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

 
We decided that the Plan does not have to pre-approve prostate artery embolization (PAE) 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 medical studies haven't proven that this service is helpful for treatment of the health 
problem. 
 
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 prostatic arterial embolization (PAE) is considered an experimental technique to treat symptomatic 
benign prostatic hyperplasia. Very limited studies have demonstrated possible short-term safety and efficacy. 
The most recent American Urological Association guidelines do not recommend this procedure outside of a 
clinical trial 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve prostate artery embolization (PAE) for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy visits provided on January 19, 2021 to May 
26, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for psychotherapy visits. You say that you are requesting reimbursement for these 
visits. The Plan denied your request. The Plan says the denial of payment for these services is correct, because 
this provider is out-of-network with the Plan and authorization was not obtained. 
 
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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for psychotherapy visits provided on January 19, 2021 
to May 26, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Botox injections.

You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 the injections. Our reviewer says that the requested injections are medically reasonable and necessary. Our physician reviewer found the record indicates that the enrollee has a neurogenic bladder due to a traumatic spinal cord injury. The record indicates that the enrollee has failed anticholinergic medications. The request is for 300U. Dose is not a controlling factor in determining the presence of a medically approved indication as defined by Medicare rules. The requested drug is being used for an indication noted by the Food and Drug Administration. The elements of the coverage criteria are satisfied. 

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 injections have been met. Therefore, we decided that the Plan has to pre-approve Botox injections.

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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on May 28, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services were not urgent, emergent, or approved in advance. 
 
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 file shows that the enrollee was seen for a re-evaluation. The 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 office visit provided 
on May 28, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone replacement grafts and guided tissue 
regeneration. 
 
You asked the Plan to pre-approve the bone replacement grafts and guided tissue regeneration. You say that the 
bone grafts and tissue regeneration are important when performing osseous surgery to achieve good results. 
You say that this is medically necessary, and the decision should be reconsidered. The Plan denied your 
request. The Plan says the services are not covered under the benefit plan and are not medically necessary. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the bone 
replacement grafts and guided tissue regeneration when the services are medically necessary and reasonable.  
  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 bone replacement grafts and guided 
tissue regeneration. Our physician reviewer found the record did not include charting of periodontal pockets 
and the radiographs did not reveal infrabony pockets. Our reviewer says that the documentation provided does 
not support the need for bone grafts and guided tissue regeneration in the areas indicated.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the bone replacement grafts and guided tissue regeneration have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the bone replacement grafts and guided tissue 
regeneration.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services as they were billed, 
for dates of service April 24 - April 30, 2020. 
 
You asked the Plan to pay for the SNF services as they were billed. You say that the documentation provided 
supports the inpatient services as billed. The Plan denied your request.   
The Plan says the documentation does not support the nursing and NTA components of the PDPM score. The 
Plan says that the clinical documentation does not support the coding of diabetes, malnutrition, and isolation. 
 
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. 
 
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 SNF services. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the Nutritional Assessment performed 
on April 26, 2020, documents that the enrollee was on a regular diet. It was noted that the enrollee was at risk 
for malnutrition related to a coronavirus diagnosis, and history of diabetes, and hypertension. Ensure clear 
twice daily was recommended. On April 29, 2020, the enrollee was being admitted to Hospice of NW. On 
April 28, 2020, the enrollee was refusing medications, was not eating much, and was drinking very little. 
The enrollee suffered a fall on April 24, 2020. The available documentation is insufficient to support the 
diagnoses of diabetes mellitus, malnutrition, and isolation for dates of service April 24 through April 30, 2020. 
 
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 SNF services (as they were billed) have not been met. Therefore, we 
decided that the Plan does not have to pay for skilled nursing facility (SNF) services as they were billed, for 
dates of service April 24 - April 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110). 
 
You asked the Plan to pre-approve the complete maxillary denture. You say that the enrollee is in need of a 
complete maxillary denture to be able to eat and digest food properly. The Plan denied your request. The Plan 
says this service is allowed one time in 5 calendar years. The Plan also says that the enrollee has already had 
this service within the past 5 years, and has reached their limit for this service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, complete maxillary denture (D5110) is 
limited to one of either codes D5110, D5211, D5213, D6110, or D6112 once per 5 calendar years. The record 
shows that the enrollee received a complete maxillary denture (D5110) on May 6, 2019, and the enrollee's 
complete maxillary denture (D5110) benefit has been exhausted. Therefore, we decided that the Plan does not 
have to pre-approve a complete maxillary denture (D5110).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Hyalgan (J7321). 
 
You asked the Plan to pre-approve Hyalgan. You say that the requested treatment is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step therapy rules for the requested treatment 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 Hyalgan. 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 Orthovisc and Monovisc before they will approve the requested drug. The requested 
drug is a new start. The provided records do not indicate that the enrollee has tried and failed the Plan's 
preferred step-one alternatives. The record does not indicate that the enrollee has a contraindication to, or 
would have an adverse effect from, the Plan's preferred step-one alternatives. The elements of the coverage 
criteria are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Hyalgan (J7321).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychological testing evaluation services (96130) 
provided on May 28, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychological services. You say that no authorization was obtained however 
please reconsider the medical records attached for supporting documents. The Plan denied your request. The 
Plan says enrollee?s must receive their medical services from an in-network provider with the exception being 
urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization 
before services being rendered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the psychological testing evaluation services 
(96130) provided on May 28, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from June 1, 2021, to June 2, 2021.

You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

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 $492 copayment for days 1-4 for inpatient hospital care. 

You received inpatient hospital care from June 1, 2021, to June 2, 2021. Therefore, you are responsible to pay the $492 copayment.

You have been asked to pay a $492 copayment for inpatient hospital care. Inpatient hospital care falls within the inpatient hospital 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 inpatient hospital care provided from June 1, 2021, to June 2, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided from September 1 to 
December 1, 2020, by a provider not enrolled in the Medicare program. 
 
You asked the Plan to pay for psychotherapy services. You say that you were assured that your insurance under 
the Plan was accepted by the provider. The Plan denied your request. The Plan says rules for payment have not 
been met. 
 
  The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for psychotherapy services provided from 
September 1 to December 1, 2020, by a provider not enrolled in the Medicare program.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care provided on May 25, 2021. 
 
You asked the Plan to waive the copayment for emergency care. You say that this was an emergency situation 
and you should have been admitted to the hospital. The Plan denied your request. The Plan says the claims 
were processed correctly and you are being charged the correct amount. 
 
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 $100 
copayment for emergency care.  
 
You have been asked to pay a $100 copayment for emergency care. Emergency care falls within the emergency 
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 emergency care provided on 
May 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen equipment (E1390), provided on April 29, 2021.

You asked the Plan to pay for the oxygen equipment. You say that the item should be covered. The Plan denied your request. The Plan says purchased oxygen equipment is statutorily non-covered.

The Plan must follow Medicare rules. Medicare rules say that for oxygen and oxygen equipment, contractors pay a monthly fee schedule amount per beneficiary. Unless otherwise noted below, the fee covers equipment, contents and supplies. Payment is not made for purchases of this type of equipment. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the oxygen equipment have not been met. Therefore, we decided that the Plan does not have to pay for the oxygen equipment (E1390), provided on April 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane. 
 
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 step therapy is not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has knee osteoarthritis. She 
has not tried and failed the Plan's required drugs, Orthovisc and Monovisc. The records do not show that the 
required drugs would be contraindicated or less effective; therefore, Durolane is 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 Durolane.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the revision of reconstructed breast services coded 19380 and 
the mastopexy coded 19316 provided on June 5, 2020. 
 
You asked the Plan to pay for the revision of reconstructed breast services and the mastopexy. You say that you 
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed 
are not supported by the documentation. 
 
  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 19380 and 19316 are not supported in the medical record. Specifically, operative 
report did not include documentation of a revision of a reconstructed breast (significant removal of tissue, re-
advancement and/or re-inset of flaps in autologous reconstruction or significant capsular revision combined 
with soft tissue excision in implant-based reconstruction); therefore, code 19380 cannot be verified. The 
operative report did not include documentation of a mastopexy; therefore, code 19316 cannot be verified. 
Based on this information, we decided that Medicare rules for coverage of the revision of reconstructed breast 
services and the mastopexy have not been met. Therefore, we decided that the Plan does not have to pay for the 
revision of reconstructed breast services coded 19380 and the mastopexy coded 19316 provided on June 5, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Purewick female external catheter system. 
 
You asked the Plan to pre-approve the Purewick system. You say that you are appealing because you do not 
understand which standard external catheter is which. You would be happy to use if you knew which one it 
was. You are not stuck on the Purewick system it's just the only one you're aware of. The Plan denied your 
request. The Plan says the requested supplies are available with a standard pouch type female external 
collection device (A4328) from an in-network provider. 
 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 Purewick system. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee would be using this device for convenience and there was no clear 
indication that the offered standard pouch type external collection device would not be appropriate for a trial. 
Therefore, this request for Purewick female external catheter does not meet the requirements in LCD for 
Medicare coverage. 
 
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 Purewick system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Purewick female external catheter system.