Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wound care dressings (A6456, A6454, A6266). 
 
You asked the Plan to pre-approve wound care dressings. You say that the requested wound care bandages are 
necessary. The Plan denied your request. The Plan says the requested wound care dressings are not medically 
necessary. 
 The Plan must follow Medicare rules. The rules state that surgical dressings are covered when a qualifying 
wound is present. A qualifying wound is defined as either of the following: a wound caused by, or treated by, a 
surgical procedure; or after debridement of the wound, regardless of the debridement technique. 
 
The record shows that the Plan made several attempts to obtain information about your wounds from the 
physicians office and the records do not indicate that you met the criteria. The records do not show that the 
wounds were caused or treated by a surgical procedure or after debridement (removal of dead tissue) of a 
wound. Therefore, we decided that the Plan does not have to pre-approve wound care dressings (A6456, 
A6454, A6266).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injections of genvisc 850 (a Medicare Part 
B prescription drug) provided on November 30, 2021, December 06, 2021, December 13, 2021, and December 
20, 2021. 
 
You asked the Plan to waive the coinsurance for the Part B drugs. You say that the amount in question is 
exorbitant and not affordable. The Plan says the coinsurance amounts you are being charged are correct. 
 
 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B prescription drugs. The allowed amounts of these drugs total $3,638, resulting 
in a total coinsurance amount of $727.60. 
 
You have been asked to pay 20% coinsurance for Part B drugs. Part B drugs fall within the Medicare Part B 
prescription drugs benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for injections of 
genvisc 850 provided on November 30, 2021, December 06, 2021, December 13, 2021, and December 20, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient treatment provided on May 18, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient treatment. You say that you were told you did not need an 
authorization and you submitted the claim to get a not covered service denial. The Plan denied your request. 
The Plan says the rendering provider is an out-of-network provider and there was no referral from an in-
network provider or an 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 the outpatient treatment provided on May 18, 
2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 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 compression 
stockings identified with code A6549.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zilretta (CPT code J3304) and the arthrocentesis, 
aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound 
guidance (CPT code 20610).  
You asked the Plan to pre-approve the services. You say that you have already tried steroid injections and they 
did not work. The Plan denied your request. The Plan says you have not tried and failed the preferred drug, 
triamcinolone acetonide injection. 
 
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 the services. Our physician reviewer 
found you have tried and failed "regular corticosteroid injection in the past", but records are incomplete as to 
whether this was the health plan's required drug, generic triamcinolone acetonide. As the provided records do 
not clearly document trial and failure of generic triamcinolone acetonide, it cannot be determined that the plan's 
required drug would likely be less effective and/or likely have adverse effects for you. 
 
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 Zilretta (CPT code J3304) and the arthrocentesis, aspiration and/or injection, major joint or 
bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance (CPT code 20610).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cataract surgery provided on November 3, 
2021. 
 
You asked the Plan to waive the copayment for cataract surgery. You say that you disagree with the copayment 
because the doctor injured your eye during the cataract procedure. The Plan denied your request. The Plan says 
you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 
copayment for outpatient surgery at a freestanding ambulatory surgical center.  
 
 
 You have been asked to pay a $350 copayment for cataract surgery. Cataract surgery falls within the Outpatient 
Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 cataract surgery provided on November 3, 
2021.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Medication assisted treatment provided on January 12, 2021 
to January 26, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Medication assisted treatment. You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says prior authorization is required for an 
out-of-network visit. 
 
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 Medication assisted treatment provided on January 
12, 2021 to January 26, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the criteria for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not treat with 
insulin three or more times per day or use an insulin pump. 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 a continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the cataract surgery provided on November 
22, 2021, and December 6, 2021. 
 
You asked the Plan to waive the copayment for cataract surgery. You say that the provider wanted the money 
right away, so you had to get care credit to pay the copays. The Plan denied your request. The Plan says the 
copayment 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 a $350 
copayment for same-day outpatient surgery in a freestanding ambulatory surgical center.  
 
 You have been asked to pay a total of $700 ($350 copayment x 2 surgeries = $700).  Outpatient surgery falls 
within the 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 the cataract surgeries provided on November 22, 2021, and December 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Mycophenolate 500MG tablet. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee is stable on current medication and 
a change in medication would put the enrollee at risk of organ rejection. The Plan denied your request. The 
Plan says this drug/device is covered by Medicare Part B. The Plan states Medicare rules say tier exceptions 
(co-pay reductions) are not available for drugs/devices covered by Part B. The Plan states Medicare also says 
drugs/devices covered by Part B cannot be covered by Part D. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the medication have not been met. This drug is covered under 
Medicare Part B and tier exceptions are only appropriate for Part D drugs. Therefore, we decided that the Plan 
does not have to pre-approve Mycophenolate 500MG tablet. Benefits for the medication 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve the acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the stay is needed due to the 
enrollee having bleeding in their stomach. The Plan denied your request. The Plan says that the stay is not 
necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the review indicates that the record showed that at the time of inpatient admission the 
admitting physician reasonably expects that the enrollee's necessary hospital care (including earlier ED and/or 
observation care) will span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pre-approve the acute inpatient hospital care.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the MRI provided on September 30, 2021. 
 
You asked the Plan to waive the copayment for MRI. You say that you would like to be reimbursed for the 
payment you made for your MRI. You say that you received a letter stating the MRI would be covered. The 
Plan denied your request. The Plan says the copayment is correct. 
 
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 $0 or 
$225 copayment for Medicare-covered diagnostic radiology services (not including X-rays). $0 copayment for 
mammography and ultrasounds. $225 copayment for all other diagnostic and nuclear medicine radiological 
services. You have been asked to pay $207, which is less than the standard $225 copayment for an MRI. The MRI 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 the MRI provided on September 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve total electric hospital bed. 
 
You asked the Plan to pre-approve total electric hospital bed. You say that the medical records provided will 
show proof of medical necessity. The Plan denied your request. The Plan says this item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve total electric hospital 
bed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the enteral formula (CPT code B4150). 
 
You asked the Plan to pre-approve the enteral formula. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the enteral formula have not been met. The criteria requires that 
feedings via an enteral access device to provide sufficient nutrients to maintain weight, and strength. Full or 
partial non-function or disease of the structures that normally permit food to reach the small bowel; or disease 
that impairs digestion and/or absorption of an oral diet, directly or indirectly by the small bowel. The medical 
documentation does not show that the enrollee meets the criteria. Therefore, we decided that the Plan does not 
have to pre-approve the enteral formula (CPT code B4150).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transport trips (A0120). 
 
You asked the Plan to pre-approve the additional routine transport trips. You say that the additional trips are 
medically necessary. The Plan denied your request. The Plan says the benefit has been exhausted. 
 
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 60 trips per year.  
 
We looked at your request, the records in the case file, and the rules. 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 transport trips (A0120).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis 5MG tablet. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the requested drug is intended for patient self-administration'. 
 
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 5MG tablet.  
 Benefits for the medication 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre 14-day sensor. 
 
You asked the Plan to pre-approve the sensor. You say that the enrollee needs the sensor because the enrollee 
fears needle sticks. The Plan denied your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 
 
 We looked at the file and Medicare rules. The documentation does not show that the enrollee is using insulin 
shots three (3) or more times a day or is using an insulin pump. Based on this information, we decided that 
Medicare rules for coverage of the sensor have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Freestyle Libre 14-day sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Individual Psychotherapy provided on December 10, 2021 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Individual Psychotherapy. You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the provider is out-of-network and it 
was determined these services were 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 Individual Psychotherapy provided on December 
10, 2021 by an out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Genvisc 850 Soln Pref Syr 25MG/2.5ML (CPT code 
J7320). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the documentation does not show a record from the enrollee's prescriber that shows they have tried one of the preferred drugs (Orthovisc, Synvisc or Synvisc One), or that the enrollee has medical 
reasons that prevent the enrollee from using one of them. 
 
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 the medication. Our physician reviewer 
found the Plan requires a trial of drug Orthovisc, Synvisc or Synvisc One, before they will approve the 
requested drug. In this case, the enrollee has not tried and failed the required drug(s). There is no 
documentation provided indicating that the plans required drug(s) 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Genvisc 850 Soln Pref Syr 25MG/2.5ML (CPT code J7320).