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

 
We decided that the Plan does not have to pre-approve Supartz FX. 
 
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 step therapy requirement is not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has right knee 
osteoarthritis. She has not tried and failed the Plan's required drug, Synvisc-One. The records do not show that 
the required drug would be contraindicated or less effective; therefore, Supartz FX is not reasonable or 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Supartz FX.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee scooter (CPT code E0118). 
 
You asked the Plan to pre-approve a knee scooter. You say that you have an upcoming foot surgery and are 
requesting a crutch substitute for use post-surgery. You state the hallways in your home are not wide enough 
for a wheelchair, and you will not be able to use a cane or a walker. The Plan denied your request. The Plan 
says there is insufficient published clinical literature demonstrating safety and effectiveness in the Medicare 
population to establish medical necessity for these products. 
 
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 a knee scooter. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is insufficient published clinical literature demonstrating safety and effectiveness in the 
Medicare population to establish the medical necessity for this product. The review has determined that the 
items/services at issue in this case are not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a knee scooter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee scooter (CPT code E0118).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laparoscopic sacrocolpopexy (57425) provided December 
14, 2021. 
 
You asked the Plan to pay for the surgical procedure. You say that due to network insufficiency, the out of 
network provider was the only available assistant at the time of the procedure and rendered services 
specifically requested by the in-network primary physician in an in-network facility. The Plan denied your 
request. The Plan says this provider is non-participating and is not eligible for enrollment with Medicare. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for laparoscopic sacrocolpopexy 
(57425) provided December 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One. 
 
You asked the Plan to pre-approve Gel-One. You say that steroids do not work anymore. The Plan denied your 
request. The Plan says you have not tried and failed Euflexxa. 
 
 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 Gel-One. Our physician reviewer found 
that you have pain related to osteoarthritis of the right knee, diagnosis confirmed with imaging studies. You 
have failed conservative treatment. A Gel-One injection has been requested. The Plan requires a trial of 
Euflexxa before they will approve the requested drug. There is no indication that the Plan's required drug 
would likely be less effective or likely have adverse effects. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Oxygen equipment (E0431, E1390) 
provided on November 22, 2020. 
 
You asked the Plan to waive the copayment for the oxygen equipment. You say that the services should be 
covered as you disagree with the charges, were not made aware of them, and they accumulated over time. The 
Plan denied your request. The Plan says the coinsurance applied correctly based on the services provided. 
 
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 Durable Medical Equipment (DME) and related supplies.  
 
 
  You have been asked to pay a 20% coinsurance for the oxygen equipment (allowed is $112.82 x 20% = 
$22.57). the oxygen equipment 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 copayment for Oxygen equipment (E0431, E1390) provided 
on November 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an interprofessional telephone/Internet/electronic health 
record assessment provided on March 9, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an interprofessional telephone/Internet/electronic health record assessment. You 
say that you would like to request reconsideration of the denied claim. The Plan denied your request. The Plan 
says the provider is out-of-network, and it was determined these services can be received in-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 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 interprofessional telephone/Internet/electronic 
health record assessment provided on March 9, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (82310, 82728, 83540, 83550, 83970, 84100) 
provided January 12, 2022. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the billed codes are not separately payable. 
 
 
 
 
 
 
 The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
lab services (82310, 82728, 83540, 83550, 83970, 84100) provided January 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a drug test provided on February 11, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a drug test. You say that you would like to request reconsideration of the denied 
claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was determined these 
services can be received in-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 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 a drug test provided 
on February 11, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Oxygen equipment (E0431, E1390) 
provided on April 22, 2020. 
 
You asked the Plan to waive the copayment for the oxygen equipment. You say that the services should be 
covered as you disagree with the charges, were not made aware of them, and they accumulated over time. The 
Plan denied your request. The Plan says the coinsurance applied correctly based on the services provided. 
 
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 Durable Medical Equipment (DME) and related supplies.  
 
 
  You have been asked to pay a 20% coinsurance for the oxygen equipment ($136.32 x 20% = $27.26). Oxygen 
equipment 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 copayment for Oxygen equipment (E0431, E1390) provided on April 22, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the total electric hospital bed (CPT code E0265). 
 
You asked the Plan to pre-approve the total electric hospital bed. You say that you are going to have spine 
surgery on July 1st, and you have to have 4 sections in your spine that needs to be worked on. You state that 
you cannot get in and out of a regular flat bed, so you need a hospital bed to be able to move around. The Plan 
denied your request. The Plan says your request is not a covered benefit. 
 
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 total electric hospital bed have not been met. The rules say a 
total electric hospital bed (E0265, E0266, E0296, and E0297) is not covered; the height adjustment feature is a 
convenience feature. Total electric beds will be denied as not reasonable and necessary. Therefore, we decided 
that the Plan does not have to pre-approve the total electric hospital bed (CPT code E0265).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve portable oxygen concentrator (CPT code E1392). 
 
You asked the Plan to pre-approve portable oxygen concentrator. You say that the enrollee needs the portable 
oxygen concentrator to be able to get around for the stores, etc. The Plan denied your request. The Plan says the 
physician review of the information provided has determined that the equipment provided to the enrollee 
continues to adequately meet the enrollee's medical need. 
 
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 portable oxygen concentrator have not been met. The Plan 
provided you with a portable oxygen homefill system on May 5, 2022. The Plan does not cover duplicate or 
redundant durable medical equipment such as oxygen device when the second item performs the same function as the one currently provided to the enrollee. Therefore, we decided that the Plan does not have to pre-approve 
portable oxygen concentrator (CPT code E1392).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a cervical traction device provided from 
January 17, 2022, to March 17, 2022. 
 
You asked the Plan to waive the coinsurance for the traction device. You say that your contract ended 
December 2021, and you should not have payments after that. The Plan denied your request. The Plan says the 
correct coinsurance was applied. 
 
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 10% 
coinsurance for durable medical equipment (DME) items and supplies. 
 
Item Allowed Amount 10% Coinsurance 
Traction Device  January 17, 2022 $59.99 $6.00 
Traction Device  February 17, 2022 $59.99 $6.00 
Traction Device  March 17, 2022 $59.99 $6.00 
Total:  $18.00 You have been asked to pay a total of $18.00, which is 10% of the allowed amount for the traction device. The 
traction device falls within the Durable Medical Equipment (DME) and Related Supplies benefit category. 
Please note that the Plan does not have jurisdiction over contracts made directly with the provider. 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 a cervical traction device provided from January 17, 2022, to March 
17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Oxygen equipment (E0431, E1390) 
provided on October 22, 2020. 
 
You asked the Plan to waive the copayment for the oxygen equipment. You say that the services should be 
covered as you disagree with the charges, were not made aware of them, and they accumulated over time. The 
Plan denied your request. The Plan says the coinsurance applied correctly based on the services provided. 
 
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 Durable Medical Equipment (DME) and related supplies.  
 
You have been asked to pay a 20% coinsurance for the oxygen equipment (allowed is $115.50 x 20% = 
$23.10). Oxygen equipment 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 copayment for Oxygen equipment (E0431, E1390) provided 
on October 22, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 15, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says records were not 
provided from the ordering provider. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering 
physicians intent that the testing be performed. Based on this information, we decided that Medicare rules for 
coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
genetic testing provided on March 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CPM exercise device (CPT code E0936). 
 
You asked the Plan to pre-approve the CPM. You say that you have ordered a shoulder CPM to be used. The 
Plan denied your request. The Plan says this is to be used for the enrollees rotator cuff surgery and not a total 
knee replacement. 
 
The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have 
received total knee replacement surgery. 
 
The enrollee has not had total knee replacement surgery. Therefore, we decided that the Plan does not have to 
pre-approve a CPM exercise device (CPT code E0936).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom breast prosthesis, post mastectomy, molded to 
patient model (CPT code L8035). 
 
You asked the Plan to pre-approve the custom breast prosthesis. You say that you are requesting a custom 
molded prosthesis due to the concave nature of your chest following surgery. The Plan denied your request. 
The Plan says the request for a custom molded breast prosthesis is not medically necessary. 
 
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 custom breast prosthesis have not been met. The rules say that 
the medical necessity for the additional features of a custom fabricated prosthesis (L8035) compared to a 
prefabricated silicone breast prosthesis has not been established, and therefore, if an L8035 breast prosthesis is 
billed, it will be denied as not reasonable and necessary. Therefore, we decided that the Plan does not have to 
pre-approve custom breast prosthesis, post mastectomy, molded to patient model (CPT code L8035).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Oxygen equipment (E0431, E1390) 
provided on May 22, 2020. 
 
You asked the Plan to waive the copayment for the oxygen equipment. You say that the services should be 
covered as you disagree with the charges, were not made aware of them, and they accumulated over time. The 
Plan denied your request. The Plan says the coinsurance applied correctly based on the services provided. 
 
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 Durable Medical Equipment (DME) and related supplies.  
 
 
  You have been asked to pay a 20% coinsurance for the oxygen equipment (allowed is $136.32 x 20% = 
$27.26). Oxygen equipment 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 copayment for Oxygen equipment (E0431, E1390) provided 
on May 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assistant at surgery services for a surgical inguinal hernia 
repair (49650) provided on August 13, 2021. 
 
You asked the Plan to pay for assistant at surgery services. You say that due to network insufficiency the out-
of-network provider was the only available assistant at the time of the procedure. The Plan denied your request. 
The Plan says rules for payment for an assistant at surgery have not been met. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for assistant at surgery services for a 
surgical inguinal hernia repair (49650) provided on August 13, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the 2 coronavirus test kits purchased on January 1, 
2022. 
 
You asked the Plan to reimburse you for the 2 coronavirus test kits. You say that you purchased 2 coronavirus 
test kits in January. You say that you felt you may have had it. You also say that you would like to be 
reimbursed for these test kits. The Plan denied your request. The Plan says test kits purchased prior to January 
15, 2022, are not eligible for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that [insert custom text from glossary].  
 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the 2 coronavirus test kits have not been met. Specifically, the file shows that the test kits were 
purchased prior to January 15, 2022, and therefore are not covered. Therefore, we decided that the Plan does 
not have to reimburse you for the 2 coronavirus test kits purchased on January 1, 2022.