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

 
We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting 
and waive the copayment from April 4, 2021, to April 5, 2021. 
 
You asked the Plan to pay for the self-administered drugs and waive the copayment. You say that you should 
only have to pay a small copayment for any drugs that are given or prescribed to you. The Plan denied your 
request. The Plan says self-administered drugs are not covered, and the copay is correct per the Evidence of 
Coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The rules also 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 $90 copayment for outpatient hospital, emergency room services.  
 
The self-administered drugs requested here are not among the types which are covered by Medicare Part B. 
Additionally, you have been asked to pay $90 copayment for the emergency room services. the emergency 
room services falls within the outpatient hospital, emergency room services 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 pay for the self-administered drugs provided in an outpatient setting and does not have to 
waive the copayment from April 4, 2021, to April 5, 2021.  
 
Benefits for the self-administered drugs and waive the copayment 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Bimatoprost 0.03% solution. 
 
You asked the Plan to pre-approve Bimatoprost 0.03% solution. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says Bimatoprost 0.03% solution is not covered 
under the enrollee's Medicare Part B 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 Bimatoprost 0.03% 
solution.  
 Benefits for Bimatoprost 0.03% solution 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
December 7, 2021. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you told the treating provider 
that you were there for a cleaning only. You also say that you should not be held responsible for this claim. The 
Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, comprehensive oral evaluation 
(D0150) is limited to one procedure every three plan years. The record shows that you received a 
comprehensive oral evaluation (D0150) on May 13, 2021 and your comprehensive oral evaluation (D0150) 
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive 
oral evaluation (D0150) provided on December 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation (D9310) provided on November 18, 2021. 
 
You asked the Plan to pay for the consultation. You say that you consulted this provider because they are the 
one who will render the services. 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 
consultation (D9310) provided on November 18, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound (76705) provided on December 14, 
2021. 
 
You asked the Plan to pay for the ultrasound. You say that the enrollee received multiple exams on the date in 
question. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure 
to Procedure (PTP) edit exists between 93976 and 76705. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP 
code edit. This service was not billed as required by Medicare coding regulations. 
 
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 the abdominal ultrasound (76705) provided on December 14, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Superion Interspinous spacer. 
 
You asked the Plan to pre-approve a Superion Interspinous spacer. You say that the requested treatment is 
considered safe and effective, as supported by its clinical beliefs to patients, continued medical professional 
adoption, and strong clinical evidence with numerous peer-reviewed studies. The Plan denied your request. The 
Plan says the requested device is not supported for use in long term relief of back and leg pain. The Plan says 
that there are currently no clinical indications for this technology. 
 
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 a Superion Interspinous spacer. Our 
reviewer says that a Superion Interspinous spacer is not considered medically reasonable and necessary in this 
case. Our physician reviewer found the requested device is considered experimental and 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 a Superion Interspinous spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve a Superion Interspinous spacer.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cervical radiofrequency injection (64633). 
 
You asked the Plan to pre-approve the injection. You say that you need to have this procedure done so the pain 
can go away. Driving id difficult and you have no one to help you so you need this treatment. The Plan denied 
your request. The Plan says the enrollee does not meet the criteria for the requested procedure. 
 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 injection. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the LCD requires at least 50% pain relief. It is not reasonable to repeat RFA when only 10% 
pain relief was achieved. The request is not medically reasonable or 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve cervical radiofrequency injection (64633).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block. 
 
You asked the Plan to pre-approve a genicular nerve block. You say that a genicular nerve block will help with 
your knee pain. The Plan denied your request. The Plan says genicular nerve blocks are not covered to treat 
osteoarthritis as this is considered investigational. 
 The Plan follows Medicare rules. Medicare rules say that there is insufficient evidence to support the use of 
peripheral nerve blocks in the treatment of diabetic peripheral neuropathy, peripheral neuropathies caused by 
other underlying systemic diseases or peripheral neuropathies causes such as degenerative or idiopathic 
reasons. 
 
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 a genicular nerve block. Our reviewer 
says that a genicular nerve block is not medically necessary. Our physician reviewer found that based on the 
medical records provided there is no documentation that the requested genicular nerve block meets the 
Medicare Local Coverage Determination (LCD): Peripheral Nerve Blocks (L36850) coverage criteria. As 
stated in the LCD: "There is insufficient evidence to support the use of peripheral nerve blocks in the treatment 
of diabetic peripheral neuropathy, peripheral neuropathies caused by other underlying systemic diseases or 
peripheral neuropathies causes such as degenerative or idiopathic reasons. Medical management using systemic 
medications is clinically indicated for the treatment of these conditions. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Zilretta. 
 
You asked the Plan to pre-approve Zilretta. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of authorization for this drug is correct, because the enrollee 
previously had Zilretta and it is not intended for repeat administration. 
 
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 Zilretta. Our reviewer says that the 
enrollee does not meet the Medicare criteria for use of Zilretta. Our physician reviewer found Zilretta is Food 
& Drug Administration (FDA) approved for the enrollee's diagnosis. However, the documentation does not 
support that the requested use would be safe and effective and otherwise medically reasonable and necessary. 
The published large-scale, long-term, peer-reviewed literature does not support more than a single injection of 
Zilretta, but the enrollee has already had Zilretta administered in the past. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zilretta have not been met. Therefore, we decided that the Plan does not have to 
pre-approve use of Zilretta.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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. Our 
physician reviewer found you appear to be more stable and should only require short-term additional acute care 
hospital services that can be safely administered at the current facility until appropriate for a lower level of 
care. There are no services at the LTACH that you require that are not already available and covered at the 
current facility. Transfer to a lower level of care may be considered when treatment is completed. 
 
 
 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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. Our 
physician reviewer found the enrollee appears to be improving and should only require short-term additional 
acute care hospital services that can be safely administered at the current facility until more stable and 
appropriate for a lower level of care. There are no services at the LTACH that the enrollee requires that are not 
already available and covered at the current facility. Transfer to a lower level of care may be considered when 
treatment is completed and when the enrollee is more stable. 
 
 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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. Our 
physician reviewer found the enrollee appears to be stable and improving and should only require short-term 
additional acute care hospital services that can be safely administered at the current facility until appropriate for 
a lower level of care. There are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Transfer to a lower level of care may be considered when 
treatment is completed. 
 
 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that it is felt that this is medically necessary at this 
time. The Plan denied your request. The Plan says the enrollee does not require the level of respiratory support 
provided by a ventilator. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 a ventilator. Our reviewer says that the 
requested ventilator is not medically reasonable and necessary. Our physician reviewer found this patient has 
restrictive lung disease related to severe obesity, probable obesity hypoventilation syndrome, diastolic heart 
failure, pulmonary hypertension, and coronary artery disease. There is a diagnosis of chronic obstructive 
pulmonary disease, although an absence of obstruction on spirometry does not support this.    
The patient has a home ventilator, but the records indicate she is not using it because of concerns about the 
Phillips recall. The records do not include an arterial blood gas (ABG) done while stable showing carbon 
dioxide retention. There is also no evidence bilevel positive airway pressure (BiPAP) with average volume-
assured pressure support (AVAPS) has been tried at home. Due to these issues, the criteria for this ventilator 
have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a portable ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns (D6740 x 2) and pontics (D6245 x 2). 
 
You asked the Plan to pre-approve a fixed bridge. You say that the enrollee does not want a removable partial 
denture on their upper. You say that the enrollee would prefer to have a fixed bridge. The Plan denied your 
request. The Plan says the there is no documentation to support that a denture cannot be used to replace missing 
teeth. 
 
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. The Plan covers a fixed bridge 
when the services are medically necessary and reasonable.  
 
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 a fixed bridge. Our reviewer says that 
the requested fixed bridge is not medically necessary. Our physician reviewer found the provided 
documentation indicates that other maxillary posterior teeth are missing. The reviewer found that coverage for 
a fixed bridge is limited to the replacement of a maxillary anterior tooth when there are no missing maxillary posterior teeth and if there is documentation that a removable partial could not be used. Therefore, the reviewer 
found that the requested fixed bridge is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a fixed bridge have not been met. Therefore, we decided that the Plan does not 
have to pre-approve retainer crowns (D6740 x 2) and pontics (D6245 x 2).
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 your doctors want you to have IRF care because you 
need intensive occupational and physical therapy. The Plan denied your request. The Plan says based on 
Medicare guidelines, the requested IRF services do not meet the requirements for approval. 
 
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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for 
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 
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 inpatient rehabilitation facility (IRF) admission and services.