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

 
We decided that the Plan does not have to pre-approve an ultrasound (77641) to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve an ultrasound at an out of network facility. You say that you live 10 minutes 
away from the hospital. You say that your plan is forcing you to go 2 hours away for an ultrasound. You also 
say that you do not have a car. The Plan denied your request. The Plan says there are in network providers 
available. 
 
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 a network provider 
available 26 miles from your home 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 ultrasound (77641) to be provided by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services. 
 
You asked the Plan to pre-approve home health aide services. You say that you do not feel safe doing activities 
of daily living (ADL) tasks due to frequent vertigo and diabetic attacks. The Plan denied your request. The Plan 
says the enrollee does not require assistance with ADLs. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health aide services have not been met. Specifically, we find that the services at issue in this 
case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve home 
health aide services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an X-ray of the chest (71045) provided on November 16, 
2021. 
 You asked the Plan to pay for an X-ray of the chest. You say that you would like this claim reprocessed based 
on the medical documentation. The Plan denied your request. The Plan says this claim has not been billed with 
an appropriate modifier as required by Medicare coding regulations. 
 
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, we have confirmed that code 71045 
is a column II code to column I code 71046. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for an X-ray of the chest (71045) provided on November 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057), and an abutment 
supported crown (D6062) to be provided by a participating provider. 
 
You asked the Plan to pre-approve a custom fabricated abutment and an abutment supported crown. You say 
that you chose this plan because you thought this would be covered. The Plan denied your request. The Plan 
says the requested dental services D6057 and D6062 are not covered dental benefits. 
 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
custom fabricated abutment (D6057), and an abutment supported crown (D6062) to be provided by a 
participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hygienic wipes. 
 
You asked the Plan to pre-approve hygienic wipes. You say that using these wipes would help prevent 
infection during catheterization. The Plan denied your request. The Plan says hygienic wipes are not a covered 
benefit. 
 
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. 
Wipes are hygienic items and are not covered. Therefore, we decided that the Plan does not have to pre-
approve hygienic wipes.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says you do 
not meet the criteria. 
 
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 does not indicate that you use insulin with at least 
three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing 
results. Based on this information, we decided that Medicare rules for coverage of the requested device have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aduhelm for the enrollee. 
 
You asked the Plan to pre-approve Aduhelm. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the use of Aduhelm in this member is not reasonable and 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 Aduhelm. Our reviewer says that 
Aduhelm is not medically reasonable and necessary. Aduhelm is FDA-approved for the treatment of 
Alzheimer's disease in patients with mild cognitive impairment or mild dementia stage of disease. The 
documentation is insufficient to support a diagnosis of Alzheimer's disease in this enrollee. The use of 
Aduhlem is not supported by one of the major drug compendia or by clinical research that appears in a CMS-
approved medical journal. The documentation in the case file does not support that Aduhelm is expected to be 
safe and effective and otherwise reasonable and necessary for the enrollee in this case. MRI imaging suggests 
the presence of cerebrovascular disease, which is evidence of a mixed etiology for the enrollee's symptoms. It 
has not been shown that Aduhelm is at least as beneficial as existing and appropriate and available medically 
appropriate alternatives for this enrollee. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of Aduhelm. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aduhelm have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aduhelm for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that your orthotics have been approved before. The 
Plan denied your request. The Plan says they are not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
The records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration because the IRF care 
is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF 
admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for exacerbation of congestive heart failure. Medical problems are stable. There are no complex 
nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the percutaneous transluminal coronary angioplasty (92921) 
provided on November 23, 2021. 
 
You asked the Plan to pay for the percutaneous transluminal coronary angioplasty. You say that you would like 
this claim reprocessed based on medical documentation. The Plan denied your request. The Plan says no 
separate payment is made for these services. 
 
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 92921 is percutaneous transluminal coronary angioplasty; 
each additional branch of a major coronary artery (List separately in addition to code for primary procedure). 
 
 
 
 We looked at the file and Medicare rules. In this case, the CPT code has a Status Code of B under the 
Physician Fee Schedule which indicates that payment for covered services are always bundled into payment for 
other services not specified. Based on this information, we decided that Medicare rules for coverage of the 
percutaneous transluminal coronary angioplasty have not been met. Therefore, we decided that the Plan does 
not have to pay for the percutaneous transluminal coronary angioplasty (92921) provided on November 23, 
2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) services (G0151 x10), 
occupational therapy (OT) services (G0152 x10), and services of clinical social worker (G0155 x5). 
 
You asked the Plan to pre-approve the PT services, OT services, and services of clinical social worker. The 
Plan denied your request. The Plan says the medical need for these services could not be determined. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy.  A doctor must certify the need for home health care services. 
 
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 PT services, OT services, and 
services of clinical social worker. Our reviewer says that these services are not medically reasonable and 
necessary for the enrollee. Our physician reviewer found there is no documentation that the requested skilled 
therapy and social work services are required to effectively provide treatment, care, and/or services in order to 
improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the 
enrollee's level of function and/or prevent deterioration. Our reviewer found that the provided records do not 
document any acute or unstable medical conditions or changes in medication or treatment which would 
necessitate home health skilled therapy or social work visits. Our physician reviewer also found that based on 
the provided records, the enrollee's needs appear to be custodial in nature. 
 
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 PT services, OT services, and services of clinical social worker have not 
been met. Therefore, we decided that the Plan does not have to pre-approve physical therapy (PT) services 
(G0151 x10), occupational therapy (OT) services (G0152 x10), and services of clinical social worker (G0155 
x5).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99233) provided on August 16, 
2021. 
 
You asked the Plan to pay for the subsequent hospital care. You say that the physician provided medically 
necessary services to the enrollee in good faith. You also say that you feel the doctor is entitled to 
reimbursement. The Plan denied your request. The Plan says the enrollee was enrolled in hospice on August 
16, 2021. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the subsequent hospital care (99233) provided on August 16, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the neck and 
spine. 
 
You asked the Plan to pre-approve the MRI. You say that this MRI is medically necessary. The Plan denied 
your request. The Plan says the enrollee has no physical findings consistent with nerve impingement and there 
is no documented lack of response to conservative measures. 
 
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 necessary. Our physician reviewer found the enrollee has not had a physical 
exam and no personal follow-up after completion of physical therapy for her right shoulder issue.  She has had 
a teleconference call.  There is no red flag related to her cervical spine, no plain film analysis of her neck and 
no justification offered in the records for the requested MRI of the cervical spine. 
 
 
 
 
 
 
 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 neck and spine.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trulance for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
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 Trulance for the enrollee.  
 
 
 Benefits for this drug 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 Retacrit. 
 
You asked the Plan to pre-approve Retacrit. You say that you would like reconsideration because the requested 
drug is medically necessary. The Plan denied your request. The Plan says the member does not have a 
medically accepted indication for coverage. 
 
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 Retacrit. Our reviewer says that the 
documentation does not support that the member has a medically accepted indication for the use of Retacrit. 
Our physician reviewer found the requested use of Retacrit is not FDA-approved for the enrollees diagnosis. 
Its use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-
approved medical journal (see appendix for list of CMS-approved journals. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Retacrit.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc One. 
 
You asked the Plan to pre-approve Synvisc One. You say that the requested drug is necessary. The Plan denied 
your request. The Plan says the enrollee has not tried and failed the preferred drug, Euflexxa. 
 
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 Synvisc One. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the Plan requires a trial of 
viscosupplemental treatment, Euflexxa, and either Durolane, Gelsyn-3, or Supartz FX. The provided records 
show that Supartz FX was tried and failed. The documentation does not outline contraindications or reasons 
why Euflexxa was not considered or that this required drug would likely be less effective and/or likely have 
adverse effects for the enrollee. Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc One have not been met. Specifically, the file does not indicate that the 
enrollee has tried and failed the required drug, Euflexxa. Therefore, we decided that the Plan does not have to 
pre-approve Synvisc One.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on November 1, 2021 by an out-of-
network (OON) naturopathy provider. 
 
You asked the Plan to pay for the OON naturopathy visit. You say that you were told that no prior 
authorization was needed and that you are covered for 3 naturopathy visits per diagnosis per year. The Plan 
denied your request. The Plan says you did not use a network provider for this service, so it is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan covers 3 naturopathy visits per diagnosis per calendar year when you receive the 
services from network providers.. 
 
The 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 November 1, 2021 by an out-of-
network (OON) naturopathy provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a cystourethroscopy provided on October 
21, 2021. 
 
You asked the Plan to waive the copayment for a cystourethroscopy. You say that your doctor sent you for this 
test. You also say that no one told you it would not be covered in full. 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 $200 
copayment for outpatient surgery at an outpatient hospital.  
 
You have been asked to pay a $200 copayment for a cystourethroscopy. A cystourethroscopy falls within the 
Outpatient Surgery, Including Services Provided at Hospital Outpatient 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 a cystourethroscopy 
provided on October 21, 2021.