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

 
We decided that the Plan does not have to pre-approve Synvisc (J7325). 
 
You asked the Plan to pre-approve Synvisc. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for the requested viscosupplement device. 
 
  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. Our reviewer says that 
Synvisc is not reasonable and necessary. Our physician reviewer found there is no indication that the patient 
has tried and failed the required drugs, Orthovisc or Supartz FX. Our reviewer also found that there is no 
indication that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the 
patient. 
 
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 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Synvisc (J7325).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ocrevus infusions (J2350). 
 
You asked the Plan to pre-approve Ocrevus infusions. The Plan denied your request. The Plan says the 
requested medication does not appear to be medically necessary and appropriate in this clinical situation. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Ocrevus infusions. Our reviewer says 
that the elements of the coverage criteria are not satisfied, and the requested service cannot be recommended. 
Our physician reviewer found the record indicates that the enrollee has a diagnosis of secondary progressive 
multiple sclerosis. Our reviewer found that the Food and Drug Administration has not stated that the requested 
drug is indicated for the enrollee's condition. Our physician reviewer also found that the Medicare approved 
drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical 
situation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ocrevus infusions have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Ocrevus infusions (J2350).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Latanoprost Solultion 0.005%. 
 
You asked the Plan to pre-approve Latanoprost Solultion. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit. 
 
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 Latanoprost Solultion 
0.005%.  
 
Benefits for Latanoprost Solultion 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 5, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on March 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a Fluorodeoxyglucose injection provided 
on February 14, 2022. 
 
You asked the Plan to waive the coinsurance for a Fluorodeoxyglucose injection. You say that according to 
your insurance policy, your copayment for this procedure is $125. You also say that this provider charged you 
an extra $51.50 for a Fluorodeoxyglucose injection, which should be automatically included to the procedure. 
The Plan denied your request. The Plan says you were charged the correct cost sharing 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 20 
percent coinsurance for each Medicare-covered medical supply for outpatient diagnostic tests and therapeutic 
services and supplies.  
 
You have been asked to pay $51.50 in coinsurance, which is 20 percent of the allowed amount for a 
Fluorodeoxyglucose injection ($257.50 allowed amount x 20% = $51.50). A Fluorodeoxyglucose injection falls within the outpatient diagnostic tests and therapeutic services and supplies 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 a Fluorodeoxyglucose injection provided on February 14, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service March 7, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 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, we have confirmed that code 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76705 billed for date of service March 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 6, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the general health panel rendered on January 7, 2022. 
 
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 services are not covered. 
 
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-
covered code. 
 
You have requested payment for services billed under code 80050. Medicare does not cover or pay for services 
billed under this code. Therefore, we decided that the Plan does not have to pay for the general health panel 
rendered on January 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99215) provided on January 26, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says the services were 
provided out-of-network and were not approved in advance. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit (99215) provided on January 26, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a COVID-19 test provided on December 12, 2021. 
 
You asked the Plan to pay for the COVID-19 test. You say that the testing was required for travel by the law.  
The Plan denied your request. The Plan says you are only covered for urgent services to prevent loss of life or 
to treat serious illness when you're outside of your service area. The testing was not urgent but required for 
travel. Medicare only covers services that are required to treat an illness. Covid testing as required by a 
governmental body in order to travel is not necessary to treat an illness. 
 
The Plan must follow Medicare rules. Medicare rules say that the routine physical checkup exclusion applies to 
examinations required by third parties such as insurance companies, business establishments, or Government 
agencies. 
 
We looked at the file and Medicare rules. Medicare says that the routine physical checkup exclusion applies to 
examinations required by third parties such as insurance companies, business establishments, or Government 
agencies. Therefore, we decided that the Plan does not have to pay for a COVID-19 test provided on 
December 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the LensX Toric, a custom distance vision high cylinder 
intraocular lens (IOL) provided on January 12, 2022. 
 
You asked the Plan to pay for the Toric lens. You say that you would like to know why the lenses were not 
covered, but the surgeon and insertion of the lens are covered. The Plan denied your request. The Plan says this 
service is not covered by your health plan or Medicare. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an Astigmatism-
Correcting (A-C) intraocular lens (IOL) during cataract surgery, the enrollee will be responsible for the 
difference in cost between the A-C IOL and a conventional IOL.  
 
While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-
correcting feature of an IOL. The record also shows that you signed a surgical estimate with the provider's 
office stating you agreed to pay the total amount that would not be covered by your insurance. Therefore, we 
decided that the Plan does not have to pay for the LensX Toric, a custom distance vision high cylinder 
intraocular lens (IOL) provided on January 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on November 1, 2021. 
 
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 services are not covered.  
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on November 1, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services (90834) provided on March 23, 2021 to 
September 15, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the telehealth services. You say that this service should be covered. The Plan 
denied your request. The Plan says these services are only eligible for coverage when obtained from a network 
provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that while outpatient mental health services are covered when provided via telehealth, these services 
are only covered when obtained through in-network providers. 
 
 
 
 
 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service 
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 telehealth services (90834) provided on March 23, 2021 to September 15, 
2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that Prolia is medically necessary. The Plan denied your 
request. The Plan says in the absence of fracture, a trial of Zoledronic Acid is required before alternatives like 
Prolia can be considered. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that Prolia is 
not medically necessary. Our physician reviewer found the record shows no trial of the plan preferred drug or 
any reason it would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Hyaluronic acid. 
 
You asked the Plan to pre-approve Hyaluronic acid. You say that the requested treatment is a medical necessity 
for you. The Plan denied your request. The Plan says rules for coverage have not been met because the 
requested drug has been prescribed for an off-label and not medically supported use. 
 
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 Hyaluronic acid. Our reviewer says that 
the requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that 
Hyaluronic acid injections into the finger joints for osteoarthritis of the hand are not FDA-approved. 
Additionally, this use of Hyaluronic acid is not supported by one of the major drug compendia or by clinical 
research that appears in a Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hyaluronic acid have not been met. Therefore, we decided that the Plan does 
not have to pre-approve treatment with Hyaluronic acid.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed and accessories (E0265, 
E0940, E0305, E0184). 
 
You asked the Plan to pre-approve a total electric hospital bed and accessories. You say that you have been 
unable to sleep, and you are currently sleeping on a recliner. The Plan denied your request. The Plan says a 
total electric bed is not a benefit of Medicare or the plan. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed and accessories (E0265, E0940, E0305, E0184).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on December 14, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that Genetic testing for thrombophilia testing for the 
Factor V Leiden (FVL) variant in F5 gene, the 20210G>(G20210A) variant in the F2 gene, and the MTHFR 
gene for all risk factors, signs, symptoms, diseases, or conditions, including cardiovascular risk assessment, are 
non-covered except for pregnant patients.  
 
We looked at the file and Medicare rules. Per LCD 36400, the requested genetic testing is not a covered 
benefit. Based on this information, we decided that Medicare rules for coverage of the testing have not been 
met. Therefore, we decided that the Plan does not have to pay for genetic testing provided on December 14, 
2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve ten additional acupuncture treatments. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested services have been denied as you do 
not have a qualifying diagnosis. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, we requested the Plans internal supplemental acupuncture policy 
criteria in order to determine your eligibility for this treatment; however, it was not provided to our 
organization. The Plan has not substantiated their denial; therefore, we must find in your favor. Therefore, we 
decided that the Plan has to pre-approve ten additional acupuncture treatments.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pulp vitality tests (D0460) provided March 17, 2022. 
 
You asked the Plan to pay for the pulp vitality tests. You say that this service helped prevent a costlier 
procedure. The Plan denied your request. The Plan says this service is not covered under your benefits. 
 
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 pay for the pulp 
vitality tests (D0460) provided March 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight additional acupuncture treatments (97810). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the enrollee has exhausted the allowable benefit for 
this service. 
 
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. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.   
We looked at the case file and the Plans rules. Based on this information, we decided that the Plans rules for 
coverage of the requested acupuncture services have not been met. Specifically, the enrollee previously 
received fifteen acupuncture visits. The Plan contract states that the supplemental acupuncture benefit offers 
coverage for a total of fifteen visits per calendar year. Therefore, the enrollee has exhausted the allowable 
benefit for these services. Therefore, we decided that the Plan does not have to pre-approve eight additional 
acupuncture treatments (97810).