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

 
We decided that the Plan does not have to pay for the lab services provided on September 29, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says we cannot 
determine how the member came to the servicing provider, or whether the services are medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering 
physicians intent that the tests be performed. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the 
lab services provided on September 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bilevel positive airway pressure (BiPap) device and 
related supplies coded as E0470, E0562, A7030, A7035, A7031, A4604 and A7038 to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve the BiPap device and related supplies. You say that this is the only place 
that is local that has the BiPap machine. There's been a recall on the equipment and a shortage on what's 
available. You have COPD and asthma. The Plan denied your request. The Plan says enrollees must receive 
their medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered. 
 
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 bilevel positive airway pressure (BiPap) 
device and related supplies coded as E0470, E0562, A7030, A7035, A7031, A4604 and A7038 to be provided 
by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer. 
 
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 services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain 
and lumbar spinal stenosis with neurogenic claudication. The record indicates that the enrollee has had 
previous spinal surgery and has post laminectomy syndrome. The record indicates that the enrollee has multi-
level degenerative disease including severe foraminal stenosis. The record does not document that the enrollee 
is not indicated for operative intervention at no more than two levels. The records do not support that the 
Vertiflex is reasonable and 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 a Vertiflex Superion spacer.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the left shoulder. 
 
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 that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has had shoulder pain for about 
a year and has failed injections. Physical examination demonstrates findings consistent with impingement and 
possible rotator cuff injury. Plain films taken in April of 2022 did not reveal pathology. The MRI is medically 
necessary for the diagnosis and treatment for the enrollee's clinical condition at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-
approve magnetic resonance imaging (MRI) of the left shoulder.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Zilretta. 
 
You asked the Plan to pre-approve Zilretta. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step therapy rules for the requested drug have not been 
met. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Zilretta. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of glucocorticoid injections before they will approve the requested drug. The requested 
drug is a new start. The provided records do not indicate that the enrollee has tried and failed the Plan's 
preferred step-one alternatives. The record does not indicate that the enrollee has a contraindication to, or 
would have an adverse effect from, the Plan's preferred step-one alternatives. The record does not indicate that 
the enrollee is receiving treatment for diabetes and the enrollee is receiving oral prednisone. 
 
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 treatment with Zilretta.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Supartz. 
 
You asked the Plan to pre-approve Supartz. The Plan denied your request. The Plan says there was no 
documentation of a history of use of Euflexxa resulting in a substandard response to therapy. The Plan also 
says that there is no history of intolerance or adverse event to Euflexxa, or a rationale that Euflexxa is not 
clinically appropriate. 
 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 Supartz. Our reviewer says that Supartz 
is not reasonable or necessary. Our physician reviewer found the provided records do not indicate that the 
enrollee has tried and failed the Plan's preferred step one alternative, Euflexxa. The record does not indicate 
that the enrollee has a contraindication to, or would have an adverse effect from the Plan's preferred step one 
alternative. Our reviewer also found that the elements of the coverage criteria are not satisfied, and the 
requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Supartz have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Supartz.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc. 
 
You asked the Plan to pre-approve Synvisc. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 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 the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has pain related to osteoarthritis of the left knee. The diagnosis was confirmed with imaging 
studies. The enrollee has failed conservative treatment. The documentation does not support that the enrollee 
has tried and failed Orthovisc, Supartz FX, Durolane, Monovisc or Synvisc-One. The documentation does not 
support that Orthovisc, Supartz FX, Durolane, Monovisc or Synvisc-One 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 Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Synvisc.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve carfilzomib and elotuzumab. 
 
You asked the Plan to pre-approve carfilzomib and elotuzumab. You say that this is medically necessary. The 
Plan denied your request. The Plan says this combination is not supported. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 carfilzomib and elotuzumab. Our 
reviewer says that the requested use of carfilzomib and elotuzumab is not supported. Our physician reviewer 
found the record indicates that the enrollee has a diagnosis of recurrent multiple myeloma, previously treated. 
The Food and Drug Administration has not stated that the requested drug regimen is indicated for the enrollee's 
condition. The Medicare-approved cancer drug compendia do not contain a supportive citation for the use of 
the requested drug regimen 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 carfilzomib and elotuzumab have not been met. Therefore, we decided that the 
Plan does not have to pre-approve carfilzomib and elotuzumab.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zolpidem. 
 
You asked the Plan to pre-approve Zolpidem. You say that this 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 Zolpidem.  
 
 Benefits for Zolpidem 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 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 medically reasonable and necessary. Our physician reviewer found there is no indication that the 
enrollee has tried and failed the required drug(s). Our reviewer also found that 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 Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Synvisc (J7325).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs LTACH services. The 
Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
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 is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where she is 
currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regeneration (D4266) and bone 
replacement grafts (D7953). 
 
You asked the Plan to pre-approve guided tissue regeneration (D4266) and bone replacement grafts (D7953). 
You say that the enrollee has a history of periodontal disease with bone loss and would benefit greatly from 
bone grafting. You say that coverage should be considered due to bone loss. The Plan denied your request. The 
Plan says the 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 
guided tissue regeneration (D4266) and bone replacement grafts (D7953).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says Medicare does not cover durable medical equipment (DME) in a skilled nursing 
facility (SNF) based on statutory definition of DME. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the wheelchair is being requested for use in a SNF or hospital. Therefore, we decided that 
the Plan does not have to pre-approve a power wheelchair.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (95886) provided on October 22, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says code 95886 was not 
billed with a specified primary procedure code. 
 
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 95886 
is an add-on code and has not been billed with an appropriate primary procedure code. 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 services (95886) provided on October 22, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen and oxygen supplies provided during ambulance 
transportation on March 11, 2022. 
 
You asked the Plan to pay for the oxygen and supplies. The Plan denied your request. The Plan says this is not 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that oxygen and other items and services provided as 
part of the transport are included in the FS base payment rate and are not separately payable.  
 
We looked at the file and Medicare rules. Payment for the requested oxygen services is included in the base 
payment for the ambulance transportation. The oxygen services are not separately payable. Based on this 
information, we decided that Medicare rules for coverage of the oxygen and supplies have not been met. 
Therefore, we decided that the Plan does not have to pay for the oxygen and oxygen supplies provided during 
ambulance transportation on March 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic services to be provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve chiropractic services. You say that you would like this service approved. 
The Plan denied your request. The Plan says the enrollee must use network providers to get care and services 
when there are network providers available. 
 
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 
chiropractic services to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns. 
 
You asked the Plan to pre-approve crowns. You say that you cannot chew on the right side due to a gap from 
jaw surgery. The Plan denied your request. The Plan says treatment, removal, or replacement of teeth or 
structures directly supporting teeth, is excluded from coverage. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve crowns.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve biologic materials to aid in soft and osseous tissue 
regeneration (D3431). 
 
You asked the Plan to pre-approve biologic materials to aid in soft and osseous tissue regeneration. You say 
that you would like an exception for coverage to be made because you experience a lot of pain when eating. 
The Plan denied your request. The Plan says this service is not covered under 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, 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 
biologic materials to aid in soft and osseous tissue regeneration (D3431).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional days of Personal Care Attendant services. 
 
You asked the Plan to pre-approve additional days of Personal Care Attendant services. The Plan denied your 
request. The Plan says the assessment reveals a need for only 28 hours per week. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 additional days of Personal Care 
Attendant services. Our reviewer says that additional personal care attendant services are not medically 
necessary. Our physician reviewer found that you do not have documented skilled nursing needs. You do not 
have documented skilled therapy needs. Your homebound status is unclear. As such, home health services, 
including home health aide services are not shown to be medically necessary and reasonable or coverable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional days of Personal Care Attendant services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve additional days of Personal Care Attendant 
services.