Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99214) provided on October 5, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service is not 
separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that it is standard medical practice for an anesthesia 
practitioner to perform a patient examination and evaluation prior to surgery. This is considered part of the 
anesthesia service and is included in the base unit value of the anesthesia code.  
 
We looked at the file and Medicare rules. Payment for the visit (99214) in this case is included in the anesthesia 
payment (01938) and is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the 
services (99214) provided on October 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300), electronic 
connection (E2311), expandable controller (E2377), and harness (E2313). 
 
You asked the Plan to pre-approve a power seat elevation system, electronic connection, expandable controller, 
and harness. You say that the need of the custom medical equipment being requested for the enrollee is 
supported. The Plan denied your request. The Plan says a power seat elevation system is not covered. The Plan 
also says there is not a medical need to control the power options through the joystick. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules also say that a power seat elevation feature (E2300) is non-covered 
because it is not primarily medical in nature.  
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 an electronic connection, expandable 
controller, and harness. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the requested electrical accessories are not 
medically necessary as the member does have use of the upper extremity and can operate and control the power 
options using the switches that are included in the basic wheelchair. 
 
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 power seat elevation system, electronic connection, expandable controller, and 
harness have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat 
elevation system (E2300), electronic connection (E2311), expandable controller (E2377), and harness (E2313).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 You asked the Plan to pre-approve Euflexxa. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy requirements 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 Euflexxa. Our reviewer says that the 
requirements for coverage of Euflexxa have not been met. Our physician reviewer found the Plan requires a 
trial of Monovisc, Orthovisc, Synvisc or Synvisc One before they will approve Euflexxa. The records do not 
indicate the enrollee has tried these drugs. The records also do not indicate that the required drugs would likely 
be less effective 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DecisionDx-SCC testing (0315U) provided on October 11, 
2022. 
 
You asked the Plan to pay for DecisionDx-SCC testing. You say that this test was medically necessary and was 
ordered by the enrollee's treating physician. The Plan denied your request. The Plan says this test is not covered 
based on Medicare criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier. We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of DecisionDx-SCC testing have not been met. Therefore, we decided that the 
Plan does not have to pay for DecisionDx-SCC testing (0315U) provided on October 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the opioid treatment program (OTP) services provided on 
November 21, 2022. 
 
You asked the Plan to pay for the OTP services. The Plan denied your request. The Plan says this provider is 
not payable for these services. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare Part B coverage is available for 
outpatient Opioid Treatment Program services provided by hospitals, CAHs, and Free-Standing Opioid 
Treatment Program facilities.  
 
We looked at the file and Medicare rules. OTP services are only payable to hospitals, CAHs, and Free-Standing 
Opioid Treatment Program facilities. Individual providers cannot be paid for OTP services. Based on this 
information, we decided that Medicare rules for coverage of the OTP services have not been met. Therefore, 
we decided that the Plan does not have to pay for the opioid treatment program (OTP) services provided on 
November 21, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Actemra (J3262). 
 
You asked the Plan to pre-approve Actemra. You say that Actemra is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
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 Actemra. Our reviewer says that 
Actemra is not medically necessary. Our physician reviewer found the record indicates that the enrollee has a 
diagnosis of  prophylaxis pf heart transplant rejection. The Food and Drug Administration has not stated that 
the requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia do not 
contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Actemra have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Actemra (J3262).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an aortic dilation gene sequence analysis panel (81410). 
 
You asked the Plan to pre-approve an aortic dilation gene sequence analysis panel. You say that the enrollee 
needs this service. The Plan denied your request. The Plan says this is a non-covered code. 
 
The Plan must follow Medicare rules. Medicare rules say that code 81410 will be denied automatically as not 
medically necessary. 
 
We looked at the file and Medicare rules. The code at issue is not covered. Therefore, we decided that the Plan 
does not have to pre-approve an aortic dilation gene sequence analysis panel (81410).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive urine drug testing for 15-21 classes (G0482) 
provided on August 18, 2022. 
 
You asked the Plan to pay for the definitive urine drug testing for 15-21 classes (G0482). You say that the 
definitive urine drug testing for 15-21 classes (G0482) provided on August 18, 2022, was medically necessary. 
The Plan denied your request. The Plan says the enrollee did not meet criteria for the provided definitive urine 
drug testing for 15-21 classes (G0482) provided on August 18, 2022. 
 
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 pay for the definitive urine drug testing for 15-21 
classes (G0482). Our reviewer says that the enrollee did not meet criteria for the provided definitive urine drug 
testing for 15-21 classes (G0482) provided on August 18, 2022. Our physician reviewer found the enrollee is 
with chronic pain syndrome (shoulder, lumbar) treated with pain medication (hydrocodone, tramadol, 
gabapentin) who underwent definitive urine drug testing for 15-21 classes (G0482) provided on August 18, 
2022. A presumptive urine drug screen resulted in positive findings for benzodiazepines, opiates, and THC. 
However, the benzodiazepines and THC were unexpected and not prescribed. However, a prior definitive drug 
screen from less than one month prior was also for benzodiazepines and was not expected to be different a few 
weeks later, so these results were actually expected based on the provided documentation, and the enrollee was 
told to be aware of sedative effects of using both opioids and benzodiazepines. Therefore, repeat definitive 
testing is not supported based on the LCD requirements. 
 
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 definitive urine drug testing for 15-21 classes (G0482) have not been met. 
Therefore, we decided that the Plan does not have to pay for the definitive urine drug testing for 15-21 classes 
(G0482) provided on August 18, 2022.
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 enrollee has multi-disciplinary acute 
care needs that require daily specialized physician management for multiple medically complex issues. The 
Plan denied your request. The Plan says the LTACH is not medically necessary, and the enrollee's needs are 
being met in the current hospital location and is unstable for transfer. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the current acute care setting. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The health plan has approved ongoing care 
in the current acute care setting.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second opinion to be provided by an out-of-network 
(OON) psychiatric provider. 
 
You asked the Plan to pre-approve a second opinion with an OON psychiatric provider. You say that the 
mental health services requested are medically necessary. You say that there are several reasons that you had to 
cancel previous appointments with the in-network provider. You say that you are old and cannot drive too far. The Plan denied your request. The Plan says they have in-network psychiatric providers available who can 
provide the enrollee with a second opinion and treatment. 
 
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. Medicare rules 
also say that plans must make care accessible to enrollees. According to Medicare rules, care is considered 
accessible to an enrollee if contract providers are available within reasonable distance and travel time from the 
enrollees home. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We were able to confirm that the Plan has 
contract providers located within reasonable distance and travel time from your home who can provide a 
psychiatric second opinion. Under Medicare rules, this means that contract providers are accessible to you. 
We found no exception that would require the Plan to pre-approve these services OON. Therefore, we decided 
that the Plan does not have to pre-approve a second opinion to be provided by an out-of-network (OON) 
psychiatric provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete denture- maxillary (D5110). 
 
You asked the Plan to pre-approve the dental services. You say that you need the dentures approved because 
the current dentures do not fit properly, and you cannot eat. The Plan denied your request. The Plan says dental 
services from an out-of-network provider are not covered by your supplemental 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. 
 
  You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve complete 
denture- maxillary (D5110).
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. The Plan denied your request. The Plan says the step therapy 
requirements 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 Prolia. Our reviewer says that Prolia is 
not medically reasonable and necessary in this case. Our physician reviewer found that the Plan requires a trial 
of drug an oral biphosphonate or zoledronic acid before they will approve the requested drug.  In this case, the 
enrollee has not tried and failed a required drug. There is no documentation provided indicating that the plans 
required drugs 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: 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 LTACH admission is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet the 
Medicare criteria for admission to an LTACH care. The enrollee can safely receive care in another setting such 
as an acute rehabilitation facility, skilled nursing facility, nursing facility, outpatient setting or home care. 
 
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 the 
enrollee 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the transcutaneous electrical nerve stimulation (TENS) 
device (E0730). 
 
You asked the Plan to pre-approve the TENS device. You say that this claim was billed correctly. The Plan 
denied your request. The Plan says this item is not covered for chronic low back pain. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. 
 
We looked at the file and Medicare rules. The medical records show that the enrollee received this device for 
treatment of low back pain. TENS is not considered reasonable and necessary for the treatment of chronic low 
back pain. Based on this information, we decided that Medicare rules for coverage of the TENS device have not been met. Therefore, we decided that the Plan does not have to pre-approve the transcutaneous electrical 
nerve stimulation (TENS) device (E0730).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Group 1 standard power operated vehicle (K0800). 
 
You asked the Plan to pre-approve the power operated vehicle. You say that you believe the power scooter is 
appropriate and medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee 
does not meet the coverage criteria for the requested item. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that you do not have a mobility deficit that impairs your participation in MRADLs. Per the 
physical therapy assessment note, the enrollee is not appropriate for any assistive device or an optimally configured manual wheelchair as the enrollee is able to ambulate without assistive device and has sufficient 
balance and ambulation skills to walk. This means that Medicare rules for coverage of a PMD have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the Group 1 standard power operated 
vehicle (K0800).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power 
options and upgraded electronics K0861, E0953, E0955, E1007, E1012, E1028, E2300, E2311, E2313, E2331, 
E2377, E2601 and K0108. 
 
You asked the Plan to pre-approve the power wheelchair. You say that this power chair is vital to keeping your 
mobility. The Plan denied your request. The Plan says the enrollee does not have a diagnosis for which the 
Group 3 power wheelchair is medically needed. Since the Group 3 Power Wheelchair with multiple power 
options is not reasonable and necessary, none of the requested accessories can be covered. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to:  
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or 
congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a Group 3 
power wheelchair with multiple power options and upgraded electronics K0861, E0953, E0955, E1007, E1012, 
E1028, E2300, E2311, E2313, E2331, E2377, E2601 and K0108.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on March 24, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
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 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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the services provided on March 24, 2022, by an out-of-network 
(OON) provider.