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

 
We decided that the Plan does not have to waive the copayment for a CT scan provided on  
September 24, 2021. 
 
You asked the Plan to waive the copayment for the CT scan. The Plan denied your request. The Plan says the 
members Evidence of Coverage under advanced imaging services has a $180 copay. The allowed amount on 
the claim for these services is $137.37 so the member responsibility is $137.37. 
 
  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 $180 
copayment for outpatient diagnostic tests and therapeutic services and supplies, Advanced Imaging Services.  
 
You have been asked to pay less than the $180 copayment for the CT scan. The CT scan falls within the 
outpatient diagnostic tests and therapeutic services and supplies, Advanced Imaging 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 CT scan provided on September 24, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Supartz (J7321). 
 
You asked the Plan to pre-approve Supartz. You say that this drug is medically reasonable and necessary for 
the enrollee's condition. The Plan denied your request. The Plan says step therapy criteria 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 Supartz. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the Plan requires a 
trial of Orthovisc, Synvisc, or Synvisc-One before they will approve the requested drug. Has the patient tried 
and failed the required drug(s). In this case, the patient has not tried and failed the required drug(s), and the 
plans required drug(s) would not 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 Supartz have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Supartz (J7321).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor transmitter. 
 You asked the Plan to pre-approve the Dexcom G6 continuous glucose monitor transmitter. You say that this 
continuous glucose monitor is medically necessary. The Plan denied your request. The Plan says this brand is 
non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. 
 
We looked at the file and Medicare rules. There is no clinical documentation showing why the plan preferred 
continuous glucose monitor would be unsafe or ineffective for this enrollee. Based on this information, we 
decided that Medicare rules for coverage of the Dexcom G6 continuous glucose monitor transmitter have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose 
monitor transmitter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) scan of the head and brain. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says the doctor says that this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found that in this case, the 
record indicates that the enrollee has tinnitus. The record indicates that magnetic resonance imaging (MRI) has 
been approved. The record does not indicate why both studies would be needed, or why the CT scan would be 
the preferred test. The provided records do not indicate the medical necessity or reasonableness, as defined by 
Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. 
 
 
 
 
 
 
 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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve computed tomography (CT) scan of the head and brain.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ophthalmology visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the ophthalmology visit. You say that you want to continue with this 
provider because he is familiar with your multiple eye issues. The Plan denied your request. The Plan says the 
provider is out-of-network. 
 
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. The records provided for review do not show that the service at 
issue is urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve the 
ophthalmology visit to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition 3 miles for a total of 53 miles. 
 
You asked the Plan to pre-approve additional mileage. You say that you only have 12 one-way trips with your 
plan. You say that you have no transportation to get to and from appointments. You say that you have already 
exhausted your transportation benefit. You also say that you need more rides. The Plan denied your request. 
The Plan says 12 one-way trips are covered per year. The Plan also says that each one-way trip must not exceed 
50 miles of driving distance.  
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 routine transportation when each one-way trip must not exceed 50 miles of driving 
distance. 
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, the file shows that 
trips exceeding 50 miles driving distance are not covered. Additionally, the record shows that only 2 of the 12 
one-way trips have been used for 2022. Therefore, we decided that the Plan does not have to pre-approve an 
addition 3 miles for a total of 53 miles.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99215) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that since transferring care to this provider, you 
have received higher quality care and have had no further hospitalizations and no further complications. The 
Plan denied your request. The Plan says the medical care you require can be provided by a network provider. 
The Plan also says that after reviewing your appeal and the available medical records, they determined that a 
network provider can care for your medical problem. 
 
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 
an office visit (99215) to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the 100mg Cyclosporine capsules. 
 
You asked the Plan to pre-approve the Cyclosporine capsules. You say that you would like reconsideration 
because the requested drug is medically necessary. The Plan denied your request. The Plan says this drug is not 
covered under Medicare Part B. 
 
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 the 100mg Cyclosporine 
capsules.  
 Benefits for the Cyclosporine capsules 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of bone marrow aspirate in the setting of spinal 
fusion surgery has not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found bone marrow aspiration is experimental, and more research is needed. 
 
 
 
 
 
 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 bone marrow aspirate for the enrollee.
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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 the enrollee does not need intensive therapies, consisting of at least 3 hours of 
therapy per day at least 5 days per week with multidisciplinary approach to daily therapy in an IRF. The 
enrollee's rehab can be safely provided at a lower intensity and alternate setting in in-home with therapy and 
supervision or in a skilled nursing facility with intermittent therapies. 
 
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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day reader. 
 
You asked the Plan to pre-approve a Freestyle Libre 14-day reader. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the member has already received this item. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee has a continuous glucose monitor (CGM). A continuous glucose monitor 
(CGM) serves the same purpose as a Freestyle Libre 14 day reader. Therefore, we decided that the Plan does 
not have to pre-approve a Freestyle Libre 14-day reader.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) scan with calcium scoring. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says this would be considered screening. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the scan. Our reviewer says that the 
requested screening is not medically reasonable or necessary. Our physician reviewer found the record 
indicates that the enrollee has hyperlipidemia without cardiac symptoms. The provided records do not indicate 
how the requested service would impact enrollee management. The provided records do not indicate the 
medical necessity or reasonableness, as defined by Medicare rules, of the requested service. The elements of 
the coverage criteria are not satisfied. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve computed tomography (CT) scan with calcium scoring.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Purewick catheter. 
 
You asked the Plan to pre-approve incontinence supplies. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is unproven and not medically necessary. 
 
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 catheter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral to a dermatologist for the 
enrollee. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says this request can be redirected to a network provider. 
 
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 
an out-of-network referral to a dermatologist for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acupuncture therapy and massage therapy for right 
hand pain. 
 
You asked the Plan to pre-approve the acupuncture and massage therapy services. You say that the Plan has 
sent three different notices for basically the same medical problem so now your case worker is going to need to 
file three different appeals. The Plan denied your request. The Plan says acupuncture is not covered for the 
treatment of hand pain. Massage therapy is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
Medicare does not cover the services of a massage therapist. However, for services provided on or after 
January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain 
requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan 
offers coverage beyond the Medicare acupuncture benefit. As such, the Plans rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, acupuncture is not covered for hand pain. Massage 
therapy is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve the 
acupuncture therapy and massage therapy for right hand pain.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 
You asked the Plan to pre-approve Evenity. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the clinical value and effectiveness of Evenity in the setting of osteoporosis in a 
male patient have not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Evenity. Our reviewer says that Evenity 
is not medically reasonable and necessary. Evenity is not FDA-approved for your diagnosis. Its use is not 
supported by one of the major drug compendia or by clinical research that appears in a Centers for Medicare & 
Medicaid Services approved medical journal. Our physician reviewer found that your condition does not meet 
criteria for coverage of Evenity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis tablet. 
 
You asked the Plan to pre-approve Eliquis. You say that the requested drug is necessary. The Plan denied your 
request. The Plan says the requested drug is considered self-administered. The Plan says self-administered 
drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not 
covered under Medicare Part B. 
 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 tablet.  
 
Benefits for Eliquis may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee can safely receive the services she needs in other settings. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for a femur fracture after a fall. The enrollees medical problems are stable. There are no complex nursing or rehabilitation needs. 
The patient does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not 
a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition 
does not meet Medicare criteria for IRF 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 inpatient rehabilitation facility (IRF) admission and services for the enrollee.