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

 
We decided that the Plan does not have to pre-approve a Vertiflex interspinous process spacer device. 
 
You asked the Plan to pre-approve a Vertiflex interspinous process spacer device. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
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 a Vertiflex interspinous process spacer 
device. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the vertiflex device is experimental. More research is 
needed. 
 
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 Vertiflex interspinous process spacer device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Vertiflex interspinous process spacer device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tier exception for Budesonide. 
 
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 drug is not eligible for a tier exception. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B drugs are not eligible for a Part D tier 
exception. 
 
We looked at the file and Medicare rules. The requested drug, budesonide, is covered by Part B Medicare and 
is not eligible for a Part D tier exception. Therefore, we decided that the Plan does not have to pre-approve a 
tier exception for Budesonide.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that you believe that this CGM is medically necessary to 
monitor your blood sugars. The Plan denied your request. The Plan says the criteria for this device have not 
been met. 
 
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. The most recent note says that the enrollee only uses one dose of 
insulin at night. 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 
(CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic (D6245) and two retainer crowns (D6740 x2). 
 
You asked the Plan to pre-approve the pontic and retainer crowns. You say that if the cavity goes deeper, you 
will be in pain which is why you would like these services to be reconsidered. The Plan denied your request. 
The Plan says these services are not covered under your benefit plan. The Plan also says that your provider 
gave an alternative that would be covered under your plan. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
pontic (D6245) and two retainer crowns (D6740 x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ROMtech PortableConnect Adaptive Rehab device. 
 
You asked the Plan to pre-approve this item. You say that this will benefit your recovery after surgery. The 
Plan denied your request. The Plan says that this is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a ROMtech PortableConnect Adaptive Rehab device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prochlorperazine 
 
You asked the Plan to pre-approve Prochlorperazine.. You say that this drug is medically necessary. The Plan 
denied your request. The Plan says the drug is not completely replacing IV administered anti-emetics. 
Coverage criteria under the Part B medical benefit is not met. 
 
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 Prochlorperazine  
 
Benefits for Prochlorperazine. 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic panel rendered on February 21, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that NGS is covered when specific criteria are met. 
 
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 these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee has a diagnosis of metastatic 
castration-resistant prostate cancer. He has previously undergone radical prostatectomy, salvage radiation 
therapy, androgen deprivation therapy, dendritic cell vaccine therapy, and bicalutamide plus dutasteride, and is 
currently on Enzalutamide and Firmagon. The Tempus gene panel does not have Food & Drug Administration 
(FDA) approval or clearance as a companion in vitro diagnostic, and an FDA-approved or -cleared indication 
for use in the enrollee's cancer. The documentation does not support that the Tempus gene panel was medically 
reasonable and necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the genetic panel rendered on February 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extractions to be rendered by an oral surgeon. 
 
You asked the Plan to pre-approve the extractions. You say that you lost all of your teeth due to the radiation 
you received, and you were advised to get the rest extracted. You also say that the oral surgeon you are 
requesting to see is the only one that would accept you. The Plan denied your request. The Plan says dental 
services are only covered when the services are performed by a participating general dentist. The Plan also says 
that dental services performed by an oral surgeon are not covered. 
 
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, the requested items or services are not 
covered when they are received by anyone other than a participating general dentist. Therefore, we decided that 
the Plan does not have to pre-approve extractions to be rendered by an oral surgeon.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Forteo for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under 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 Forteo for the enrollee.  
 
Benefits for this drug 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit to be provided by an OON provider. 
 
You asked the Plan to pre-approve the office visit. You say that you need to see the specialist. The Plan denied 
your request. The Plan says an in-network provided was recommended to you. 
 
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 
the office visit to be provided by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Injectafer (J1439). 
 
You asked the Plan to pre-approve Injectafer. 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 coverage of 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 Injectafer. 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 Infed and Venofer before they will approve the requested drug, Injectafer. Based 
on the medical records provided, the enrollee has not tried and failed the required drugs. There is no indication 
that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Injectafer (J1439).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for a Prolia injection provided on September 
24, 2021. 
 
You asked the Plan to reduce the cost share for a Prolia injection. You say that you cannot afford this amount 
twice a year. You also say in your research you should only pay $45 per injection. The Plan denied your 
request. The Plan says you have been charged the correct cost sharing 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 20% 
coinsurance for part B drugs.  
 
You have been asked to pay $251.64, which is 20% of the allowed amount for a Prolia injection ($1,258.20 
allowed amount x 20% coinsurance = $251.64). A Prolia injection falls within the Medicare Part B Prescription Drugs 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 reduce the cost share for a Prolia injection provided on 
September 24, 2021.  
 
Benefits for a Prolia injection 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia (CPT code 99135) provided on April 5, 2021. 
 
You asked the Plan to pay for the anesthesia. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is not covered as billed. 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
CPT code 99135 is assigned a status code = B. The rules say B: Payment for covered services are always 
bundled into payment for other services not specified. There will be no RVUs, or payment amounts for these 
codes and no separate payment is ever made. When these services are covered, payment for them is subsumed 
by the payment for the services to which they are incident (an example is a telephone call from a hospital nurse 
regarding care of a patient). Based on this information, we decided that Medicare rules for coverage of the 
anesthesia have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia (CPT 
code 99135) provided on April 5, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy sessions to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the physical therapy sessions. You say that you are not satisfied with the in-
network provider services and would like to see an out-of-network provider. The Plan denied your request. The 
Plan says there are in-network providers that are located closer to the enrollee's residence that provide the same 
quality of service as the out-of-network provider. 
 
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 sessions 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 Zioptan. 
 
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 self-administered drugs are not covered. 
 
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 Zioptan.  
 
Benefits for these services 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit (99203) to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a specialist office visit. You say that all paperwork was provided to the Plan 
and denied, and the requested provider has treated you in the past and he knows your condition. The Plan 
denied your request. The Plan says the medical care you require can be provided by a network provider, and 
after reviewing your appeal and the available medical records, they agree with your medical group that a 
network provider can care for your medical problem. 
 
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 specialist office visit (99203) to be provided by an out-of-network (OON) provider.  Your complaint about the Plan potentially wanting you to get a major surgery and skin graft is not a valid 
appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. 
Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to waive the cost share for an injection. We decided that the Plan does not have to 
waive the cost share for a PET scan.  
 
You asked the Plan to waive the cost share for a PET scan and an injection. You say that you were under the 
impression that covered services are covered at 100%.  
 You also say that the service provider or your primary care physician should have told you how much you 
would have to pay out of pocket because now you are stuck with an expected bill. The Plan denied your 
request. The Plan says that you have been charged the correct amount. 
 
We decided that the Plan has to waive the cost share for a regadenoson injection (code J2785).  
 
The Plan says you must pay 20% coinsurance for a regadennoson injection. According to Medicare, code 
J2785 is packaged into payment for other services, and not separately payable. Therefore, we decided that the 
Plan has to waive the cost share for a regadenoson injection.  
 
We also decided that the Plan does not have to waive the cost share for a PET scan. 
 
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 outpatient diagnostic tests, including PET scans at a freestanding provider. 
 
You have been asked to pay a $100 copayment for a PET scan. A PET scan falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies 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 cost share for a PET scan. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 18, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided 
that the Plan does not have to pay for the laboratory services rendered on October 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the prophylaxis (D1110) provided on November 18, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the prophylaxis. You say that you were not aware that the treating provider 
was not in-network. You also say that you live on a very tight budget and do not have any means to pay this 
bill. The Plan denied your request. The Plan says services performed by an OON provider are not covered 
because your healthcare plan does not have OON benefits. The Plan also says that you did not contact the Plan 
prior to the date of service to verify benefits and provider eligibility. 
 
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, you are responsible for 100% of the 
cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to 
pre-approve the prophylaxis (D1110) provided on November 18, 2021 by an out-of-network (OON) provider.