Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gas permeable contact lens (V2531) provided on June 10, 
2022. 
 
You asked the Plan to pay for gas permeable contact lens (V2531). You say that you need special contact 
lenses because you have keratoconus. The Plan denied your request. The Plan says this service is not covered 
under the patient's current benefit plan.  
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 does not cover gas permeable contact lenses (V5231). 
 
We looked at the file and the Plan's rules. This service is excluded from the plan benefits. Based on this 
information, we decided that the Plan's rules for coverage of gas permeable contact lens (V2531) have not been 
met. Therefore, we decided that the Plan does not have to pay for gas permeable contact lens (V2531) provided 
on June 10, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve travel and lodging expenses. 
 
You asked the Plan to pre-approve travel and lodging expenses. You say that the reimbursement is necessary. 
The Plan denied your request. The Plan says the services can be performed at a facility within 100 miles from 
your home. 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 looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of travel and lodging expenses have not been met. Therefore, we decided that the Plan does not have 
to pre-approve travel and lodging expenses.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction of peripheral nerve or branch (64640 x 3). 
 
You asked the Plan to pre-approve the injections. You say that the services are medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
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 injections. Our reviewer says that 
the requested injections are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the role of radiofrequency ablation (RFA) of the genicular nerves is still being investigated. It is 
considered experimental at this point. Therefore, the reviewer found that the requested injections are 
considered not medically reasonable or 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 the injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve destruction of peripheral nerve or branch (64640 x 3).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ER services provided on April 28, 2022. 
 
You asked the Plan to waive the copayment for ER services. You say that you said you left the ER without 
treatment because they were busy so you shouldnt be charged. 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 $67.80 
copayment for Emergency care. 
 
You have been asked to pay a $67.80 copayment for ER services. This item/service 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. 
You have been asked to pay $67.80 which is less than the standard $90 copayment for ER services. Therefore, 
we decided that the Plan does not have to waive the copayment for ER services provided on April 28, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block (64454). 
 
You asked the Plan to pre-approve the injection. You say that the requested service is necessary. You say that if 
it is helpful, the enrollee will proceed with radiofrequency nerve ablation for longer relief. You also say that the 
enrollee is suffering while this is being denied. The Plan denied your request. The Plan says the requested 
service is not medically necessary. 
 
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 injection. Our reviewer says that the 
requested injection is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the role of genicular nerve blocks and radiofrequency ablation (RFA) is still being investigated. It is 
considered experimental. Therefore, the request is considered not medically reasonable or 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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a genicular nerve block (64454).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo (J2777). 
 
You asked the Plan to pre-approve Vabysmo. You say that phase three pivital trials indicate improved drying 
of the macula compared to Eylea. You also say that Vabysmo also demonstrated an ability to allow for longer intervals between injections. The Plan denied your request. The Plan says the requested drug is not medically 
necessary. 
 
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 Vabysmo. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has tried and failed any of the plan's preferred drugs. The reviewer found that the 
documentation does not sufficiently support that Eylea or Lucentis would likely be less effective, and/or would 
likely have adverse effects for the enrollee in this case. Therefore, the reviewer found that the step therapy 
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 Vabysmo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vabysmo (J2777).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a special power wheelchair (group 3 power wheelchair) 
with two (2) or more power seat options and accessories (K0861, E0956, E1028, E2363, E2605, E1012, E2311, 
E0955, E0953, E0950, E2377, E2313, E1007). 
 
You asked the Plan to pre-approve a special power wheelchair and accessories. You say that the documentation 
provided for the wheelchair and accessories, are medically necessary to meet the enrollee's current needs. The 
Plan denied your request. The Plan says the enrollee does not have a medical need for multiple power options 
included with a group 3 power wheelchair. 
 
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 a special power wheelchair and 
accessories. Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
enrollee has a group 3 qualifying diagnosis of a neurological condition of post-polio paralysis. The 
documentation indicates the enrollee has a mobility deficit that impairs MRADLs in the home and cannot be 
overcome with a manual wheelchair, walker, or cane due to falls, weakness, and limited shoulder range of 
motion from a rotator cuff tear. While he may be able to safely use the requested wheelchair, the 
documentation does not reveal that the requested chair with multiple power options is medically necessary. The 
documentation does not reveal that the enrollee uses a ventilator attached to a wheelchair or is at high risk for 
development of a pressure ulcer. There is no evidence of intermittent catheterization. The documentation does 
not indicate objective evidence of spasticity on a BLE physical exam that needs a power seating system for 
management therefore the request for power recline exceeds the enrollee's medical needs. He does not require a 
drive control interface other than a hand or chin-operated standard proportional joystick. The request for a 
group 3 power wheelchair with multiple accessories exceeds the enrollee's medical need. 
 
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 special power wheelchair and accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a special power wheelchair (group 3 power wheelchair) with 
two (2) or more power seat options and accessories (K0861, E0956, E1028, E2363, E2605, E1012, E2311, 
E0955, E0953, E0950, E2377, E2313, E1007).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy requirements 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 Prolia. Our reviewer says that the 
requirements for coverage have not been met. Our physician reviewer found the Plan requires a trial of 
zoledronic acid 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 required drugs would likely be less 
effective or 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated wheelchair seat cushion, any size 
(E2609) and custom fabricated wheelchair back cushion, any size (E2617). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the requested accessories are 
medically necessary. The Plan denied your request. The Plan says based on your current status and the 
provision of standard skin protection seating in the approved wheelchair, the Plan does not find adequate 
evidence to overturn the initial determination. 
 
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 you do not have unique needs requiring customized cushions. Your condition allows 
use of standard cushioning. You do not have a unique or unusual body shape or function. You are able to shift 
weight and do not have skin breakdown. 
 
 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 a custom fabricated wheelchair seat cushion, any size (E2609) and custom 
fabricated wheelchair back cushion, any size (E2617).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assay of urine creatinine (82570) and analysis of pH in 
body fluid (83986) provided March 29, 2022. 
 
You asked the Plan to pay for the analysis of creatinine and pH in urine. You say that this testing should be 
covered. The Plan denied your request. The Plan says this testing is not separately billable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the analysis of creatinine and pH in urine have not been met. Specifically, we find that the testing 
described by the billed code is considered specimen validity testing which is not separately payable. Therefore, 
we decided that the Plan does not have to pay for the assay of urine creatinine (82570) and analysis of pH in 
body fluid (83986) provided March 29, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic services (97110) provided on June 3, 2020. You asked the Plan to pay for therapeutic services. You say that these services were medically necessary and 
were billed correctly. The Plan denied your request. The Plan says these services are not supported 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. 
 
We find that CPT code 97110 is not supported in the medical record. Specifically, the documentation shows 
that this claim was billed by a Nurse Practitioner but the therapy services at issue were rendered by a Physical 
Therapist. There is no indication that the Nurse Practitioner was present on site while the therapy services were 
being rendered. The incident-to requirements have not been met in this case. Based on this information, we 
decided that Medicare rules for coverage of therapeutic services have not been met. Therefore, we decided that 
the Plan does not have to pay for therapeutic services (97110) provided on June 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug coded J3490 provided on March 24, 2022. 
 
You asked the Plan to pay for the drug coded J3490. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 90 units of CPT code J3490 are not supported in the medical record. The medical record only 
supports 1 unit of CPT code J3490. Based on this information, we decided that Medicare rules for coverage of 
the drug coded J3490 have not been met. Therefore, we decided that the Plan does not have to pay for the drug 
coded J3490 provided on March 24, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that you would like admission to a rehabilitation facility. The Plan denied your request. The Plan says the criteria for admission to the IRF have not been met.

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 that your medical problems are stable and there are no complex nursing or rehabilitation needs. 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675). 
 
You asked the Plan to pay for a pneumatic compression device. You say that the medical record summary is 
attached to support the use of the pneumatic compression device for treatment of pre/post-surgical 
lymphedema. The Plan denied your request. The Plan says pneumatic compression device is not covered by 
Medicare to prevent deep vein thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (0037U) billed for date of service March 24, 
2022. 
 
You asked the Plan to pay for genetic testing. You say that the services at issue were a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for payment for testing services have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that if the specimen was stored for more than 30 
calendar days before testing, the specimen is considered to have been archived and the DOS of the test/service 
must be the date the specimen was obtained from storage. 
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Specifically, the case record shows that March 24, 2022, is not 
the date of retrieval of the specimen from storage. Therefore, we decided that the Plan does not have to pay for 
genetic testing (0037U) billed for date of service March 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied 
your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 DME. Our physician reviewer 
found as the medical records provided do not adequately document that this enrollee has neuromuscular 
disease, thoracic restrictive disease, or chronic respiratory failure consequent to chronic obstructive pulmonary 
disease, the ventilator at issue in this case does not meet Medicare criteria for medically necessary and 
reasonable for this 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 the DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the home ventilator (CPT code E0466).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the GTC (genomic testing cooperative) Hematology Profile provided 
March 3, 2022. 
 
You asked the Plan to pay for the GTC Hematology Profile. You say that this test was approved by the MolDX 
program and was medically necessary. The Plan denied your request. The Plan says that there are Medicare 
coverage determinations which indicate that panels including the FANCC and BLM genes are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as covered. This determination 
was made and is specific to the test at issue. Though this panel does include genes that another coverage rule 
indicates are non-covered, we find there is no basis to overrule the specific coverage decision made by the 
MolDx contractor for this particular test. Based on this information, we decided that Medicare rules for 
coverage of the GTC Hematology Profile have been met. Therefore, we decided that the Plan has to pay for the 
GTC (genomic testing cooperative) Hematology Profile provided March 3, 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.