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

 
We decided that the Plan does not have to pre-approve a kidney dialysis procedure and services to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a kidney dialysis procedure and services. You say that you do not agree 
with the change to another renal center because you have been with this center for many years. You also say 
your providers visit you and provider you with the follow-up you need in the same place. The Plan denied your 
request. The Plan says the requested provider is a non-contracted provider starting on June 1, 2022. The Plan 
also says that they notified you in March 2022 and started a coordinated transition of care process to a facility 
that is closer to your home. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a kidney dialysis procedure and services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
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 requested CGM. You say that the enrollee requires this in order to help 
with glucose control. The Plan denied your request. The Plan says this is not covered for enrollees using only 
one daily insulin injection. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily administrations. Based on this information, we decided that Medicare rules for 
coverage of the requested CGM have not been met. Therefore, we decided that the Plan does not have to pre-
approve the Freestyle Libre continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Life Alert emergency alert system. 
 
You asked the Plan to pre-approve the requested Life Alert system. You say that you have had a hip replaced 
and have limited mobility. You feel that you need this system to be prepared in case of a fall. The Plan denied 
your request. The Plan says this is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that emergency alert systems are excluded from 
coverage as they do not serve a diagnostic or therapeutic purpose. 
 
Though the requested Life Alert system may be appropriate for you, neither Medicare nor the Plan provide 
coverage for this device. Therefore, we decided that the Plan does not have to pre-approve a Life Alert 
emergency alert system.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical laparoscopy partial nephrectomy to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a surgical laparoscopy partial nephrectomy. You say that you need to have 
this surgery quickly, and the requested provider has offered a 50 percent discount because of your history. You 
also say that the surgeon you are scheduled with has more experience and has done over 500 of these kidney 
surgeries and does two to three per week. The Plan denied your request. The Plan says they did not receive a 
request for authorization for this member to be evaluated at the requested provider. The Plan also says that they 
do not authorize out-of-network facilities when they have in-network facilities 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 
a surgical laparoscopy partial nephrectomy to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a Freestyle Libre CGM. You say that you need this for your hypoglycemia. 
The Plan denied your request. The Plan says this is not covered for your condition 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and 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 assesses 
adherence to their CGM regimen and diabetes treatment plan. 
 
 
 We looked at the file and Medicare rules. The documentation indicates that you do not have diabetes and use 
insulin with at least three daily injections. Based on this information, we decided that Medicare rules for 
coverage of a Freestyle Libre CGM have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 1 heavy-duty power-operated vehicle (K0801). 
 
You asked the Plan to pre-approve a power-operated vehicle. You say that the requested power-operated 
vehicle is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage 
for a power-operated vehicle have not been met. 
 
The Plan must follow Medicare rules. The rules say that a power-operated vehicle is covered if the criteria 
listed in the Medicare rules section have been met. 
 
We looked at the file and Medicare rules. In this case, the enrollee does not weigh 285 to 450 pounds. Based on 
this information, we decided that Medicare rules for coverage of the requested power-operated vehicle have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a Group 1 heavy-duty power-
operated vehicle (K0801).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and related 
supplies (E0656, E0668). 
 
You asked the Plan to pre-approve a pneumatic compression device and related supplies. You say that the 
requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for 
coverage for PCDs have not been met. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. The rules also say that if the base PCD is not 
covered, related accessories are not eligible for payment. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Because the base PCD cannot be covered in this case, the requested related accessories also cannot 
be covered. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and related supplies (E0656, E0668).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve minimally-invasive sacroiliac joint fusion for the 
enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no clinical or radiographic documentation that there is any further problem since 
4/12/22 surgery. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that minimally invasive sacroiliac joint fusion remains experimental for degnerative back pain with 
documented sacroiliac joint instability fracture or lesion. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve minimally-invasive sacroiliac joint fusion for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and 
pelvis with contrast (74177). 
 
You asked the Plan to pre-approve a CT scan of the abdomen and pelvis with contrast. You say that the service 
is medically necessary. The Plan denied your request. The Plan says the requested service is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a CT scan of the abdomen and pelvis 
with contrast. Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
enrollee's abdominal physical examination was unremarkable and there are no signs indicating a CT of the 
abdomen and pelvis is necessary at this point. 
 
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 CT scan of the abdomen and pelvis with contrast have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the 
abdomen and pelvis with contrast (74177).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) to be provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve PT. You say that you feel comfortable with your current physical therapist 
and you do not want to go to a different provider. The Plan denied your request. The Plan says you must 
receive care from network providers. 
 
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 
physical therapy (PT) to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a standard wheelchair with elevating leg rests to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a standard wheelchair with elevating leg rests. You say that the member just 
had prostate surgery and needs a wheelchair. The Plan denied your request. The Plan says there are in-network 
providers within a reasonable distance from your location that can provide this service or item. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
  
 
 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a standard wheelchair with elevating leg rests 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 treatment with Aranesp (J0881). 
 
You asked the Plan to pre-approve Aranesp. 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 Aranesp. 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 drugs Retacrit or Procrit before they will approve the requested drug. The case file does 
not contain documentation of trial and failure of Retacrit or Procrit. The documentation does not support that 
Retacrit or Procrit would likely be less effective and/or would likely have adverse effects for the enrollee in this 
case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Aranesp (J0881).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings (A6549 x 4) and non-elastic 
extremity binders (A4465 x 4). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says these items are not covered under your contractual policy 
or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 and  
non-elastic extremity binders described by code A4465 are noncovered because they do not meet the statutory 
definition of a surgical dressing.  
  
Although these items may be appropriate, they do not fall into a covered benefit category and cannot be paid 
for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings (A6549 x 4) and non-elastic extremity binders (A4465 x 4).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve replacement hearing aids. 
 
You asked the Plan to pre-approve replacement hearing aids. You say that you would like Bluetooth hearing 
aids because they connect to your phone, and it would eliminate the need to take them out of your ears. The 
Plan denied your request. The Plan says your current hearing aids are less than 3 years old. The Plan also says 
that the requested replacement hearing aids are not a covered benefit under your plan. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only once every 3 years.  
 
We looked at the file and the Plan's rules. The record shows that you last received hearing aids on August 30, 
2021. Based on this information, we decided that the Plan's rules for coverage of replacement hearing aids have 
not been met. Therefore, we decided that the Plan does not have to pre-approve replacement hearing aids.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by the requested out-of-
network provider. 
 
You asked the Plan to pre-approve an office visit to be provided by the requested out-of-network provider. The 
Plan denied your request. The Plan says out-of-network services are not approved unless they are not available 
in-network or are 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 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an office 
visit to be provided by the requested out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of a leadless pacemaker. 
 
You asked the Plan to pre-approve the insertion of a leadless pacemaker. You say that this is medically 
necessary. The Plan denied your request. The Plan says this is not covered outside of approved studies. 
 
The Plan must follow Medicare rules. Medicare rules say that the Centers for Medicare & Medicaid Services 
(CMS) covers leadless pacemakers through Coverage with Evidence Development (CED). CMS covers 
leadless pacemakers when procedures are performed in Food and Drug Administration (FDA) approved 
studies.  
 
We looked at the file and Medicare rules. The record does not show that this procedure would be performed in 
an FDA-approved study. Based on this information, we decided that Medicare rules for coverage of the 
insertion of a leadless pacemaker have not been met. Therefore, we decided that the Plan does not have to pre-
approve the insertion of a leadless pacemaker.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve therapeutic CGM. You say that your doctor is requesting this device. The 
Plan denied your request. The Plan says you do not meet the Medicare criteria for a therapeutic CGM. 
 
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 perform blood glucose 
testing at least four times per day, use insulin with at least three daily injections, require frequent self-adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with your 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of therapeutic CGM have not been met. Therefore, 
we decided that the Plan does not have to pre-approve use of a therapeutic continuous glucose monitor (CGM).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nurtec. 
 
You asked the Plan to pre-approve Nurtec. You say that the requested drug is necessary for the enrollee. The 
Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-
administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the 
requested drug is not covered under Medicare Part B. 
 
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 Nurtec.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pudendal nerve block to be provided by the requested 
out-of-network provider. 
 
You asked the Plan to pre-approve a pudendal nerve block to be provided by the requested out-of-network 
provider. The Plan denied your request. The Plan says the Plan can provide this service in-network with an in-
network board certified pain specialist. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a 
pudendal nerve block to be provided by the requested out-of-network provider.