Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya (J3245). 
 
You asked the Plan to pre-approve Ilumya. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says step therapy criteria have not been met. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Ilumya. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found that the Plan requires 
a trial of Remicade, Inflectra or Infliximab and Stelara before they will approve the requested drug, Ilumya. 
Based on the medical records provided there is no indication that the patient has tried and failed the required 
drugs. There is no indication that the plan's required drug(s) would likely be less effective and/or likely have 
adverse effects for the patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Ilumya (J3245).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) visit (99282) provided on 
October 20, 2021. 
 
You asked the Plan to pay for the ED visit. You say that this bill is too high, and it should have been covered 
under your plan. The Plan denied your request. The Plan says this claim is denied correctly and is not covered 
under the medical plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the emergency department (ED) 
visit (99282) provided on October 20, 2021.  
 
Please Note: This service was denied under your medical benefits because it is dental related. You may wish to 
speak with your provider to see if a new claim can be submitted with a dental code to the Plan.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the spinal injection provided on November 29, 2021. 
 
You asked the Plan to pay for the spinal injection. You say that this was denied using rules for epidural 
injections which is not what was performed. This is a medically necessary treatment. The Plan denied your 
request. The Plan says the records do not support that payment should be made. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare requires that services 
provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in 
accordance with Medicare's policies. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the spinal injection have not been met. Specifically, the documentation submitted does not include 
a valid signature from the persons responsible for the care of the beneficiary. The electronic signature section of the note is blank, and the only potential signature is typed but not dated. In addition, the record submitted 
has no documentation to prove it is for the date of service at issue. Therefore, we decided that the Plan does not 
have to pay for the spinal injection provided on November 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental 
pneumatic appliance (E0673). 
 
You asked the Plan to pay for a pneumatic compression device and appliance. You say that you are requesting 
re-evaluation of the claims. The Plan denied your request. The Plan says pneumatic compression device is not 
covered by Medicare to prevent deep vein thrombosis during and/or following surgery.  
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
In this case, the enrollee used the equipment in the facility during and/or after surgery. Payment for this service 
would have been included under the facility claim. Payment for this service is the responsibility of the facility 
or hospital that provided the surgery. Therefore, we decided that the Plan does not have to pay for a pneumatic 
compression device (E0675) and segmental pneumatic appliance (E0673).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 24 additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need additional routine 
transportation. The Plan denied your request. The Plan says the supplemental benefit for routine transportation 
has been exhausted. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 24 additional routine transportation trips.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cardiac positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve PET scan. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the requested PET scan is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve PET scan. Our reviewer says that the 
enrollee does not meet the Medicare criteria for the requested PET scan. Our physician reviewer found other 
methods of stress testing have not been performed. Guidelines do not support the use of cardiac PET imaging 
in this role, so it would not be considered medically reasonable and necessary in the enrollee's clinical 
management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PET scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a cardiac positron emission tomography (PET) scan.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroplasty services (0201T). 
 
You asked the Plan to pre-approve sacroplasty services. You say that this procedure is medically reasonable 
and necessary. The Plan denied your request. The Plan says there are not enough studies on sacroplasty 
servcies to show it is safe and effective. 
 
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 sacroplasty services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that sacroplasty is experimental. More research is needed before coverage can be 
approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sacroplasty services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve sacroplasty services (0201T).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99202) Chiropractic manipulative 
treatment (98940) provided December 16, 2021 to December 23, 2021. 
 
You asked the Plan to pay for the chiropractic services. You say that you are appealing this decision to deny 
payment. Chiropractic services is a covered benefit. The Plan denied your request. The Plan says these services 
are not covered under the Plan benefits. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
 
 
 
 
 
 The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the outpatient office visit (99202) Chiropractic manipulative treatment 
(98940) provided December 16, 2021 to December 23, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial nursing facility care (99304) provided on March 
31, 2021.  
You asked the Plan to pay for the initial nursing facility care. You say that the provider rendered medically 
necessary services to the enrollee in good faith. The Plan denied your request. The Plan says this claim was 
correctly denied for definite duplicate claim. 
 
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 the initial nursing facility care (99304) 
provided on March 31, 2021. have been met. The provider has not sent in any medical records to show that 
these services are unique and different from the other billed initial nursing facility care (99304) which was 
paid. Therefore, we decided that the Plan does not have to pay for the initial nursing facility care (99304) 
provided on March 31, 2021.
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 the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available and being provided at the health care setting being offered by the health plan. 
 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro orthosis device. 
 
You asked the Plan to pre-approve a MyoPro orthosis device. You say that the MyoPro is supported as an 
appropriate intervention and is reasonably and medically necessary as recognized by medical communities and 
key opinion leaders in rehabilitation. The Plan denied your request. The Plan says the medical literature and the 
clinical documentation associated with this appeal falls within the investigational and experimental aspects of 
care. 
 
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 MyoPro orthosis device. Our reviewer 
says that the requested orthosis is not reasonable and necessary for the diagnosis or treatment of illness or 
injury or to improve the functioning of a malformed body member. Our physician reviewer found there is 
insufficient literature in the peer reviewed publications to assess safety, efficacy, long term outcomes or patient 
management associated with the use of the MyoPro Orthosis for upper extremity paralysis/paresis from 
conditions such as multiple sclerosis or other neuromuscular/neurological disease or injury. 
 
 
  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 MyoPro orthosis device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro orthosis device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair, group 2 heavy duty, captains 
chair, patient weight capacity 301 to 450 pounds (K0825). 
 You asked the Plan to pre-approve a power wheelchair. You say that your current wheelchair is not functioning 
properly, and it is unsafe. You are unable to leave your apartment until you receive a new wheelchair. The Plan 
denied your request. The Plan says you received a power wheelchair on August 12, 2021. The Plan also says 
that you say that your wheelchair is broken. According to the DME company where you received your current 
power wheelchair, you are refusing repairs to your wheelchair and want a new wheelchair. 
 
The Plan follows Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. Medicare rules say equipment which the beneficiary owns or is a capped rental item 
may be replaced in cases of loss or irreparable damage.  
 
The file shows that you received a wheelchair on August 12, 2021. The reasonable useful lifetime of durable 
medical equipment is determined through program instructions of five years of when the equipment is 
delivered. The records also show that you are refusing repairs to your broken wheelchair. Therefore, we 
decided that the Plan does not have to pre-approve a power wheelchair, group 2 heavy duty, captains chair, 
patient weight capacity 301 to 450 pounds (K0825).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the semi-precision abutments - 
placement (D6191) provided January 4, 2022. 
 
You asked the Plan to provide additional payment for the semi-precision abutments. You say that you feel this 
is a standard step in the covered implant process. The Plan denied your request. The Plan says this claim has 
been reprocessed and paid up to your $2,000 annual dental allowance. 
 
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 50% of the 
cost of the semi-precision abutments up to the $1,000 dental allowance.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that this claim was 
reprocessed. At the time the claim was reprocessed you had $646 remaining in your dental allowance. This 
amount was applied to your claim. Therefore, we decided that the Plan does not have to provide additional 
payment for the semi-precision abutments - placement (D6191) provided January 4, 2022.
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 your medical needs are being met in the current acute setting. 
 
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 
currently undergoing treatment at an acute care hospital (ACH) for pancreatitis. You were intubated/ventilated, 
received a tracheotomy and have since been decannulated. There is no evidence that you require services that 
are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no 
advantage in transferring you to the LTACH. You can remain at the current ACH until such time no acute 
services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing 
long term care needs. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair accessory, expandable controller, 
including all related electronics and mounting hardware, upgrade provided at initial issue (E2377), a power 
wheelchair accessory, electronic connection between wheelchair controller and 2 or more power seating system 
motors, including all related electronics, indicator feature, mechanical function selection switch, and fixed 
mounting hardware (E2311) and a power wheelchair accessory, harness for upgrade to expandable controller, 
including all fasteners, connectors and mounting hardware (E2313). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the requested wheelchair and 
accessories are medically necessary to meet the enrollee's current needs. The Plan denied your request. The 
Plan says although there are two approved power options/features on this wheelchair (tilt and elevating leg 
rests), there is not a medical need to control these power options/features through the joystick. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 wheelchair accessories. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the enrollee has a neurologic 
disorder with functional deficits. She meets criteria for use of a power mobility device. The requested 
accessories are not medically necessary as she does have use of her hands and can operate and control the 
power options using the switches that are included in the basic wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a power wheelchair accessory, expandable controller, including all related 
electronics and mounting hardware, upgrade provided at initial issue (E2377), a power wheelchair accessory, 
electronic connection between wheelchair controller and 2 or more power seating system motors, including all 
related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware 
(E2311) and a power wheelchair accessory, harness for upgrade to expandable controller, including all 
fasteners, connectors and mounting hardware (E2313).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular implant/abutment supported removable 
denture for edentulous arch (D6111). 
 
You asked the Plan to pre-approve the mandibular implant/abutment supported removable denture. The Plan 
denied your request. The Plan says this service is allowed one time in 5 calendar years. The Plan also says that 
the enrollee has already had this service within the past 5 years and has reached the limit for this service.  
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the enrollee is limited to one of either 
codes D5120 or D5212 or D5214 or D6111 or D6113 once per 5 calendar years. The record shows that the 
enrollee received a complete mandibular denture (D5120) on October 27, 2021 and the enrollee's mandibular 
denture benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a 
mandibular implant/abutment supported removable denture for edentulous arch (D6111).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on 
November 10, 2021. 
 
You asked the Plan to pay for the office visit. You say that the provider regularly complies with all 
administrative requirements for payment. You say that the medical records support the medical necessity of the 
services provided and you are requesting payment of the claim. The Plan denied your request. The Plan says 
this provider is not a network provider with the Plan and the services were not approved in advance. 
  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. 
Therefore, we decided that the Plan does not have to pay for the office visit provided by an out-of-network 
provider on November 10, 2021.