Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 2, 2021, by an OON 
provider. 
 
You asked the Plan to pay for the office visit. You say that you did not obtain a prior authorization and it was 
medically necessary to treat the enrollee. The Plan denied your request. The Plan says the rendering and 
referring providers are both OON providers and there was no approved authorization. Also, the service 
rendered was not urgent or emergent. 
 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 provided on November 2, 2021, by 
an OON provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Gelsyn-3 (J7328). 
 
You asked the Plan to pre-approve Gelsyn-3. 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 Gelsyn-3. 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. The enrollee 
has not tried and failed the required drugs. The available documentation does not support that Orthovisc or 
Supartz FX would likely be less effective, and/or would likely have adverse effects 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 Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Gelsyn-3 (J7328).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an OON 
provider. 
 
You asked the Plan to pre-approve the specialist office visit. You say that you could not get ahold of any in-
network providers and the OON provider can do everything you need in 1 visit. The Plan denied your request. 
The Plan says there are multiple in-network providers that are accepting new patients and they are within the 
allowed service area. 
 
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 to be provided by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve brachioplasty and subcutaneous fat liposuction and 
excision, excessive skin and subcutaneous tissue (includes lipectomy) of the upper extremity. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says based on the records, the liposuction and lipectomy in the setting of excessive skin of 
the upper extremity without complicating factors is not a reconstructive procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our reviewer found the records indicate that there 
is no functional impairment, and no evidence of intertrigo from the excessive upper arm skin due to weight 
loss. The elements of the coverage criteria are not satisfied. The requested service cannot be 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve brachioplasty and subcutaneous fat liposuction and excision, excessive skin and 
subcutaneous tissue (includes lipectomy) of the upper extremity.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the F2 and F5 genetic testing services. 
 
You asked the Plan to pre-approve the F2 and F5 genetic testing services. You say that this testing is medically 
reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing of the F2 and F5 genes for all risk 
factors, signs, symptoms, diseases, or conditions, including cardiovascular risk assessment, are non-covered 
except for pregnant patients. Based on this information, we decided that Medicare rules for coverage of the F2 
and F5 genetic testing services have not been met. Therefore, we decided that the Plan does not have to pre-
approve the F2 and F5 genetic testing services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oxygen equipment. 
 
You asked the Plan to pre-approve the requested services. You say that oxygen equipment is no longer capped. 
The Plan denied your request. The Plan says the rental period is capped. 
 
The Plan must follow Medicare rules. The rules say that there is no further payment for oxygen equipment after 
36 rental payments have been made.    
 
We looked at the file, and Medicare rules. The records show that 36 rental payments were made between July 
2018, and July 2021. The supplier who provided the equipment during the 36th rental month is required to 
continue to provide the equipment, accessories, contents (if applicable), maintenance, and repair of the oxygen 
equipment during the 5-year reasonable useful lifetime of the equipment. Based on this information, we 
decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve oxygen equipment.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an OON 
provider. 
 
You asked the Plan to pre-approve the specialist office visit. You say that you would like a second opinion 
from the OON provider. The Plan denied your request. The Plan says the enrollee has already had a second 
opinion and an in-network provider has been approved which provides the same quality of service. 
 
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 to be provided by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional trips. You say that you require dialysis 3 times per week. The 
Plan denied your request. The Plan says your benefit only allows 72 trips for this service. 
 
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 72 one-way trips per year.  
 
 
 We looked at your request, the records in the case file, and the rules. The file shows that you have used 72 trips 
this year. Based on this information, we decided that you have exhausted the Plan maximum benefit for 
coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional 
routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve initial lymphedema therapy. 
 
You asked the Plan to pre-approve initial lymphedema therapy. You say that this treatment is medically 
necessary for your condition. The Plan denied your request. The Plan says records do not indicate you have a 
diagnosis of lymphedema. 
 
The Plan must follow Medicare rules. Medicare rules say that a diagnosis of lymphedema is required for 
lymphedema treatment to be covered. 
 
We looked at the file and Medicare rules. In this case, there is no diagnosis of lymphedema presented. Based 
on this information, we decided that Medicare rules for coverage of initial lymphedema therapy have not been 
met. Therefore, we decided that the Plan does not have to pre-approve initial lymphedema therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat. 
 
You asked the Plan to pre-approve a raised toilet seat. You say that this item is necessary for your condition. 
The Plan denied your request. The Plan says this considered a non-covered hygiene item. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve upper eyelid blepharoplasty (15823). 
 
You asked the Plan to pre-approve upper eyelid blepharoplasty. You say that this is medically necessary. The 
Plan denied your request. The Plan says the requirements for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that upper eyelid blepharoplasty is covered when 
overhanging skin or upper lid position secondary to dermatochalasis, blepharochalasis, blepharoptosis, or 
pseudoptosis is sufficiently low to produce a visually significant field restriction considered by this policy to be 
approximately 30 degrees or less from fixation. Published literature correlates this amount of field restriction 
with a Margin Reflex Distance (MRD) or pseudo-MRD of 2.0 millimeters (mm) or less.  
We looked at the file and Medicare rules. The submitted records show that both eyes have a MRD and pseudo-
MRD that is greater than 2 mm. Based on this information, we decided that Medicare rules for coverage of 
upper eyelid blepharoplasty have not been met. Therefore, we decided that the Plan does not have to pre-
approve upper eyelid blepharoplasty (15823).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a duplex scan provided on December 16, 
2021. 
 
You asked the Plan to waive the copayment for a duplex scan. You say that you would like the plan to 
reconsider their decision and have them cover this claim. The Plan denied your request. The Plan says you have 
been charged the correct copayment amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $160 
in-network copayment for Medicare-covered non-radiological diagnostic services, not including x-rays, 
performed in a physician's office or at a free-standing facility (such as radiology center or medical clinic).   
You have been asked to pay $87.91, which is less than the standard $160 in-network copayment for a duplex 
scan. The duplex 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 copayment for a duplex scan provided on 
December 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for the Part B drugs and laboratory services from 
October 23, 2021 to October 24, 2021. 
 
You asked the Plan to waive the cost for the Part B drugs and laboratory services. You say that you were 
inpatient at this time. The Plan denied your request. The Plan says you have been charged the correct 
copayment amounts. 
 
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 part B drug and a $25 copayment for lab services.  
 
 
  You have been asked to pay a total of $356.53 for the Part B drugs and laboratory services. 
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
October 23, 2021 Part B Drug $570.00 $456.00 114.00 
October 23, 2021 Laboratory services $28.00 $3.00 $25.00 
October 24, 2021 Part B Drug $962.63 $770.10 192.53 
October 24, 2021 Laboratory services $28.00 $3.00 $25.00 
TOTAL    $356.53 
 
The Part B drugs fall within the Medicare Part B prescription drugs benefit category and the laboratory 
services fall 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 for the Part B drugs and laboratory services from October 23, 2021 to 
October 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the injections and office visit provided on 
July 10, 2020 and August 11, 2020. 
 
You asked the Plan to waive the cost share for the injections and office visit. You say that the cost of the 
medication is astronomical.  You say that you would have never considered the medication without being 
assured you had a grant from an osteoporosis company. The Plan denied your request. The Plan says the cost 
share applied 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 10% 
coinsurance for part B covered chemotherapy drugs administered at non-hospital-affiliated facilities and a $20 
copayment for a specialist physician office visit. 
 
 
 You have been asked to pay a total of $400.10 for the injections and office visit.  
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
July 10, 2020 Injection $1900.50 $1710.45 $190.05 
August 11, 2020 Office Visit $177.00 $78.77 $20.00 
August 11, 2020 Injection $1900.50 $1710.45 $190.05 
TOTAL:    $400.10 
 
The injections fall within the Medicare Part B prescription drugs benefit category. The office visit falls 
within the Physician/Practitioner services, including doctors office visits 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 the injections and office visit provided on July 10, 2020 and August 
11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Flexitouch pneumatic compression device for the 
enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says a trial of a basic pump must be documented in the medical record. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found an addendum to a podiatry note dated 12/31/2021 reports lymphedema of the abdomen but the physical 
examination for this note only reports swelling of the lower extremities. As the enrollee has not failed an 
adequate 4 week trial of a standard pump as required by the Local Coverage Determination (LCD): Pneumatic 
Compression Devices (L33829), it cannot be said that the enrollee has unique characteristics that would 
indicate the segmented pump over a standard pump. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Flexitouch pneumatic compression device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Purewick urinary catheter (K1006). 
 
You asked the Plan to pre-approve incontinence supplies. You say that the enrollee is fully incontinent at all 
times with urine 24 hours a day, 7 days per week, which includes sleep time. This the absolute need for the 
overnight use of the Purewick. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve a Purewick urinary catheter 
(K1006).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH admission is medically 
necessary. The Plan denied your request. The Plan says the enrollee's medical needs are being met in the 
current acute setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found all medically necessary care is being provided in the current acute care facility. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
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 medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital on May 1, 2022 after a fall with left elbow fracture. She was discharged home but returned to the 
emergency department on May 18, 2022 after another fall. She had no acute injuries and was discharged the 
same day. She is medically stable and able to ambulate with no distress or difficulty. She does not require close 
supervision of a physical medicine and rehabilitation physician three times per week for the ongoing 
management of any active or acute exacerbations of chronic medical conditions. While she may benefit from 
further therapy, she does not require an intensive therapy program in an IRF. 
 
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 inpatient rehabilitation facility (IRF) admission and services.