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

 
We decided that the Plan does not have to pre-approve a power operated vehicle, group 1 standard, patient 
weigh capacity up to and including 300 pounds. 
 
You asked the Plan to pre-approve a power operated vehicle. You say that the item is 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 a power mobility device will be covered 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 a power operated vehicle. Our reviewer 
says that the item is not medically necessary. Our physician reviewer found the documentation does not support 
that the power operated vehicle will significantly improve the enrollees ability to participate in mobility 
related activities of daily living (MRADLs) and the enrollee will use it in the home. The documentation does 
not reveal that the requested Group 1 power operated vehicle is medically necessary per Local Coverage 
Determination (LCD):(L33789). 
 
 
 
 
 
 
 
 
 
 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 power operated vehicle have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a power operated vehicle, group 1 standard, patient weigh capacity up to and 
including 300 pounds.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient hospital visit provided on 
August 20, 2021. 
 
You asked the Plan to waive the copayment for the outpatient hospital visit. You say that you should not be 
responsible for the charges. The Plan denied your request. The Plan says the copayment amount 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 $250 
copayment for each outpatient hospital visit.  
 
 
 
 
 
 You have been asked to pay $121.87, which is less than the Plan's EOC documented $250 copayment for an 
outpatient hospital visit. Outpatient hospital visits fall within the Outpatient Surgery, Including Services 
Provided at Hospital Facilities and Ambulatory Surgical Centers 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 outpatient hospital visit provided on August 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient office visit, and a radiologic examination 
provided on November 24, 2021. 
 
You asked the Plan to pay for a new patient office visit and a radiologic examination. You say that you were 
not informed x-rays, and a new patient evaluation were non-covered services. The Plan denied your request. 
The Plan says the services are not a covered benefit. 
 
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.  
 
 We looked at the file, the Plans rules and Medicare rules. The rules say that the only chiropractic service 
Medicare covers is manual manipulation of the spine to correct a subluxation. Therefore, we decided that the 
Plan does not have to pay for a new patient office visit, and a radiologic examination provided on  
November 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aloxi. 
 
You asked the Plan to pre-approve Aloxi. The Plan denied your request. The Plan says the use of Aloxi with 
the drug regimen of Gemcitabine and Vinorelbine is not supported. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 Aloxi. Our physician reviewer found 
that the enrollee has non-small cell lung cancer. His treatment plan includes Vinorelbine and Gemcitabine. The 
use of Aloxi for management of nausea and vomiting associated with the chemotherapy regimen has been 
requested. The requested use of Aloxi is not supported as an FDA approved indication. The use is not 
supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical 
journal. The use is not listed as not indicated, not supported or not recommended in any of the compendia. The 
documentation does not support that the requested drug is safe and effective and otherwise reasonable and 
necessary for this enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aloxi have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Aloxi.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller, harness, electronic 
connection, and transit option. 
 
You asked the Plan to pre-approve an expandable controller, harness, electronic connection, and transit option. 
You say that the items 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 wheelchair accessories are covered 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 an expandable controller, harness, 
electronic connection, and transit option. Our reviewer says that the items are not medically necessary. Our 
physician reviewer found the expandable controller (E2377), expandable controller harness (E2313), and 
electro connect (E2311) and other types of proportional input devices (e.g., mini-proportional or compact 
joysticks, touchpads, chin control, head control, etc.) are not medically necessary per Local Coverage Article: 
Wheelchair Options/Accessories - Policy Article (A52504). The enrollee does not require non-proportional 
input devices (e.g., sip and puff, head array, etc.). The enrollee does not require a separate display (i.e., for 
alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer 
through the chair's drive control), or an attendant control. The enrollee has 3 power options of tilt, recline, and 
power elevating leg rests but the enrollee does not need to control the power options through a joystick. The 
documentation does not support that this enrollee is unable to use her right upper extremity to control any 
power options through their own switches. A transit option does not serve a primary medical need and 
therefore is not covered. 
 
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 expandable controller, harness, electronic connection, and transit option have 
not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller, 
harness, electronic connection, and transit option.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Methylprednisolone tablets. 
 
You asked the Plan to pre-approve Methylprednisolone tablets. You say that the patient improved after 
previously taking the Medrol pack. The Plan denied your request. The Plan says Methylprednisolone dose pack 
is a benefit exclusion. 
 
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 Methylprednisolone tablets.  
 
  Benefits for Methylprednisolone tablets 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: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for a revision of total knee arthroplasty (27486) provided on October 7, 
2020. 
 
You asked the Plan to pay for a revision of total knee arthroplasty. You say that you have provided records to 
substantiate the services at issue. The Plan denied your request. The Plan says that rules for payment have not 
been met because the available records do not support the service billed. 
 
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 27486 is "Revision of total knee arthroplasty, with or without allograft; 1 component." 
 
We asked our coder 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 a revision of total knee arthroplasty. Our reviewer says that 
the services at issue meet criteria for reimbursement. Our reviewer found that the procedure note does indicate 
that a polyethylene exchange occurred during the procedure on October 7, 2020. The description for CPT code 
27486 states one of the femoral or tibial components or the polyethylene liner is removed as determined by the 
physician. In order to remove the components, an osteotome or saw may be used. The available medical 
records do support that the procedure coded 27486 was provided on October 7, 2020. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a revision of total knee arthroplasty have been met. Therefore, we decided that 
the Plan has to pay for a revision of total knee arthroplasty (27486) provided on October 7, 2020.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (denosumab) injection (CPT code J0897). 
 
You asked the Plan to pre-approve the medication. You say that the enrollee has osteoporosis; therefore, Prolia 
is medically necessary and is the drug of choice. The Plan denied your request. The Plan says the enrollee does 
not meet the Plan's policy step therapy with trial/failure of an oral/ intravenous (IV) bisphosphonate therapy for 
a period of at least twenty-four (24) months. The Plan states there is no record of previous therapy with 
bisphosphonates and the chart notes show the enrollee has gastroesophageal reflux disease (GERD) and may not be able to tolerate oral therapy; however, the enrollee is still a candidate for Reclast. The Plan states the 
enrollee is not a candidate for Prolia. 
 
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 the medication. Our physician reviewer 
found the Plan requires a trial of an oral or IV bisphosphonate for a period of at least 24 months before they 
will approve the requested drug. In this case, the enrollee has not tried and failed the required drug. The chart 
notes show member has GERD and may not be able to tolerate oral therapy, however, the enrollee is still a 
candidate for Reclast. There is no documentation provided indicating that the Plans required drugs would 
likely be less effective and/or likely have adverse effects for the enrollee. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prolia (denosumab) injection (CPT code J0897).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Ultra Voice Speaking device. 
 
You asked the Plan to pre-approve an Ultra Voice Speaking device. You say that the services are necessary. 
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria 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 an Ultra Voice Speaking device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the provided medical records do not indicate why the alternative treatments 
are less effective than the requested service. 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 an Ultra Voice Speaking device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an Ultra Voice Speaking device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an endocrinology specialist office visit 
provided on April 7, 2021. 
 
You asked the Plan to waive the copayment for an endocrinology specialist office visit. You say that the 
doctor's office is showing a charge and a payment adjustment of $9.01, and this was part of a previous bill that 
was already paid. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
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 $35 
copayment for an in-network specialist office visit.  
 
 You have been asked to pay a $35 copayment for an endocrinology specialist office visit. The Plan confirmed 
with the providers office that there was a credit of $9.01 applied to your visit on April 7, 2021. Therefore, the 
provider only billed you for the remaining balance of $25.99 ($35 copayment - $9.01 credit = $25.99).  An 
endocrinology specialist office visit falls within the Physician/Practitioner Services, Including Doctors Office 
Visits 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 an endocrinology specialist 
office visit provided on April 7, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the esophagogastroduodenoscopy, flexible, 
transoral; with biopsy, single or multiple (43239) provided on October 21, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $450 
copayment for Medicare-covered surgery provided to you at an outpatient hospital, including but not limited to 
hospital or other facility charges and physician or surgical charges. 
 You have been asked to pay $437.72 for the Medicare-covered surgery provided at an outpatient hospital. The 
service provided in this case falls under the outpatient surgery benefit category. This is the Plans allowed 
amount for this service which is less than the applicable copayment. 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 esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple (43239) 
provided on October 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lapiplasty procedure to be provided by the requested 
out-of-network provider. 
 
You asked the Plan to pre-approve a lapiplasty procedure to be provided by the requested out-of-network 
provider. The Plan denied your request. The Plan says this provider is not contracted with the Plan and you can 
see a contracted podiatrist with the Plan. 
 
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 a 
lapiplasty procedure to be provided by the requested out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cinacalcet HCL (CPT code J0604). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 Medicare rules says that you cannot get a tiering exception for very high-cost drugs on a specialty tier. The 
information we have says this is a very high-cost drug on a specialty tier. You do not qualify for a tiering 
exception per Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided 
that Medicare rules for coverage of the medication have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Cinacalcet HCL (CPT code J0604).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Rytary capsule. 
 
You asked the Plan to pre-approve Rytary. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Rytary 
capsule.  
 Benefits for Rytary 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Farxiga, 10mg tablets. 
 
You asked the Plan to pre-approve Farxiga, 10mg tablets. You say that he could experience another 
cardiovascular event if his lipid panel is not under control very soon. You say that the medication is medically 
necessary for the enrollee's medical condition. The Plan denied your request. The Plan says this medication 
falls under Part D 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 Farxiga, 10mg tablets.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on October 27, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you pay for this insurance, and it is impossible to 
get track year to year if the provider is in-network. 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. 
Therefore, we decided that the Plan does not have to pay for the office visit provided on October 27, 2021, by 
an out-of-network (OON) provider.