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

 
We decided that the Plan does not have to pre-approve Livalo. 
 
You asked the Plan to pre-approve Livalo. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Livalo.  
 
Benefits for Livalo 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 additional chiropractic visits. 
 
You asked the Plan to pre-approve additional chiropractic visits. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
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 additional chiropractic visits. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the record indicates 
that you have had chiropractic care. The record indicates that the requested treatment is maintenance therapy 
and is insufficient to suggest that further treatment is not reasonably expected. The elements of the coverage 
criteria are not satisfied. The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional chiropractic visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional chiropractic visits.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on February 15, 2022. 
 
You asked the Plan to pay for psychotherapy services. You say that this doctor knows everything about your 
needs and you do not want to go through all of your past with a new provider. The Plan denied your request. 
The Plan says this provider does not accept Medicare assignment. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
psychotherapy services provided on February 15, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron. 
 
You asked the Plan to pre-approve Ondansetron. You say that this is medically necessary. The Plan denied 
your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug 
plan. 
 
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 Ondansetron.  
 
Benefits for Ondansetron 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 naturopathic services provided on February 15, 2022. 
 
You asked the Plan to pay for naturopathic services. You say that you have seen traditional doctors over the 
years for a variety of health problems stemming from inflammation in your body. You say that you have been 
very sick, but the doctors you have seen have not gotten to the root of the problem and since seeing this 
provider you have made vast improvements to your well-being. The Plan denied your request. The Plan says 
your request is not a covered benefit because your records show you did not receive the office visit services 
from a Medicare approved practitioner. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services.  
 
The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have 
to pay for naturopathic services provided on February 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the rollator basket (CPT code A9270). 
 
You asked the Plan to pre-approve the rollator basket. You say that you feel as though the services are a 
covered benefit. The Plan denied your request. The Plan says the basket is not necessary and not covered. 
 
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 the rollator basket (CPT code A9270).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyaluronan or derivative, monovisc, for intra-articular 
injection, per dose (CPT code J7327), arthrocentesis, aspiration and/or injection, major joint or bursa (eg, 
shoulder, hip, knee, subacromial bursa); without ultrasound guidance (CPT code 20610) and arthrocentesis, 
aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound 
guidance, with permanent recording and reporting and (CPT code 20611). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says your request is not medically necessary because the enrollee's records show 
that this procedure has been ineffective in the past. 
 
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 items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documentation that support that the Monovisc injection at issue in this case meets Medicare criteria for medically reasonable and necessary per Social Security Act, Section 1862(a)1(A). 
Provided records do not document that there was a significant improvement in pain and functional capacity 
achieved with the prior Monovisc injection to support a repeat injection. 
 
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 hyaluronan or derivative, monovisc, for intra-articular injection, per dose (CPT code 
J7327), arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial 
bursa); without ultrasound guidance (CPT code 20610) and arthrocentesis, aspiration and/or injection, major 
joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording 
and reporting and (CPT code 20611).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided on July 28, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the SNF services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and prior 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 skilled nursing facility (SNF) services provided on 
July 28, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve an amalgam (D2150) for tooth #20. 
 
You asked the Plan to pre-approve an amalgam for tooth #20. You say that a crown is necessary and the only 
clinically acceptable method of treatment. The Plan denied your request. The Plan says that the requested 
service for tooth #20 is not clinically necessary. 
 
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. The Plan covers an amalgam 
for tooth #20 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 an amalgam for tooth #20. Our 
reviewer says that the documentation provided meets the criteria for coverage for a two-surface restoration 
(D2150) for tooth #20. Our physician reviewer found there is a two-surface restoration on tooth #20 which is 
defective. Our reviewer found that the replacement of this restoration with another restoration is the standard of 
care. Our physician reviewer also found that a crown restoration would not meet the criteria for coverage. 
 
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 an amalgam for tooth #20 have been met. Therefore, we decided that the Plan 
has to pre-approve an amalgam (D2150) for tooth #20.  
 
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 foot and ankle prosthetic equipment (L5972, L5986) 
provided on September 2, 2021. 
 
You asked the Plan to pre-approve the foot and ankle prosthetic equipment. You say that you would like this 
claim reprocessed and approved for payment. The Plan denied your request. The Plan says this claim was not 
billed as required by Medicare rules.  
The Plan must follow Medicare rules. Medicare rules say that when submitting a prosthetic claim, the billed 
code for knee, foot, ankle and hip components must be submitted with modifiers K0 - K4, indicating the 
expected beneficiary functional level. 
 
We looked at the file and Medicare rules. In this case, the foot and ankle equipment coded L5972 and L5986 
were not billed with the appropriate modifier as required for payment. Based on this information, we decided 
that Medicare rules for coverage of the foot and ankle prosthetic equipment have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the foot and ankle prosthetic equipment (L5972, L5986) 
provided on September 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oncology (prostate) gene expression profile by real-time 
RT-PCR of 3 genes (ERG, PCA3, and SPDEF), urine, algorithm reported as risk score (CPT code 0005U). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the request for this testing is not medically necessary since the PSA level is greater than 
10 ng/ml and there is treatment indicating concern for active prostatitis. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the request for this testing is not medically necessary since the PSA level is greater than 10 
ng/ml and there is treatment indicating concern for active prostatitis. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve oncology (prostate) gene expression profile by real-time RT-PCR of 3 genes (ERG, PCA3, 
and SPDEF), urine, algorithm reported as risk score (CPT code 0005U).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a hospital outpatient clinic visit provided 
on March 2, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to waive the copayment for hospital outpatient clinic visit. You say that you would like to 
request reconsideration for payment. The Plan denied your request. The Plan says the cost share applied is 
correct. The members deductible hadnt been met for the year 2022. 
 
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 $95 
copayment for a hospital outpatient clinic visit.  
 
You have been asked to pay a $95 copayment for hospital outpatient clinic visit. Hospital outpatient clinic 
visits fall within the hospital outpatient hospital services 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 a hospital outpatient clinic visit provided on March 2, 2022 by an out-of-network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99213) provided on December 7, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and prior 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 an office visit (99213) provided on December 7, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on December 17, 2020. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says a corrected 
claim must be submitted within 1 year from the date of the initial determination. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for physician's services was not filed until February 18, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on December 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an oxygen concentrator on March 10, 
2022. 
 
You asked the Plan to waive the coinsurance for an oxygen concentrator. You say that you believe that you 
don't owe anything for this service. The Plan denied your request. The Plan says according to the member's 
EOC, the enrollee is responsible for 20% of the allowed amount for Medicare covered Durable Medical 
Equipment (DME) and related supplies. 
 
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 20% 
coinsurance for an oxygen concentrator. The allowed amount was $65.70, the plan paid $52.56, and the 
enrollee responsibility is $13.14 (20% of $65.70). 
 
You have been asked to pay a 20% coinsurance for an oxygen concentrator. An oxygen concentrator falls 
within the Durable medical equipment (DME) and related 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 coinsurance for an oxygen concentrator on March 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 very heavy duty power wheelchair (K0827). 
 
You asked the Plan to pre-approve a Group 2 very heavy duty power wheelchair. You say that the requested 
item is a medical necessity for you. The Plan denied your request. The Plan says medical necessity rules for 
coverage of a replacement for your previously issued bariatric wheelchair have not been met. 
 
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 Group 2 very heavy duty power 
wheelchair. Our reviewer says that the requested item is not medically necessary and reasonable in this case. 
Our physician reviewer found that the documentation does not support that you require a drive control interface 
other than a hand or chin-operated standard proportional joystick or meet coverage criteria for a power tilt or a 
power recline seating system.  
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 Group 2 very heavy duty power wheelchair have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Group 2 very heavy duty power wheelchair (K0827).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gradient compression stockings identified with code 
A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that you are requesting a 
reconsideration of the Plan's denial. The Plan denied your request. The Plan says this item is not a covered 
benefit under your contractual policy or by Medicare for your condition. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
 Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve gradient 
compression stockings identified with code A6530.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hysterectomy. 
 
You asked the Plan to pre-approve hysterectomy. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 hysterectomy. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided record is not sufficient to establish the medical necessity of the requested service. 
The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, 
of the requested service. The elements of the coverage criteria are not satisfied. The requested service is not 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hysterectomy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve hysterectomy.