Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter placement of intravascular stent(s), 
cervical carotid artery, percutaneous; with distal embolic protection (37215), transcatheter placement of intravascular stent(s), cervical carotid artery, percutaneous (37216), transcatheter placement of intravascular 
stent(s), intrathoracic common carotid artery or innominate artery (37217, 37218) and arterial catheterization or 
cannulation for sampling, monitoring or transfusion (36625). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not have a proven blockage of 80% or more as required under the 
NCD. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation does not support that the enrollee is symptomatic. As the enrollee is asymptomatic, 
the documentation does not support that the enrollee is at high risk for carotid endarterectomy, and has carotid 
artery stenosis greater than or equal to 80%. The documentation does not support that the requested procedures 
are medically reasonable and necessary for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transcatheter placement of intravascular stent(s), cervical carotid artery, percutaneous; with 
distal embolic protection (37215), transcatheter placement of intravascular stent(s), cervical carotid artery, 
percutaneous (37216), transcatheter placement of intravascular stent(s), intrathoracic common carotid artery or 
innominate artery (37217, 37218) and arterial catheterization or cannulation for sampling, monitoring or 
transfusion (36625).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
November 24, 2021. 
 
You asked the Plan to waive the copayment for the office visit. You say that this appointment should have been 
a follow up since you only received results from your imaging. The Plan denied your request. The Plan says the 
copayment applied correctly. 
 
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 for each in-network Medicare-covered visit with a specialist. 
 
You have been asked to pay $45 for the specialist office visit. 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 the specialist office visit provided on November 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medication assisted treatment provided on February 9, 2021, 
and February 23, 2021 
 
You asked the Plan to pay for medication assisted treatment. The Plan denied your request. The Plan says prior 
authorization was not obtained by the provider or facility. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for medication assisted treatment provided on February 9, 2021, and 
February 23, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transthoracic echocardiography (93306) rendered by the 
out-of-network (OON) provider on December 11, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the transthoracic echocardiography (93306) rendered by the out-of-network (OON) 
provider on December 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) to be provided by 
a participating provider. 
 
You asked the Plan to pre-approve a complete maxillary denture. You say that you would like pre-authorization 
for a complete maxillary denture. The Plan denied your request. The Plan says the benefit limit for D5110 has 
already been exhausted. 
 
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. The Plan covers one complete 
maxillary denture every five years. 
 
We looked at the file and Medicare rules. Evidence was provided to show that D5110 was provided on March 
29, 2021. Based on this information, we decided that the Plan's rules for coverage of a complete maxillary 
denture have not been met. Therefore, we decided that the Plan does not have to pre-approve a complete 
maxillary denture (D5110) to be provided by a participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve a power seat elevation system (E2300). You say that you would like the 
Plan to reconsider their denial. The Plan denied your request. The Plan says a power seat elevation system 
represented by code E2300 is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say a power seat elevation system (E2300) is statutorily 
non-covered by Medicare and the Plan. 
 
We looked at the file and Medicare rules. Medicare specifically excludes coverage of power seat elevation 
systems coded as E2300. Therefore, we decided that the Plan does not have to pre-approve a power seat 
elevation system (E2300).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight abutment supported cast metal crowns (D6062 
x8). 
 
You asked the Plan to pre-approve the abutment supported cast metal crowns. You say that the screws were put 
in your mouth last year and you need the crowns. You also say that you need to continue with the process 
because you are experiencing a lot of pain since the treatment is incomplete. The Plan denied your request. The 
Plan says this service is not covered under your benefit plan. 
 
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 eight 
abutment supported cast metal crowns (D6062 x8).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan Supartz. 
 
You asked the Plan to pre-approve Hyalgan Supartz. You say that the requested Hyalgan Supartz is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested 
Hyalgan Supartz.  
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 Hyalgan Supartz. Our reviewer says 
that the enrollee does not meet criteria for the requested Hyalgan Supartz. Our physician reviewer found the 
record indicates that the enrollee has a diagnosis of osteoarthritis of the knee. The record does not indicate that 
the enrollee has tried and failed or has a contraindication to non-pharmacologic therapies or simple analgesics. 
The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's 
condition. The Medicare approved drug compendia do not contain a supportive citation for the use of the 
requested drug in the enrollee's clinical situation. The elements of the coverage criteria are not satisfied. The 
requested service cannot be 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 Hyalgan Supartz have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Hyalgan Supartz.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that you would like the Plan to reconsider their denial. The 
Plan denied your request. The Plan says no records were provided to show you meet Medicare criteria for the 
requested CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections does not require frequent self-adjustment of insulin dosage based on the 
blood glucose testing results and has not had an in-person visit with their treating physician to assesses 
adherence to their CGM regimen and diabetes treatment plan. Based on this information, we decided that 
Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehension tissue disorder panel. 
 
You asked the Plan to pre-approve the requested testing. You say that the enrollee's condition may have genetic 
etiology. The Plan denied your request. The Plan says the genetic screening is not reasonable or necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested testing. Our physician 
reviewer found that the enrollee has a medical history of bilateral spontaneous dissection of the internal carotid 
arteries, as well as coronary artery disease and atrial fibrillation. Neuroimaging was suggestive of 
fibromuscular dysplasia. There are no specific genes associated with the classic form of fibromuscular 
dysplasia, however there can be phenotypic overlap with genetic connective tissue disorders such as forms of 
Ehlers-Danlos syndrome or other genetic disorders associated with vascular fragility/aneurysm or 
malformation. The clinical documentation is insufficient to support that the results of the testing will impact the 
clinical management of the enrollee in this case. The documentation does not support that a comprehensive 
tissue disorder panel is medically 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 the requested testing have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a comprehension tissue disorder panel.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prefabricated abutments (D6058), and abutment 
supported porcelain/ceramic crowns to be provided by a participating provider. 
 
You asked the Plan to pre-approve prefabricated abutments and abutment supported porcelain/ceramic crowns. 
You say that this dental work is medically necessary. The Plan denied your request. The Plan says the 
requested dental services are not a covered dental benefit. 
 
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 
prefabricated abutments (D6058), and abutment supported porcelain/ceramic crowns to be provided by a 
participating provider.
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 you require that are not available 
and being provided at the health care setting being offered by the health plan. The requested LTACH services 
are not medically necessary, reasonable, and appropriate for your diagnosis and condition and able to be 
furnished safely and effectively only on an inpatient basis. 
 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 14, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says this claim was not billed with the correct POS 
code. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on May 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism with recliner chair. 
 
You asked the Plan to pre-approve a seat lift mechanism with recliner chair. You say that this device is 
medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section 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 seat lift mechanism with recliner 
chair. Our reviewer says that the requested seat lift mechanism is not medically reasonable and necessary. Our 
physician reviewer found the documentation does not reveal objective imaging evidence of documentation of 
(a) severe arthritis of the hip or knee. and/or (b) a neuromuscular disease. The patient has a history of knee 
arthritis but there is no objective imaging documenting the severity. The seat lift is not likely to (a) effect improvement in the patient's condition; or (b) arrest or retard deterioration in the patient's condition. The 
records do not show that the patient is totally incapable of standing from a chair in the home. The patient has 
the ability to ambulate in the documentation. The patient does not meet the criteria for the seat lift mechanism 
and subsequently the recliner chair will not be 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 a seat lift mechanism with recliner chair have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a seat lift mechanism with recliner chair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and 
management of an established patient (99336) rendered by the out-of-network (OON) provider on October 22, 
2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established 
patient (99336) rendered by the out-of-network (OON) provider on October 22, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Supartz FX. 
 
You asked the Plan to pre-approve Supartz FX. You say that the enrollee has been stable on Supartz FX for 
years and the trial of other drugs would take up to 2 months to assess response. You say that this would delay 
treatment for their knee pain that is currently under control and could lead to knee replacement surgery. The 
Plan denied your request. The Plan says the enrollee must have tried and had an ineffective treatment response 
to all preferred agents.  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 Supartz FX. Our reviewer says that 
Synvisc-One is not approved, as step criteria have not been met. Our physician reviewer found that the enrollee 
has not trialed viscosupplement treatments such as Orthovisc and Euflexxa. Step therapy, as outlined by the 
plan, requires that these be trialed first. The documentation does not outline contraindications or reasons these 
medications were not considered or that the Plans additional 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 Supartz FX have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Supartz FX.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Leuprolide acetate injection (J9217) 
provided on January 20, 2022. 
 
You asked the Plan to waive the coinsurance for the Leuprolide acetate injection. You say that the services 
should be covered as you disagree with the charges. The Plan denied your request. The Plan says the 
coinsurance applied correctly based on the services 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 20% 
coinsurance for Medicare Part B prescription drugs, and the administration of them.  
 
 
  You have been asked to pay a 20% coinsurance for the Leuprolide acetate injection (allowed is $1,204.38 x 
20% = $240.88). Leuprolide acetate injections fall within the Medicare Part B prescription drugs 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 coinsurance for Leuprolide acetate injection (J9217) provided 
on January 20, 2022.