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

 
We decided that the Plan does not have to pre-approve a hysterectomy to be provided by an OON provider. 
 
You asked the Plan to pre-approve the hysterectomy. You say that this service is medically necessary. The Plan 
denied your request. The Plan says this service is available by a provider in your 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 
a hysterectomy to be provided by an OON provider.
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 enrollee's needs an IRF to be able to ambulate household distance and perform self-care. The Plan denied your request. The Plan says an IRF admission 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 in the Medicare rules section.

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 enrollee is medically stable and does not require close supervision for the ongoing management of any active or acute exacerbations of chronic medical conditions. While the enrollee can benefit from physical and occupational therapy, their needs can be safely provided in an alternate level of care such as a skilled nursing facility.

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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) with supplies and 
accessories (K0553). 
 
You asked the Plan to pre-approve a CGM with supplies and accessories. You say that the items are medically 
necessary. The Plan denied your request. The Plan says you do not use insulin with at least three daily 
injections and requires frequent self-adjustment of insulin dosage based on the blood glucose testing results. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections and requires frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM with 
supplies and accessories have not been met. Specifically, use insulin with at least three daily injections and 
requires frequent self-adjustment of insulin dosage based on the blood glucose testing results. Therefore, we 
decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) with supplies and 
accessories (K0553).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Darzalex Faspro.

You asked the Plan to pre-approve Darzalex Faspro. You say that this is a better treatment option and the enrollee cannot complete the step therapy suggestion. The Plan denied your request. The Plan says the Plan requires a trial of Velcade before it will approve Darzalex Faspro.

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 Darzalex Faspro. Our reviewer says that the enrollee does not meet criteria for a step therapy exception for Darzalex Faspro. Our physician reviewer found the enrollee has not tried and failed the Plan's preferred drug of Velcade. The record does not show that this drug would likely be less effective and/or 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 Darzalex Faspro have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Darzalex Faspro.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft (D4263), a guided tissue 
regeneration (D4266), and an osseous surgery (D4261), provided by a participating provider. 
 
You asked the Plan to pre-approve a bone replacement graft, a guided tissue regeneration, and an osseous 
surgery. You say that you would like the Plan to approve these services. The Plan denied your request. The 
Plan says the requested 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 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 
bone replacement graft (D4263), a guided tissue regeneration (D4266), and an osseous surgery (D4261), 
provided by a participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift chair. 
 
You asked the Plan to pre-approve a seat lift chair. You say that this is necessary.  The Plan denied your 
request. The Plan says a seat lift chair is not covered. 
 
The Plan must follow Medicare rules. The rules say that seat lift chairs are not covered. Coverage is limited to 
a seat lift mechanism. 
 
 
 
 
 
 Although a seat lift chair may be appropriate, Medicare does not cover this item and the Plan must provide 
coverage only for items that Medicare covers. Therefore, we decided that the Plan does not have to pre-approve 
a seat lift chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for resin-based composites (D2391, D2330) received on 
March 24, 2022, and May 19, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you feel misled because the services were 
not billed as one charge, but rather, each filling was billed separately. You say you were under the impression 
there would only be one charge and one copayment. The Plan denied your request. The Plan says you are 
responsible for any charged amount above the Plans cost-sharing amount when your services are received 
from an out-of-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. 
 
 
 You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for resin-based composites (D2391, D2330) 
received on March 24, 2022, and May 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the topical application of fluoride varnish provided on 
August 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denial. The Plan denied 
your request. The Plan says this service is not a covered benefit under your dental plan. 
 
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 
topical application of fluoride varnish provided on August 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingivectomy or gingivoplasty (D4212) for tooth #21 
provided on July 19, 2022. 
 
You asked the Plan to pay for the dental service. You say that the dental service was medically necessary, and 
the claim should be paid in full. The Plan denied your request. The Plan says the denial of payment for this 
service is correct, because gingivectomy or gingivoplasty is not covered by the Plan. 
 
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 
gingivectomy or gingivoplasty (D4212) for tooth #21 provided on July 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for admission to an inpatient acute hospital. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan 
denied your request. The Plan says there is no clinical information for which to review this request. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that there is no documentation provided indicating medical necessity for inpatient hospital services. The review has determined that the record did not show that at the time of inpatient 
admission the admitting physician reasonably expected that the patient's necessary hospital care (including 
earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for admission to an inpatient acute hospital.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression socks. 
 
You asked the Plan to pre-approve compression socks. You say that you would like these compression stocks 
covered. The Plan denied your request. The Plan says this equipment is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve compression socks.
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 the requested Prolia is medically necessary. The Plan 
denied your request. The Plan says the enrollee must try and fail one IV bisphosphonate therapy first. 
 
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 the Plan's 
step therapy criteria have not been met. Our physician reviewer found based on the medical records provided 
there is no indication that the enrollee has tried and failed the required drug(s). Based on the medical records 
provided and the Medicare-approved major drug compendia there is no indication that the Plan's required 
drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve arthrocentesis (20611) and durolane injection (J7318). 
 
You asked the Plan to pre-approve arthrocentesis and durolane injection. You say that the requested 
arthrocentesis and durolane injection are medically necessary. The Plan denied your request. The Plan says that 
the requested arthrocentesis and durolane injection 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 arthrocentesis and durolane injection. 
Our reviewer says that the requested arthrocentesis and durolane injection are medically necessary. Our 
physician reviewer found Durolane is Food and Drug Administration-approved for osteoarthritis pain in 
patients who have not responded to conservative nonpharmacologic therapy or to simple analgesics, such as 
acetaminophen. Although provided records do not show failure of the recently ordered physical therapy 
treatment, records do show failure of Norco and acetaminophen with continued knee pain. The Local Coverage 
Determinations referred to in the case file by the health plan are not in the correct jurisdiction and are not 
binding 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 arthrocentesis and durolane injection have been met. Therefore, we decided that 
the Plan has to pre-approve arthrocentesis (20611) and durolane injection (J7318).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implantable neurostimulator, pulse generator, any 
type (L8679) percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral 
nerve) (64555).  
You asked the Plan to pre-approve the Dyansys auricular electrical device. You say that you would like to 
provide the following information to support that this is not an investigational procedure. The Plan denied your 
request. The Plan says this technology is still considered experimental and investigational. There is not enough 
proof to show it works and is safe. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Dyansys auricular electrical device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the implantable neurostimulator, pulse generator, any type (L8679) percutaneous 
implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) (64555).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553). 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that the device is medically 
necessary. The Plan denied your request. The Plan says rules for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not require 
frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on October 9, 2020, to October 30, 2020. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service May 1, 2020. Therefore, 
we decided that the Plan does not have to pay for the dental services on October 9, 2020, to October 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation (D4921) for all four quadrants 
provided by a participating provider. 
 
You asked the Plan to pre-approve gingival irrigation. You say that you would like the Plan to approve these 
services. The Plan denied your request. The Plan says the requested dental service is not a covered benefit. 
 
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 
gingival irrigation (D4921) for all four quadrants provided by a participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power seat elevation system (E2300). 
 
You asked the Plan to pre-approve the power seat elevation system. You say that the item is medically 
necessary. The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the power seat elevation system (E2300).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11042 billed for date of service April 18, 
2022. 
 
You asked the Plan to pay for procedure code 11042. You say that the enrollee had different procedures 
performed on different wounds. The Plan denied your request. The Plan says payment for code 11042 is 
bundled into payment for code 11104. 
 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 11042 is a column II code to column I code 11104. 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 11042 
billed for date of service April 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation (D0150) provided on July 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay the claim in full 
because this was a new provider you saw. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on the date of service of January 18, 2022. 
Therefore, we decided that the Plan does not have to pay for an oral evaluation (D0150) provided on July 19, 
2022.  
  Your complaint about your experience with a prior provider is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.