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

 
We decided that the Plan does not have to pre-approve stab phlebectomy of tributary varicose veins. 
 
You asked the Plan to pre-approve the requested phlebectomy procedures. You say that this treatment should 
be approved. The Plan denied your request. The Plan says only after treatment of the larger vein can these 
smaller veins be treated. 
 
The Plan follows Medicare rules. Medicare rules say that tributary vein treatment is covered after conservative 
therapy when saphenous reflux is not present or already successfully eliminated. 
 
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 requested phlebectomy procedures. 
Our reviewer says that the treatment of the requested tributary veins is not medically reasonable and necessary. 
Our physician reviewer found the documentation does not meet criteria for coverage of stab 
phlebectomy.  Specifically, criteria require that phlebectomy would only be covered if the truncal veins were 
either reflux free or previously treated.  There must also be a period of 6 weeks of conservative therapy in the 
absence of truncal reflux to see if the additional phlebectomy is necessary. Currently the patient has evidence 
of truncal reflux for which treatment has been planned and approved. Coverage of further services will require 
a reevaluation of the patient more than 6 weeks (during which time conservative therapies are utilized and 
documented) following truncal vein ablation.  
 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 requested phlebectomy procedures have not been met. Therefore, we 
decided that the Plan does not have to pre-approve stab phlebectomy of tributary varicose veins.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan must pay for pre-approved continued SNF care services after May 21, 2022. 
 
You asked the Plan to pay for pre-approved continued SNF care services. You say that you are still in bed and 
receiving skilled care. The Plan denied your request. The Plan says that continuation of SNF care is not 
medically necessary. 
 
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will 
stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before 
the last covered day. This notice must include a description of the enrollee's right to an appeal. 
 
We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or 
more days before May 21, 2022. The NOMNC submitted is not signed by the enrollee or signed by a staff 
member attesting the NOMNC was delivered. The Plan must pay for SNF services until the 100-day SNF care 
benefit is exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided 
that the Plan has to pre-approve continued SNF care services after May 21, 2022.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power wheelchair, group 3 standard, single power 
option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (CPT code K0856). 
 You asked the Plan to pre-approve the power wheelchair. You say that the enrollee is unable to safely move 
around the enrollee's house without a powered wheelchair. The Plan denied your request. The Plan says it is not 
clear from the limited information that the enrollee requires this as opposed to a standard power wheelchair. 
The Plan states the enrollee may indeed eventually require a power wheelchair, but the present documentation 
raises the question of what has caused the enrollee's apparent rapid decline and the examination submitted is 
scanty and does not meet CMS requirements. The Plan states after the enrollee has been seen by a neurologist, 
the request can be resubmitted with more complete information. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair. Our physician 
reviewer found the enrollee has a mobility limitation that impairs the ability to complete MRADLs. The 
documentation states the enrollee has falls with cane and walker and does not have arm strength to use a 
manual wheelchair. The documentation is not clear that the home is appropriate for the requested wheelchair as 
there are no objective measurements of the home indicating that the enrollee's home provides adequate access 
between rooms, maneuvering space, and surfaces for use of the wheelchair that is requested. The 
documentation is not clear that given the enrollee's seizure history that the enrollee is safe to use a power 
wheelchair. Without evidence that the wheelchair will provide adequate space in the home it is not clear that 
the requested wheelchair will significantly improve participation in MRADLs in the home. The Medicare 
criteria have not been met. 
 
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 power wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the power wheelchair, group 3 standard, single power option, sling/solid 
seat/back, patient weight capacity up to and including 300 pounds (CPT code K0856).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve 10 fractions of intensity-modulated radiation therapy/image-
guided radiation therapy (IMRT/IGRT). 
 
You asked the Plan to pre-approve IMRT/IGRT. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says that the denial of authorization for these services is correct, because 
IMRT/IGRT is not medically necessary and complex isodose treatment is suggested instead. 
 
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 IMRT/IGRT. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found given the guidelines' recognition of hippocampal sparing IMRT as a consideration in the setting 
of prophylactic brain radiation, and at least on randomized trial demonstrating a benefit, this treatment is 
offered in accordance with accepted standards 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 IMRT/IGRT have been met. Therefore, we decided that the Plan has to pre-
approve 10 fractions of intensity-modulated radiation therapy/image-guided radiation therapy (IMRT/IGRT).  
 
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 an epidural injection provided on December 20, 2021. 
 
You asked the Plan to pay for an epidural injection. The Plan denied your request. The Plan says despite 
multiple outreaches by the Health Plan, this provider has not submitted any clinical records to support the 
medical necessity of the service(s). 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of an epidural injection provided by on 
December 20, 2021 have been met. Therefore, we decided that the Plan does not have to pay for an epidural 
injection provided on December 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an epidural injection provided on November 8, 2021. 
 
You asked the Plan to pay for an epidural injection. The Plan denied your request. The Plan says despite 
multiple outreaches by the Health Plan, this provider has not submitted any clinical records to support the 
medical necessity of the service(s). 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of an epidural injection provided on 
November 8, 2021 have been met. Therefore, we decided that the Plan does not have to pay for an epidural 
injection provided on November 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oncology visit provided on November 8, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the OON oncology visit. You say that there was authorization obtained for these 
services. The Plan denied your request. The Plan says OON care is not covered by the Plan. 
 
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. There was an authorization for 
radiation oncology services; however, the provider at issue is not a radiation oncologist. 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 an oncology visit provided on November 8, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for the requested 
service have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
 We reviewed the file and the Medicare rules. We find that the enrollee is not a current smoker or former 
smoker who quit within the last 15 years. Therefore, we decided that the Plan does not have to pre-approve a 
low dose computed tomography (LDCT) scan for lung cancer screening.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional transportation trips to health care related locations 
other than your primary care provider's office. 
 
You asked the Plan to provide additional routine transportation. You say that you need additional transportation 
to continue to see your specialists for post-surgical follow up appointments. The Plan denied your request. The Plan says additional trips beyond the 30 one-way rides provided by your benefit are not covered under any 
circumstances. 
 
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 30 trips per year to health care related locations other than your primary 
care providers office.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that your request exceeds the Plans maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to provide additional transportation trips to health care related locations 
other than your primary care provider's office.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis 5 mg tablet. 
 
You asked the Plan to pre-approve Eliquis. You say that this drugs is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical 
benefit. 
 
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 Eliquis 5 mg tablet.  
 
 
  
Benefits for Eliquis 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a re-evaluation post-operative office visit (D0171) provided 
by a participating provider on January 5, 2022. 
 
You asked the Plan to pay for a re-evaluation post-operative office visit. You say that you had to go to another 
dentist to talk about your tooth pain. The Plan denied your request. The Plan says the dental service provided 
has been correctly denied. 
 
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 pay for a re-
evaluation post-operative office visit (D0171) provided by a participating provider on January 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a physician office visit (99204) to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a physician office visit. You say that the requested out-of-network care is a 
medical necessity for you. The Plan denied your request. The Plan says rules for coverage for out-of-network 
care have not been met. 
 
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 physician office visit (99204) to be provided by an out-of-network (OON) provider.  
 Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Genvisc (J7320). 
 
You asked the Plan to pre-approve Genvisc. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step therapy rules for the requested drug have not been 
met. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Genvisc. 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 Orthovisc or Supartz FX before they will approve the requested drug. In this case, 
the enrollee has not tried and failed the required drugs. There is no documentation provided indicating that the 
Plans 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 Genvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Genvisc (J7320).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walker holder for a power wheelchair. 
 
You asked the Plan to pre-approve the holder. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is a convenience accessory that is not medically necessary. 
 
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 walker holder for a power wheelchair.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Aurora Spine ZIP fusion procedure to L4-5 (22612, 
C1821). 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of the Aurora Spine ZIP fusion 
procedure in the setting of lumbar spinal stenosis has not been demonstrated in the peer-reviewed literature. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The Aurora Zip 
fusion procedure is experimental in spinal surgery. More research is needed. Our physician reviewer found that 
your condition does not meet 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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Aurora Spine ZIP fusion procedure to L4-5 (22612, C1821).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Dalfampridine tablet. 
 
You asked the Plan to pre-approve Dalfampridine. You say that the requested drug is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have 
not been 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 drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with 
Dalfampridine tablet.  
 Benefits for Dalfampridine 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vision services (V2784, V2025, V2781) provided January 
14, 2022. 
 You asked the Plan to pay for the vision services. You say that the eyewear should be covered in full. The Plan 
denied your request. The Plan says the benefit is limited to $250 towards the retail price of eyewear. Taxes are 
not included in this amount. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The plan benefit provides a $250 annual allowance towards eyeglasses or contact lenses. Applicable 
taxes are not covered. Any amount over the $250 benefit is the enrollee's responsibility. 
 
We looked at the file and the Plan's rules. The total cost was $477. The $250 allowance was applied leaving the 
enrollee responsible for the remaining amount plus sales tax. The Evidence of Coverage states that applicable 
tax is non-covered and any amount over $250 for covered eyewear is the enrollee's responsibility. Based on this 
information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, 
we decided that the Plan does not have to pay for vision services (V2784, V2025, V2781) provided January 14, 
2022.