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

We decided that the Plan does not have to pre-approve Prolia. 
 
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 a history of 
osteoporosis. She has not tried and failed the Plan's required drug, zoledronic acid. The records do not show 
that the required drug would be contraindicated or less effective; therefore, Prolia 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 Prolia.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve HDR Electronic Brachytherapy. 
 
You asked the Plan to pre-approve HDR Electronic Brachytherapy. You say that you have been having 
treatments for your cancer and still have treatment left to be done. You say that the cancer is spreading and the 
quicker it is removed, the better it is for your health. The Plan denied your request. The Plan says that the 
clinical value and effectiveness of HDR electronic brachytherapy in this setting have not been demonstrated in 
the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 HDR Electronic Brachytherapy. Our 
reviewer says that HDR Electronic Brachytherapy is considered medically reasonable and necessary in this 
case. Our physician reviewer found this is an established therapy for indications such as the enrollee's and 
should be considered the standard therapy for specific cases at the physician's discretion. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HDR Electronic Brachytherapy have been met. Therefore, we decided that the 
Plan has to pre-approve HDR Electronic Brachytherapy.  
 
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve left total knee replacement. 
 
You asked the Plan to pre-approve left total knee replacement. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that replacement/revision knee arthroplasty is considered 
reasonable and necessary when specific criteria are met. 
 
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 left total knee replacement. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the record provided 
does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The requested service is not 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 left total knee replacement have not been met. Therefore, we decided that the 
Plan does not have to pre-approve left total knee replacement.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the right shoulder 
for the enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that this is needed for chronic right shoulder pain. The 
Plan denied your request. The Plan says there was no treatment trial reported for right shoulder pain. 
 
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 the MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found the Neer and Hawkins 
tests were negative. The pain is atraumatic and chronic. There are no red flags to mandate immediate MRI 
without a six week trial of physical therapy done first. In fact, physical therapy was ordered the same date the 
shoulder injection was done. The therapy has not yet been completed. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the right shoulder for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that you do not have clinical conditions that cannot be 
appropriately treated in the current hospital, and there are no issues for which LTACH may offer a therapeutic 
advantage. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. You are 
receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are 
not available at the acute care hospital where he is currently receiving care. Our physician reviewer found that 
your condition does not meet Medicare criteria for LTACH services. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on May 31, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing facility. You say that you have re-applied for in-network 
status and have been denied. You say under traditional Medicare, these claims would not be denied. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the services at issue were urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the subsequent nursing facility care provided on May 31, 2021, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the enrollee does not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and 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 assesses 
adherence to their CGM regimen and diabetes treatment plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not treat with insulin 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).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter for the enrollee. 
 
You asked the Plan to pre-approve a power scooter. You say that the enrollee would benefit greatly from 
having a power scooter to maintain her independence, remain socially active, and continue engaging in 
activities that are important to her. The Plan denied your request. The Plan says that this equipment is not 
needed and is not appropriate for use outside the enrollee's house. 
 
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 a power scooter for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the specimen collection provided on December 5, 2020.  You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the claim processed correctly.  

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 G2023 is specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), any specimen source. We find that CPT code G2023 is not payable when submitted on an outpatient hospital claim. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the specimen collection provided on December 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the eye refraction testing provided on May 20, 2021.  You asked the Plan to pay for the refraction testing. You say that you require this testing to be done every time you are seen by the optometrist due to your medical conditions which require monitoring. You feel that the Plan should cover these necessary services. The Plan denied your request. The Plan says this is only covered by the Plan when done during a routine eye exam.  Medicare never covers refraction testing even when provided with otherwise covered vision services for diagnosis and treatment of eye conditions/diseases. The Plan offers a supplemental benefit which limits refraction coverage to those done as part of your annual routine eye exam.  We looked at the file and the Plan's rules. This refraction testing was performed as part of a medical eye exam for the diagnosis and treatment of an eye condition. Medicare does not provide coverage in this situation, nor does your supplemental benefit since this was not done during a routine eye exam. Based on this information, we decided that the Plan's rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction testing provided on May 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orencia Clickject. 
 
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 self-administered drugs are not covered. 
 
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 Orencia Clickject.  
 
Benefits for these services 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: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the testing described by codes 87631, U0003, and U0005. We decided 
that the Plan does not have to pay for all other billed codes.  
 
You asked the Plan to pay for the testing described by codes 87631, U0003, and U0005. You say that this 
should be covered. The Plan says that code 87631 cannot be paid since the records show that this code is not 
correct since many more than 3-5 pathogens were tested, and more than 5 pathogens are not covered. It is noted 
that this is not a COVID-19 test. 
 
We decided that the Plan has to pay for the testing described by codes U0003 and U0005.  
 
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 provided no valid rationale to support the denial of the COVID testing, other than to say, this was not 
a COVID-19 test. However, the requisition form clearly indicates that a COVID-19 test was ordered, and the 
lab report included the results for this test. As such, payment for the COVID testing is required. Therefore, we 
decided that the Plan has to pay for the testing described by codes U0003 and U0005.  
 
We also decided that the Plan does not have to pay for all other billed codes. 
 
The Plan follows Medicare rules. Medicare rules say that PCR panels of 6 or more panels are not covered, 
though panels of 3-5 may be covered only when the criteria in the Medicare rules section are met.  
 
Code 87631 is for payment of the first five pathogens tested. However, the documentation supports that this 
sample was taken in an assisted living facility, meaning it was not ordered that is equipped to care for critically 
ill patients, nor was it ordered by an infectious disease specialist. As for the remaining codes, these represent 
tests for pathogens in excess of the 5 covered per Medicare policy. Therefore, we decided that the Plan does not 
have to pay for all other billed codes. 
 
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: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve the LINQ implant (insertable heart rhythm monitoring device) 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 that there is no documentation or additional clinical documentation provided for 
unrevealing or indeterminant Holter Monitor noninvasive cardiac monitoring. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has a contra-indication to anti-coagulation with the recent gastrointestinal (GI) bleeding, and 
have a 25-day external loop monitor which showed very short and limited episodes of atrial fibrillation with a 
very low total burden of atrial fibrillation (AF). The results of a more prolonged implantable monitor may 
impact long-term therapy with anticoagulation as the 25 day external loop recorder did not definitively 
diagnose sufficient AF to make a determination about the safety of stopping the anti-coagulation in the setting 
of the recent GI bleed However, if there was recurrent prolonged AF on the implantable Linq monitor this 
would likely push the risk-benefit towards continuing anti-coagulation. As such, the results of the implantable 
monitor would impact the enrollee's long term medical management, and would therefore be considered 
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 the services have been met. Therefore, we decided that the Plan has to pre-
approve the LINQ implant (insertable heart rhythm monitoring device) for the enrollee.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis - adult (D1110) and periodic oral evaluation 
- established patient (D0120) provided on July 6, 2021. 
 
You asked the Plan to pay for the dental cleaning and periodic oral exam. You say that you are an in-network 
provider. The Plan denied your request. The Plan says the services were rendered out-of-network and therefore 
are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The Plan covers the dental 
cleaning and periodic oral exam when the services are medically necessary and reasonable.  
 
 
 We looked at the file and Medicare rules. In this case it appears that services were provided by an out-of-
network provider. 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. Based on this information, we decided that the Plan's rules for 
coverage of the dental cleaning and periodic oral exam have not been met. Therefore, we decided that the Plan 
does not have to pay for the prophylaxis - adult (D1110) and periodic oral evaluation - established patient 
(D0120) provided on July 6, 2021.  
 
Non-contract provider appeals require a Waiver of Liability form indicating that the enrollee is not being held 
responsible for the items or services at issue. In this case, you signed and completed a Waiver of Liability form, 
indicating that you are a non-contract provider. 
 
You claim that you are a contract provider with the Plan. Contract providers do not have appeal rights through 
the Independent Review Entity (IRE) process. If you are indeed a contract provider with the Plan, you will 
need to contact the Plan directly regarding any appeal processes that they have for contract providers.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for outpatient bilateral 
blepharoplasty 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 the health plan requires the use of in-network providers. 
 
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 for outpatient bilateral blepharoplasty for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the out-of-network outpatient mental 
health services you received from February 2, 2021, to May 18, 2021. 
 
You asked the Plan to waive the copayments for the out-of-network outpatient mental health services. You say 
that when you signed up with the Plan, you were told this provider was in-network. The Plan denied your 
request. The Plan says these copayments were charged correctly.  Phone records show that you called the Plan 
on January 31, 2021, (prior to services being rendered) and were advised that this provider was not in network. 
 
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 $45 
copayment per visit for out-of-network outpatient mental health care.  
 
You have been asked to pay a $45 copayment per visit for the out-of-network outpatient mental health services. 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 copayments for the out-of-network outpatient mental health services you 
received from February 2, 2021, to May 18, 2021.