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

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that the Euflexxa injections are medically necessary. The 
Plan denied your request. The Plan says a trial of Orthovisc or SupartzFX is required before alternatives can be 
considered. 
 
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 Euflexxa. Our reviewer says that 
Euflexxa is not medically necessary. Our physician reviewer found the record shows no trial of the plan 
preferred drugs, or any reason they would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on April 9, 2021. You asked the Plan to pay for laboratory services. You say that this testing was necessary and is supported as 
billed. The Plan denied your request. The Plan says there is insufficient information to support the medical 
necessity of these services. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of laboratory services have been met. 
Specifically, no medical records or progress notes from the ordering physician were submitted for review. 
Without this information, the medical necessity of these tests cannot be verified. Therefore, we decided that the 
Plan does not have to pay for laboratory services provided on April 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair ramp (A9270). 
 
You asked the Plan to pre-approve a wheelchair ramp. You say that the enrollee needs a ramp for their home 
because they are not able to use their wheelchair to go down the stairs due to not having proper care in the 
rehabilitation facility. The Plan denied your request. The Plan says this item is not covered. 
 
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 a wheelchair ramp (A9270).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a back brace (L0650) provided on July 7, 2020. 
 
You asked the Plan to pay for the back brace. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed item. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The records provided make no note of the need for this equipment or how it would be used. The 
record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for a back brace (L0650) provided on July 7, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 16, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service 
on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 provided on February 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
sensor kit. 
 
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 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 you do 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 Freestyle Libre continuous glucose monitor (CGM) sensor kit.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 15, 2021. You asked the Plan to pay for laboratory services. You say that these services were necessary and are supported 
as billed. The Plan denied your request. The Plan says there is insufficient medical records in the 
documentation provided to support the necessity of these services. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of laboratory services have been met. 
Specifically, no medical records or progress notes from the ordering physician were provided for review. 
Without this information, the medical necessity of these tests cannot be verified. Therefore, we decided that the 
Plan does not have to pay for laboratory services provided on February 15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010 billed for date of service August 11, 
2022. 
 
You asked the Plan to pay for procedure code 97010. You say that these services were necessary. The Plan 
denied your request. The Plan says they have agreed to pay for the other therapeutic services; however, 
procedure code 97010 is considered bundled and not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 97010 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 97010 billed for date of service August 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 26, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported as 
billed. The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 provided on July 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve HBB (hemoglobin, subunit beta) genetic testing 
(81364). 
 
You asked the Plan to pre-approve HBB genetic testing. You say that this testing is medically necessary and 
appropriate. The Plan denied your request. The Plan says this testing is excluded from coverage under 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that the MolDX Team has determined HBB gene 
testing is a statutorily excluded service.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of HBB genetic testing have not been met. Specifically, this service is excluded from Medicare 
coverage. Therefore, we decided that the Plan does not have to pre-approve HBB (hemoglobin, subunit beta) 
genetic testing (81364).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuous glucose monitor supplies (A4239). 
 
You asked the Plan to pre-approve the continuous glucose monitor supplies (A4239). You say that you are 
traveling to India and need the supplies. The Plan denied your request. The Plan says you do not require insulin 
three or more times daily. 
 
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 you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the continuous 
glucose monitor supplies (A4239). have not been met. Therefore, we decided that the Plan does not have to 
pre-approve continuous glucose monitor supplies (A4239).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office visit provided on October 6, 2021. 
 
You asked the Plan to pay for the office visit. You say that you learned that a different provider submitted a bill 
for this date of service and was paid. You say that you do not understand why the correct provider was not paid 
as their office submitted the requisite information. You also say that you do not know why two different 
providers submitted bills for the exact amount on the same date of service. The Plan denied your request. The 
Plan says that this service has previously been paid. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the reason for denial has not been substantiated. There were no 
records provided to support the services that were billed in this case. As a result, we cannot determine that the 
provider should not be paid. Therefore, we decided that the Plan has to pay for the office visit provided on 
October 6, 2021.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 15, 2022. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says non-emergent, non-
urgent services with out-of-network providers require prior authorization. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on March 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the physician's services. You say that you would like to stay with the current 
provider because he knows your background. The Plan denied your request. The Plan says medically necessary 
care is available in-network and there are no extenuating circumstances making it medically necessary to obtain 
the service 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic CGM. 
 
You asked the Plan to pre-approve therapeutic CGM. You say that you are requesting a therapeutic CGM. The 
Plan denied your request. The Plan says the enrollee does not meet the criteria for a therapeutic CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Supporting medical records, were not submitted with this request. 
Without supporting medical records, you have not shown that coverage is appropriate at this time. Based on 
this information, we decided that there is insufficient information in the record to determine if Medicare rules 
for coverage of therapeutic CGM have been met. Therefore, we decided that the Plan does not have to pre-
approve therapeutic CGM.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Actemra. 
 
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 services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found Actemra is not approved by the Food 
and Drug Administration (FDA) for the enrollee's diagnosis of kidney transplant rejection and its use in this 
setting is not supported by one of the major drug compendia or clinical research appearing in a Medicare-
approved medical journal. Actemra is therefore not safe and effective or medically necessary for the enrollee 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Actemra.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on April 27, 2022. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says this provider type is 
not eligible in the Medicare program. 
 
The Plan must follow Medicare rules. Medicare rules say that a Marriage Family Therapist is not eligible to 
participate in the Medicare program.  
 
We looked at the file and Medicare rules. The provider at issue in this case is a Marriage Family Therapist. 
Medicare says that a Marriage Family Therapist is not eligible to participate in the Medicare program.  
Therefore, we decided that the Plan does not have to pay for psychotherapy provided on April 27, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for a rollator (E0143, E0156) provided on March 7, 2022. 
 
You asked the Plan to pay for the rollator. You say that this equipment was medically necessary. The Plan 
denied your request. The Plan says that they were unable to review the claim within the allotted time frame, 
and insufficient medical records were provided. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is sufficient 
information in the record to determine if Medicare rules for coverage of the rollator have been met. The record 
included clinical records that detailed the need for this equipment and an itemized physician order for this 
equipment. Therefore, we decided that the Plan has to pay for a rollator (E0143, E0156) provided on March 7, 
2022.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 16, 2021. You asked the Plan to pay for laboratory services. You say that this testing was medically necessary and is 
supported as billed. The Plan denied your request. The Plan says there is insufficient information to support 
medical necessity in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of laboratory services have been met. 
Specifically, no progress notes or medical records from the enrollee's treating physician were submitted for 
review. Without this documentation, the medical necessity of these services cannot be verified. Therefore, we 
decided that the Plan does not have to pay for laboratory services provided on February 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a flex walk system (L5981) an axial rotation unit 
(L5986). 
 
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 requested prosthetic components at appeal exceed the enrollee's needs. 
 
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 that the documentation provided does not support the use of a K3 level flex walk system and axial 
rotation unit for the patients transtibial prosthesis. There is insufficient clinical documentation regarding the 
patients current level of mobility and function and why he requires a prosthesis with K3 components. The 
most recent documentation indicates that the patient requires a walker to assist with mobility and has a knee 
flexion contracture. It is not clear if he has the potential to be K3 level ambulator and there is no assessment 
tool or inventory regarding the patients current potential K level. This information is needed to determine if 
the requested prosthetic flex walk system and axial rotation unit is appropriate 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a flex walk system (L5981) an axial rotation unit (L5986).