scan have been met. 
 
The Plan follows Medicare rules. Medicare rules say that an FDG PET scan is covered for certain indications 
and 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 PET scan. Our reviewer says that 
the criteria for coverage have not been met. Our physician reviewer found the enrollee is noted to have a 
primary diagnosis of a mild cognitive impairment (MCI). The records provided for review did not support that 
the enrollee met diagnostic criteria for both FTD and AD as required by the NCD. Rather the records provided 
for review did not readily mention either diagnosis. As the enrollee does not meet diagnostic criteria for both 
AD and FTD, the initial requirement for coverage of the requested procedure would not be considered to have 
been satisfied at this time. As the requirements of the NCD have not been met this service would not be 
reasonable and necessary. 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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. You were admitted for 
weakness and pain in hips and ribs. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the medical record does document 
a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation 
program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the 
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 acute IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ambien for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that the enrollee has failed temazepam and trazodone. 
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 Ambien 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee is not expected to need this level of care for 25 
days or more. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. The patient 
appears to be improving but requires additional short-term acute care services for less than 25 days to help 
stabilize before considering transfer to a different location. Wound care can be performed by nursing staff and 
appears to not be complex enough for LTACH. The patient does not require services at the LTACH that are not 
already provided and available at the current facility. Our physician reviewer found that the enrollee's condition 
does not meet Medicare criteria for LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation. 
 
You asked the Plan to pre-approve the additional trips. The Plan denied your request. The Plan says this 
requested exceeds the benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this 
case. The Plan covers a maximum of 50 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the requested additional trips will exceed the Plan maximum benefit for coverage of routine transportation. 
Therefore, we decided that the Plan does not have to pre-approve additional trips for routine transportation.
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 have bad circulation in your 
left leg and you need these because your doctor, a specialist in veins, recommended you to use compression 
stockings. The Plan denied your request. The Plan says this item 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 foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that without corrective arches you will constantly 
have this pain. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
While you may need orthopedic shoe inserts to help with your foot problem, Medicare and the plan do not 
cover them in your case. This is because they are not being used as part of a leg brace, or to treat diabetic foot 
disease. 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of the neck. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. 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 CT scans 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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has suggestion of external 
compression of the airway. The CT of the neck is needed to investigate this and is reaosonable and medically 
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 been met. Therefore, we decided that the Plan has to pre-
approve a computed tomography (CT) scan of the neck.  
 
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's needs could possibly be met a lower level care. 
 
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. There 
is no evidence of medical issues that require monitoring by an inpatient rehab physician three times a week. 
The documentation does not support that there is a need for an intensive therapy program with 3 hours a day at 
current level of function and an interdisciplinary approach to rehab care. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for IRF care. 
 
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 acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve consultation and extraction services with an oral 
surgeon. 
 
You asked the Plan to pre-approve the services with an oral surgeon. You say that tooth #30 needs to be 
extracted and it is close to the nerve. You say that a general dentist cannot perform the extraction because you 
might end up paralyzed. You say that you have a cardiac condition and that if you get too nervous you could 
have a heart attack. You say that you have not been able to eat properly because of the tooth and that if it gets 
infected again it will affect your health. The Plan denied your request. The Plan says the services being 
requested are not covered benefits under your contract. 
 
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 coverage is limited to services 
performed by a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve 
consultation and extraction services with an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Resound Linx Quattro hearing aids. 
 
You asked the Plan to pre-approve the Resound Linx Quattro hearing aids. You say that you would like 
reconsideration because this hearing aid was recommended by a Plan provider. The Plan denied your request. 
The Plan says this hearing aid benefit is limited to the TruHearing Advanced 19 and Premium 19 hearing aids. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan only covers 
TruHearing Advanced and Premium hearing aids. 
 
We looked at your request, the file, and the Plan's rules. Based on this information, we decided that the Plan's 
rules for coverage of the Resound Linx Quattro hearing aids have not been met. Specifically, the Plan covers 
TruHearing Advanced 19 and Premium 19 hearing aids. Resound Linx Quattro hearing aids are not a covered 
benefit. Therefore, we decided that the Plan does not have to pre-approve Resound Linx Quattro hearing aids.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Stelara. 
 
You asked the Plan to pre-approve Stelara. You say that the enrollee has tried and failed topical steroid creams. 
The Plan denied your request. The Plan says the medication does not fall 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 Stelara.  
 
Benefits for Stelara may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.