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

 
We decided that the Plan does not have to pre-approve Hyalgan. 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that Hyalgan is not approved by the 
Food and Drug Administration (FDA) for the enrollee's diagnosis of wrist pain with post-traumatic 
osteoarthritis. The use is not supported by one of the major drug compendia or by clinical research that appears 
in a Medicare-approved medical journal. Hyalgan is therefore not reasonable or 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 Hyalgan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on December 7, 
2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 06, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
December 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the wound care procedures performed by 
an in-network provider on October 4, 2022, and October 11, 2022, and the specialist visit provided by an in-
network provider on October 18, 2022. 
 
You asked the Plan to waive the copayment for the wound care procedures and the specialist visit. You say that 
you do not agree with the cost sharing applied to these services. The Plan denied your request. The Plan says 
this cost sharing was charged correctly. 
 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 a $290 
copayment for each in-network Medicare-covered outpatient hospital facility visit, and a $45 copayment for 
each in-network Medicare-covered visit with a specialist. 
 
You have been asked to pay a $580 copayment for the wound care procedures ($290 x 2 services = $580). 
These items/services fall within the outpatient surgery, including services provided at hospital outpatient 
facilities and ambulatory surgical centers benefit category. You have also been asked to pay a $45 copayment 
for the specialist visit. This item/service falls within the physician/practitioner services, including doctors 
office visits 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 the wound care procedures 
performed by an in-network provider on October 4, 2022, and October 11, 2022, and the specialist visit 
provided by an in-network provider on October 18, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 45385 and 45381 provided on September 22, 2022. 
 
You asked the Plan to pay for codes 45385 and 45381. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported. 
 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, the CPT Code Manual definition of code 45385 is colonoscopy, flexible; with removal of tumor(s), 
polyp(s), or other lesion(s) by snare technique. 
The CPT Code Manual definition of code 45381 is colonoscopy, flexible; with directed submucosal 
injection(s), any substance. 
 
We find that CPT codes 45385 and 45381 are not supported in the medical record. Specifically, the operative 
report did not include documentation of a flexible colonoscopy with removal of tumor(s), polyp(s), or other 
lesion(s) by snare technique; therefore, code 45385 cannot be verified. 
 
The operative report did not include documentation of a flexible; with directed submucosal injection(s), any 
substance; therefore, code 45381 cannot be verified. 
 
Based on this information, we decided that Medicare rules for coverage of codes 45385 and 45381 have not 
been met. Therefore, we decided that the Plan does not have to pay for codes 45385 and 45381 provided on 
September 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SSBCI benefits. 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you believe you are eligible for the SSBCI 
benefits. The Plan denied your request. The Plan says you do not meet all the criteria to be eligible for SSBCI 
benefits. 
 
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. We looked at the file and Medicare rules. The Plan requested medical records from your provider but did not 
receive any, and without medical records we cannot determine whether you meet the criteria for the SSBCI 
benefits. Based on this information, we decided that there is insufficient information in the record to determine 
if Medicare rules for coverage of SSBCI benefits have been met. Therefore, we decided that the Plan does not 
have to pre-approve SSBCI benefits.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Genotropin. 
 
You asked the Plan to pre-approve Genotropin. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 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 Genotropin.  
 
Benefits for Genotropin 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (A4239). 
 
You asked the Plan to pre-approve the CGM. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the items denied correctly as the enrollee does not meet the 
clinical requirements to be approved. 
 
  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 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 their 
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 the CGM have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuous glucose monitor (A4239).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor sensor. 
 
You asked the Plan to pre-approve the Freestyle Libre continuous glucose monitor sensor. The Plan denied 
your request. The Plan says the enrollee does not require insulin three or more times daily. 
 
 
 
 
 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 injections. Based on this information, we decided that Medicare rules for coverage of 
the Freestyle Libre continuous glucose monitor sensor have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Freestyle Libre continuous glucose monitor sensor.
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 the office visit. You say that the enrollee's current provider was not helpful. 
The Plan denied your request. The Plan says network providers are available to render necessary care. 
 
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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3000). 
 
You asked the Plan to pre-approve foot orthotics. You say that the items should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3000).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the toe amputation provided on November 
11, 2022. 
 
You asked the Plan to waive the copayment for the toe amputation. You say that you should not have to pay 
due to the poor treatment received. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
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 a $325 
copayment for outpatient surgery at an outpatient hospital facility. 
 
You have been asked to pay a $325 copayment for the toe amputation. This item/service falls within the 
outpatient surgery at an outpatient hospital facility 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 the toe amputation provided on November 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visit to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve office visit. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says enrollees may obtain services from an out-of-network provider only when 
providers of specialized services are not available in-network (i.e., a unique sub-specialty where the plan does 
not have a contracted provider), or in urgent and/or emergent situations. To obtain authorization for a provider 
of specialized services that are not available in-network, the enrollees primary care physician (PCP) will submit 
a referral request and any supporting documentation to their assigned IPA/medical group. 
 
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 
office visit to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to increase the reimbursement for an inpatient hospital stay provided 
from August 7, 2022, to August 9, 2022. 
 
You asked the Plan to increase the reimbursement for an inpatient hospital stay. You say that you do not 
understand why the inpatient stay was not covered when the emergency room visit was covered. The Plan 
denied your request. The Plan says that you have been reimbursed the correct amount. 
 
The rules say a plan must pay for a medical service or item if regular Medicare would pay for it in this case. 
Your contract clearly says that the Plan will reimburse for covered out-of-network emergency and urgent care 
services outside of the United States and its territories at Original Medicare reimbursement rates. 
 
The record shows that the provider received payment in the amount of $6,538.99, which is the total allowed 
amount for the inpatient hospital stay. The Plan confirmed that you need to contact the provider and request 
they provide you with a refund of the payment that was made. This is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to increase the 
reimbursement for an inpatient hospital stay provided from August 7, 2022, to August 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontic - porcelain fused to high noble metal (D6240) 
and retainer crown - porcelain fused to high noble meta (D6750). 
 
You asked the Plan to pre-approve  the dental services. You say that due to health issues, you need the 
requested dental services to help chew your food. The Plan denied your request. The Plan says your benefit for 
the requested item or service has already been exhausted. 
  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. This benefit includes the 
requested retainer crown - porcelain fused to high noble meta (D6750) but is limited to two caps (or crowns) 
per year. One crown in five years per tooth. Pontic - porcelain fused to high noble metal (D6240) is not covered 
under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D6240 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve pontic - 
porcelain fused to high noble metal (D6240). 
 
We looked at the file, the Plans rules, and Medicares rules. You previously received two covered crown - 
porcelain/ceramic (D2740) Tooth #28 and 29 on date of service January 23, 2023. Therefore, this service was 
exhausted on date of service January 23, 2023. Although these are two different services, they fall within the 
same category in your Evidence of Coverage and are subject to the same frequency limitations. Therefore, we 
decided that the Plan does not have to pre-approve retainer crown - porcelain fused to high noble meta 
(D6750).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary as the enrollee has not 
received the services needed following their inpatient care. The Plan denied your request. The Plan says the 
enrollee does not have complex medical needs. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), a harness (E2313) and an expandable controller 
(E2377). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that it is deemed that the enrollee meets 
medical necessity for a group 3 power wheelchair with power seat functions including tilt, recline, and 
elevating leg rests. The Plan denied your request. The Plan says although there are two approved power options 
on this wheelchair, there is not a medical need to control these 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.  
 
 
 
 
 
 
 
 
 
 
 
 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 wheelchair accessories. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found according to Medicare, a power mobility device is medically necessary if an enrollee 
has a mobility limitation that significantly impairs his ability to participate in one or more mobility-related 
activities of daily living. The mobility limitation cannot be sufficiently and safely resolved using a fitted cane, 
walker, or the enrollee does not have sufficient upper extremity function to self-propel an optimally configured 
manual wheelchair. Additionally, if any POV or PWC is only for use outside the home, it is denied as 
noncovered. The enrollee must also have the mental and physical capabilities to safely operate the power 
wheelchair and the home provides adequate access between rooms, maneuvering space, and surfaces for the 
operation of the PWC. An expandable controller is an electronic system that is capable of accommodating one 
or more additional features and can operate 3 or more powered seating options. The requested electrical 
accessories are not medically necessary as the enrollee 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 wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection between wheelchair controller and two or more power 
seating system motors (E2311), a harness (E2313) and an expandable controller (E2377).