Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulator (TENS) 
device. 
 
You asked the Plan to pre-approve a TENS device. You say that you would like this item for pain management. 
You have had back pain for many years. The Plan denied your request. The Plan says you do not meet criteria 
for the requested device. 
 
The Plan must follow Medicare rules. Medicare rules say that TENS therapy for chronic low back pain is not 
covered.  
 
We looked at the file and Medicare rules. Review of the file shows that you are requesting this device for the 
use for your chronic low back pain. Based on this information, we decided that Medicare rules for coverage of 
a TENS device have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
transcutaneous electrical nerve stimulator (TENS) device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve a power wheelchair. You say that you would like to request reconsideration 
of the denied authorization. The Plan denied your request. The Plan says the provider is out-of-network, and it 
was determined these services can be received in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a power wheelchair 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 Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that you have an injured knee that needs to be treated and 
are not sure why this was denied. The Plan denied your request. The Plan says you do not meet the Part B Step 
Therapy requirements for the Euflexxa injection. 
 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 
elements of the coverage criteria are not satisfied, and the requested service cannot be recommended. Our 
physician reviewer found the record provided is insufficient to determine whether step therapy requirements 
are satisfied. The provided records do not indicate that the enrollee has tried and failed the Plan's preferred step 
one alternative. Our reviewer also found that 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. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ear molds (V5264) to be rendered by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the ear molds. You say that you would like to receive the ear molds from 
this OON provider because of their standard of material and service. The Plan denied your request. The Plan 
says the provider requested to render this service does not participate in the Plan's network of providers. 
 
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 when they are provided by a network hearing aid provider.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the ear molds have not been met. Therefore, we decided that the Plan does not have to pre-approve 
ear molds (V5264) to be rendered by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (71045) provided on February 9, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this claim is a 
duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on March 3, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the services have not been met. Therefore, 
we decided that the Plan does not have to pay for the services (71045) provided on February 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation (A0120). 
 
You asked the Plan to pre-approve additional transportation. You say that you would like additional 
transportation to and from your medical appointments. The Plan denied your request. The Plan says you have 
used all of the trips allowed by your plan, and this request exceeds the benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 60 one-way trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency transportation (A0120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S8429 billed for date of service October 1, 
2021. 
 
You asked the Plan to pay for procedure code S8429. You say that this hospital does not bill insurance for 
equipment and you were told this item would be billed under code S8429. The Plan denied your request. The 
Plan says the billed code is invalid for Medicare purposes. The Plan says that it has attempted to contact the 
provider multiple times to get the coding fixed, but was unsuccessful.  The Plan says that it cannot pay this 
claim until a correct code is provided. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S8429 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S8429 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S8429 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S8429 billed for date of service October 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for spine surgery provided on April 26, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for spine surgery. You say that you are appealing the claim payment denial. The 
Plan denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 spine surgery at issue in this appeal. The Plan did not pre-approve the 
spine surgery at issue. We found no exception that would require the Plan to pay for the spine surgery. 
Therefore, we decided that the Plan does not have to pay for spine surgery provided on April 26, 2022, by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve the excision, benign lesion including margins, except skin tag 
(unless listed elsewhere), scalp, neck, hands, feet, genitalia (11426) and application of a skin substitute graft to 
trunk, arms, legs, total wound surface area up to 100 sq. cm; first 25 sq. cm or less wound surface area (Integra) 
(15271) for the enrollee. 
 You asked the Plan to pre-approve these services. You say that the application of lntegra Bilayer is intended to 
optimize the dermal regeneration to facilitate definitive coverage with a split thickness skin graft. The Plan 
denied your request. The Plan says that that this type of skin substitute is only used for certain problems. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. This patient has a 
malignant melanoma that will require wide excision located on the lower leg in a challenging area to heal. The 
Integra skin graft matrix is being used to support healing of the dermis with blood supply to better support the 
likelihood of the area accepting skin graft. Our physician reviewer found that the enrollee's condition meets 
criteria for coverage of these services. 
 
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 the excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, 
hands, feet, genitalia (11426) and application of a skin substitute graft to trunk, arms, legs, total wound surface 
area up to 100 sq. cm; first 25 sq. cm or less wound surface area (Integra) (15271) for the enrollee.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lower 
extremity for the enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that you believe the services are a covered benefit. The 
Plan denied your request. The Plan says there is no information to support medical necessity at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. The rules also say that MRIs are covered only when they are medically necessary.  
 
Despite multiple attempts on the plan's part, medical records were not received for this request. The medical 
necessity for this requested MRI cannot be verified. Based on this information, we decided that Medicare rules for coverage of the MRI have not been met. 
Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the 
lower extremity for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation. 
 
You asked the Plan to pre-approve additional transportation. You say that you would like 10 more one-way 
trips, as you have already reached the maximum number of trips that your plan offers. The Plan denied your 
request. The Plan says your plan allows for 10 one-way trips per plan year for routine non-emergency visits to 
plan-approved locations. The Plan also says that extra one-way transportation trips cannot be approved. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 10 one-way trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service April 5, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this code should be paid separately. The 
Plan denied your request. The Plan says procedure code 99100 is considered bundled and not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service April 5, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services you received on October 9, 
2021, from a Licensed Marriage and Family Therapist (LMFT). 
 
You asked the Plan to pay for the LMFT services. You say that this claim needs to be processed. The Plan 
denied your request. The Plan says services provided by a LMFT are not covered.  The Plan says that they have 
no record of you calling prior to getting these services confirming this provider's eligibility. 
 
The Plan must follow Medicare rules. Medicare rules say that the only provider types eligible to provide 
Medicare-covered mental health services are as follows: Physicians, Clinical Psychologists, Clinical Social 
Workers, Clinical Nurse Specialists, Nurse Practitioners, Physician Assistants, Certified Nurse-Midwives, 
Independently Practicing Psychologists, and Certified Registered Nurse Anesthetists. The provider you saw 
was a LMFT, which is not an eligible provider type. Therefore, we decided that the Plan does not have to pay 
for outpatient mental health services you received on October 9, 2021, from a Licensed Marriage and Family 
Therapist (LMFT).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for out of network specialist visit provided on 
December 1, 2021. 
 
You asked the Plan to waive the copayment for specialist visit. You say that you were made to see the nurse 
practitioner instead of your doctor so this should be waived. The Plan denied your request. The Plan says the 
copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $55 
copayment for each out of network Medicare covered individual or group therapy visit.  
 
 
 
 You have been asked to pay $55 copayment for specialist visit. Specialist visits fall within the Outpatient 
Mental Health Care 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 waive the copayment for out of network 
specialist visit provided on December 1, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services you received on March 19, 
2021, from a Licensed Marriage and Family Therapist (LMFT). 
 
You asked the Plan to pay for the LMFT services. You say that this claim needs to be processed. The Plan 
denied your request. The Plan says services provided by a LMFT are not covered.  The Plan says that they have 
no record of you calling prior to getting these services confirming this provider's eligibility. 
 
The Plan must follow Medicare rules. Medicare rules say that the only provider types eligible to provide 
Medicare-covered mental health services are as follows: Physicians, Clinical Psychologists, Clinical Social 
Workers, Clinical Nurse Specialists, Nurse Practitioners, Physician Assistants, Certified Nurse-Midwives, 
Independently Practicing Psychologists, and Certified Registered Nurse Anesthetists. The provider you saw 
was a LMFT, which is not an eligible provider type. Therefore, we decided that the Plan does not have to pay 
for outpatient mental health services you received on March 19, 2021, from a Licensed Marriage and Family 
Therapist (LMFT).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient mental health services to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve outpatient mental health services. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-
network, and it was determined these services can be received in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
outpatient mental health services 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 Gel One. 
 
You asked the Plan to pre-approve Gel One. You say that you disagree with the Plan's 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 Gel One. 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, diagnosis confirmed with imaging studies. 
The documentation does not support that the enrollee has tried and failed Durolane, Monovisc, or Synvisc-One. 
The documentation does not support that 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 Gel One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel One.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the member has no medical need for follow up in 
radiation oncology. The member is currently being followed up with a Hematology/Oncology Department and 
GYN Oncology. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out-of-network (OON) provider.