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

 
We decided that the Plan does not have to pre-approve hemochromatosis (HFE) genetic testing services 
(81256). 
 You asked the Plan to pre-approve HFE genetic testing services. You say that this is medically necessary for 
the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage of the genetic 
testing services have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve HFE genetic testing services. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the review has determined that the enrollee does not satisfy the coverage 
criteria for the requested HFE genetic testing service. These services otherwise 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 HFE genetic testing services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve hemochromatosis (HFE) genetic testing services (81256).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services provided on July 7, 2021. 
 
You asked the Plan to pay for the services provided. You say that you had this visit when on vacation. The Plan 
denied your request. The Plan says the claim was processed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. We find that evaluation and management code 99281 was billed along with 
a chest x-ray, coded 71045. CPT code 71045 has a status indicator of S, which means a modifier 25 is needed 
on the evaluation and management code.  Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the emergency room services provided on July 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the determination of refractive state (92015) provided 
on July 26, 2021. 
 You asked the Plan to pre-approve the determination of refractive state. You say that you would like the Plan to 
pay for this service. The Plan denied your request. The Plan says this vision service is not covered by your 
medical plan. The Plan also says that you did not have Optional Supplemental Benefits for vision during the 
date of service. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers eye refractions when you are enrolled in the optional supplemental plan for vision 
care. 
 
We looked at the file and the Plan's rules. You were not enrolled in an optional supplemental benefit for vision 
on this date of service, and eye refractions are not covered under original Medicare vision care. Based on this 
information, we decided that the Plan's rules for coverage of the determination of refractive state have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the determination of refractive state 
(92015) provided on July 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the two hearing aids (V5298 x2) provided 
on September 23, 2021 by a Plan approved hearing aid vendor. 
 
You asked the Plan to waive the copayment for the hearing aids. You say that the treating provider was listed 
as a Plan approved hearing aid vendor. You also say that you paid for the hearing aids up front, and would like 
to be reimbursed. The Plan denied your request. The Plan says the copayment amount that you are being 
charged 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 $999 
copayment per year, per ear for Premium hearing aids when purchased through the Plan's approved hearing aid 
vendor.   
You have been asked to pay a $999 copayment per year, per ear for Premium hearing aids when purchased 
through the Plan's approved hearing aid vendor for the hearing aids. The hearing aids fall within the Hearing 
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 two hearing aids 
(V5298 x2) provided on September 23, 2021 by a Plan approved hearing aid vendor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the scratch resistant coating (V2760) and frames (V2020) 
provided on December 29, 2021.  
You asked the Plan to pay for the scratch resistant coating and frames. You say that your plan offers a flat 
reimbursement rate of $200.00 regardless of the provider who is used. You also say that you would like this 
claim to be reprocessed. The Plan denied your request. The Plan says you have already received the maximum 
amount of coverage allowed for this type of service. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan pays up to $200 every year for non-Medicare covered eyewear. 
 
We looked at the file and the Plan's rules. The record shows that you met the $200 eyewear benefit maximum 
while processing this claim for the December 29, 2021 date of service and your annual maximum eyewear 
benefit has been exhausted. Based on this information, we decided that the Plan's rules for coverage of the 
scratch resistant coating and frames have not been met. Therefore, we decided that the Plan does not have to 
pay for the scratch resistant coating (V2760) and frames (V2020) provided on December 29, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care after June 9, 2022. 
 
You asked the Plan to pre-approve SNF care after June 9, 2022. You say that the continued admission to a SNF 
is medically necessary. The Plan denied your request. The Plan says the continued admission to a SNF is not 
medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care after June 9, 2022. Our 
reviewer says that continued daily skilled services are not necessary. Our physician reviewer found based on 
the medical records provided there is no documentation that the enrollee requires the services on an inpatient 
basis, only in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care after June 9, 2022 have not been met. Therefore, we decided that the 
Plan does not have to pre-approve skilled nursing facility (SNF) care after June 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the life alert (A9280) and emergency response service 
fee (S5161). 
 
You asked the Plan to pre-approve the life alert and emergency response service fee. You say that the service is 
medically necessary. The Plan denied your request. The Plan says these are not covered services. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured.  
 
 
 
 
 Therefore, we decided that the Plan does not have to pre-approve the life alert (A9280) and emergency 
response service fee (S5161).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injection medial branch block (MBB) 
services. 
 
You asked the Plan to pre-approve MBB services. You say that this is medically reasonable and necessary. The 
Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that diagnostic facet joint injection procedures should be 
performed with the intent that if successful, radiofrequency ablation (RFA) procedure would be considered the 
primary treatment goal at the diagnosed level(s). For continued facet joint injection services, there must be 
documentation of why the patient is not a candidate for radiofrequency ablation. 
 
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 MBB services. Our reviewer says that 
the requested injection services are not medically reasonable and necessary. Our physician reviewer found the 
patient has had 2 sets of diagnostic MBBs. There is no indication for a continuing series of MBBs. The next 
step would normally be RFA unless there is specific reason why the patient is not a candidate. The request is 
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 MBB services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint injection medial branch block (MBB) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xeomin. 
 
You asked the Plan to pre-approve Xeomin. You say that the services are necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xeomin.  
 
 
 
 
  
Benefits for Xeomin may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99205) billed on March 22, 2021. 
 
You asked the Plan to pay for the office visit (99205). You say that the attached documentation proves medical 
necessity. The Plan denied your request. The Plan says procedure code 99205 was billed with an incorrect 
place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99205 is office or other outpatient visit for the evaluation 
and management of a new patient, which requires a medically appropriate history and/or examination and high 
level of medical decision making. When using time for code selection, 60-74 minutes of total time is spent on 
the date of the encounter.  
  We find that CPT code 99205 is not supported in the medical record. Specifically, an outpatient office visit was 
billed with an inpatient place of service code. Based on this information, we decided that Medicare rules for 
coverage of the office visit (99205) have not been met. Therefore, we decided that the Plan does not have to 
pay for the office visit (99205) billed on March 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan. 
 
You asked the Plan to pre-approve Hyalgan. You say that the requested Hyalgan is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Orthovisc OR Supartz FX first. 
 
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 Hyalgan. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the record indicates that the 
enrollee has osteoarthritis of the knee. The requested medication is a new start. The provided records do not 
indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not 
indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred 
step one alternative. 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 Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hyalgan.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is medically reasonable 
and necessary. The Plan denied your request. The Plan says this procedure is considered 
experimental/investigational. 
 
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 Vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found current evidence based medical guideline and peer reviewed literature do not fully 
support the requested spinal decompression device procedure over the gold standard of lumbar laminectomy. 
There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for 
this enrollees medical condition as discussed above. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception to guidelines. 
 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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the specialized Drive Nitro Euro style 4 Wheel rollator 
walker with seat (99070). 
 
You asked the Plan to pre-approve the specialized Drive Nitro Euro style 4 Wheel rollator walker with seat. 
You say that the item is medically necessary. The Plan denied your request. The Plan says your request for the 
specialized Drive Nitro Euro style 4 Wheel rollator walker with seat is not medically necessary because your 
doctor has not documented the specific needs as to why you need this specialized equipment, and your appeal 
indicates that the specific request is for mobility outside the home. 
 The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve the specialized Drive Nitro Euro style 4 Wheel rollator walker with seat (99070).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine. 
 
You asked the Plan to pre-approve an MRI of the lumbar spine. You say that you have radiating nerve pain 
from your hip down to your foot. You say that the nerve pain is causing your leg to give out. The Plan denied 
your request. The Plan says the requested MRI does not meet the medical necessity criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of the lumbar spine. Our 
reviewer says that the requested MRI is not medically reasonable and necessary. Our physician reviewer found 
the record indicates that the enrollee has chronic pain syndrome and knee pain. The record does not indicate the 
occurrence of acute injury or the presence of red flag symptoms or physical examination findings. The record 
does not document neurological deficits attributable to a lumbar spine etiology. The requested service is not 
medically necessary and reasonable for the diagnosis and treatment for the enrollee's clinical condition at this 
time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the lumbar spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3. 
 
You asked the Plan to pre-approve Gelsyn-3. The Plan denied your request. The Plan says the enrollee has not 
tried and failed Orthovisc or Supartz FX. 
 
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 physician reviewer 
found the enrollee has primary osteoarthritis of the left knee. The Plan requires a trial of Orthovisc or Supartz 
FX before they will approve the requested drug. The documentation does not show that the enrollee has tried 
and failed the required drugs. The documentation does not support that Orthovisc or Supartz FX would likely 
be less effective 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 Gelsyn-3.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87150) provided April 26, 2021. 
 
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 documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (87150) provided April 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided on November 23, 2021. 
 
You asked the Plan to pay for foot orthotics. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on November 
23, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transport (A0428) and ground 
mileage (A0425) provided on September 30, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that transportation back to the enrollee's 
residence is a covered service. The Plan denied your request. The Plan says the ambulance services were not 
medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 pay for the ambulance services. Our reviewer says 
that the ambulance services were not medically necessary. Our physician reviewer found the documentation 
does not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other 
type of vehicle) were contraindicated for the enrollee. The reviewer found that the enrollee needed the 
expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can 
provide for safe transport. The reviewer also found that the documentation does not support that the ambulance 
transport on September 30, 2021 was medically reasonable and 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 the ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for the non-emergency ambulance transport (A0428) and ground mileage (A0425) 
provided on September 30, 2021.