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

 
We decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869, 22870). 
 
You asked the Plan to pre-approve the insertion of a Vertiflex device. You say that this is medically necessary. 
The Plan denied your request. The Plan says this is experimental. 
 
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 insertion of a Vertiflex device. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the Vertiflex device is experimental. More research is needed to show it is safe 
and effective. 
 
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 insertion of a Vertiflex device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869, 22870).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous spacer placement (22867). 
 
You asked the Plan to pre-approve the procedure. You say that the service is medically necessary. The Plan 
denied your request. The Plan says this procedure is experimental and non-covered. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested Inspan device remains experimental in spine surgery. More research is needed. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an interspinous spacer placement (22867).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 28, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the referring physician is responsible for 
obtaining authorization. The Plan denied your request. The Plan says the rendering provider is an out-of-
network provider and there is no referral from an in-network provider or an approved authorization. Also, the 
service rendered was not urgent or emergent. 
 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 laboratory services provided on September 28, 
2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mobile arm supports and mounting brackets for a power 
wheelchair (E02627, E1028). 
 
You asked the Plan to pre-approve the arm supports and brackets. You say that these features are medically 
necessary. The Plan denied your request. The Plan says the requested accessories are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that options and accessories for wheelchairs are covered if 
the beneficiary has a wheelchair that meets Medicare coverage criteria and the option/accessory itself 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 the arm supports and brackets. Our 
reviewer says that the requested items are not medically necessary. Our physician reviewer found there is no 
documentation that the requested accessories meet Medicare criteria for medically necessary. Records do not 
support that the requested accessories serve a medical purpose. 
 
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 arm supports and brackets have not been met. Therefore, we decided that the 
Plan does not have to pre-approve mobile arm supports and mounting brackets for a power wheelchair 
(E02627, E1028).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Biktarvy. 
 
You asked the Plan to pre-approve Biktarvy. You say that the requested drug is medically reasonable and 
necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered 
under the enrollee's medical 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 Biktarvy.  
 
Benefits for Biktarvy 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care (99309) provided on 
December 8, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the claim was processed and 
denied for no authorization for service because the provider is not in-network, however, you have since re-
applied for in-network status. The Plan denied your request. The Plan says the service obtained by the member 
was rendered by a provider who is not under contract with the Plan, and this service was not authorized. 
 
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 subsequent nursing facility care (99309) provided 
on December 8, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided by a network facility on October 1, 2021. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you get this service once a year and 
you were told the low-dose CT scan was covered with no cost. The Plan denied your request. The Plan says 
you have been asked to pay 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 $325 
copayment per day for other Medicare-covered diagnostic radiology services that are not ultrasounds. For this 
date of service, you have been asked to pay the allowed amount of the claim because this amount is less than 
the standard $325 copayment for the CT scan. You have been asked to pay a $107.49 copayment for the CT scan. The CT scan falls within the Outpatient 
diagnostic tests and therapeutic services and supplies benefit category. The medical record shows the CT scan 
was indicated as a follow-up to suspicious finds on a prior lung screening CT scan, which makes this CT scan 
diagnostic in nature. 
 
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 a computed tomography (CT) scan provided by a network 
facility on October 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on December 2, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that you are requesting reconsideration on this 
claim for payment. The Plan denied your request. The Plan says the rendering provider is an out-of-network 
provider and there was no approved authorization. Also, the service rendered was not urgent or emergent. 
  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 a home health visit provided on December 2, 
2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that medically necessary care is available 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 
medical services 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 office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that the out-of-network podiatrist has been 
approved in the past due to the enrollee's language barrier. The Plan denied your request. The Plan says the 
provider is out-of-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 office visit to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has pain related to 
osteoarthritis of the right knee, confirmed on imaging studies. She has not tried and failed the Plan's required 
drugs, Orthovisc and Supartz FX. The records do not show that the required drugs would be contraindicated or 
less effective; therefore, Gelsyn-3 is not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Gelsyn-3.
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. 
 
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 records do not show you need an intensive program with a team of 
health care professionals and doctors that specialize in complex medical needs as well as rehab. 
 
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.  
 You are medically stable and do not need physical medicine and rehabilitation physician close supervision 3 
times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic 
medical conditions. You do not need intensive therapies, consisting of at least 3 hours of therapy per day at 
least 5 days per week with multidisciplinary approach to daily therapy in an IRF. At the current level of 
function, the enrollee's rehab can be safely provided at a lower intensity and alternate setting. Our physician 
reviewer found that your 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nitro style rollator walker (E1399). 
 
You asked the Plan to pre-approve nitro style rollator walker. You say that you have been fighting to get your 
walker for months. You do not know what else you need for your situation. The Plan denied your request. The 
Plan says the Plan provided a walker with a seat on January 8, 2020 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary.  
 
 
 
 
 
 
 The file shows that you have rolling walker with seat that was provided on January 8, 2020. The rolling walker 
with seat serves the same purpose as nitro style rollator walker. Therefore, we decided that the Plan does not 
have to pre-approve nitro style rollator walker (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99203) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that before when you were employed, this provider 
was your dermatologist, and you would like to return to your doctor of record. The Plan denied your request. 
The Plan says this provider is not a network provider, and you do not meet the guidelines to get medically 
needed care from a doctor that is not 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 
an office visit (99203) to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 
You asked the Plan to pre-approve Feraheme. You say that the enrollee is on oral therapy that is insufficient. 
The Plan denied your request. The Plan says the enrollee has not tried and failed Infed and Venofer. 
 
 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 Feraheme. Our physician reviewer 
found that the enrollee has iron deficiency anemia with inadequate response to oral iron replacement. The Plan 
requires a trial of Infed and Venofer before they will approve the requested drug. The enrollee has not tried and 
failed the required drugs. Based on the medical records, there is no indication that the plan's required drugs 
would likely be less effective 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 Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a repair, revision, and/or reconstruction 
procedure on the femur and knee joint (27447) nor waive the copayment for physical therapy (97161) rendered 
on November 22, 2021. 
 
You asked the Plan to waive the coinsurance for a repair, revision, and/or reconstruction procedure on the 
femur and knee joint and to waive the copayment for physical therapy. You say that you were inpatient for 1-2 
days once you got out of surgery and did not receive any rehabilitation. You also say they could not get you out 
of bed and forced you to go home, and this was not supposed to be an outpatient. 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% 
coinsurance per visit for outpatient surgery, including services provided at hospital outpatient facilities and 
ambulatory surgical centers. Your contract with the Plan also clearly says that you must pay a $40 copayment 
for each Medicare-covered therapy visit. 
 
You have been asked to pay $2,635.77, which is 20% coinsurance of the allowed amount for repair, revision, 
and/or reconstruction procedure on the femur and knee joint ($13,178.86 allowed amount x 20% coinsurance = 
$2,635.77). A repair, revision, and/or reconstruction procedure on the femur and knee joint falls within the 
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
benefit category. You have also been asked to pay 22.86, which is less than the $40 copayment for and physical 
therapy. Physical therapy falls within the outpatient rehabilitation services benefit category. The record shows 
both services were rendered on November 22, 2021. 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 
repair, revision, and/or reconstruction procedure on the femur and knee joint (27447) nor waive the copayment 
for physical therapy (97161) rendered on November 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the FreeStyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the FreeStyle Libre CGM. You say that you would like reconsideration 
because your condition i suncontrolled and you have difficulty checking your blood glucose levels. The Plan 
denied your request. The Plan says the information provided by your doctor did not meet the requirements for 
coverage. 
 
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 you do not use insulin with at least 
three daily injections or 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 FreeStyle Libre CGM 
have not been met. Therefore, we decided that the Plan does not have to pre-approve the FreeStyle Libre 
continuous glucose monitor (CGM).