Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve twenty-four (24) additional routine transportation trips 
(A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you disagree with the 
denial. The Plan denied your request. The Plan says additional trips would exceed your benefit limit. 
 
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 trips per year.  
 
 We looked at your request, the records in the case file, and the rules. The records show that you have used 
twenty-two (22) one-way transportation trips out of the allowed twenty-four (24) one-way trips approved. Once 
24 trips are used, the benefit will be exhausted. Based on this information, we decided that the Plans rules for 
coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-
approve twenty-four (24) additional routine transportation trips (A0120).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy requirements 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 Prolia. Our reviewer says that the 
requirements for coverage of Prolia have not been met. Our physician reviewer found the Plan requires a trial 
of zoledronic acid before they will approve the requested drug. In this case, the enrollee has not tried and failed 
zoledronic acid. There is no documentation provided indicating that zoledronic acid would likely be less 
effective or 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Olumiant. 
 
You asked the Plan to pre-approve Olumiant. You say that you believe this treatment is warranted, appropriate, 
and medically necessary. The Plan denied your request. The Plan says Olumiant is a self-administered drug and 
does not fall under Part B 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 Olumiant.  
 
Benefits for Olumiant 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (44602) provided on May 7, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
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 44602 is "Suture of small intestine (enterorrhaphy) for 
perforated ulcer, diverticulum, wound, injury or rupture; single perforation". 
 
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 the services. Our reviewer says that the use of code 44602 is 
not supported by the records provided. Our reviewer found that there is a more appropriate CPT code that 
describes the location of the procedure performed. 
 
We looked at this coder'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 pay for the services (44602) provided on May 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an advanced knee and foot feature. 
 You asked the Plan to pre-approve the requested items. You say that the enrollee meets the definition of a 
functional level 3 amputee. The Plan denied your request. The Plan says a level 3 knee and foot exceeds the 
enrollee's needs. 
 
The Plan follows Medicare rules. Medicare rules say that lower limb prostheses are only covered under certain 
medical indications. 
 
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 items. Our physician 
reviewer found that the Ossur OP4 knee helps to walk or run with appropriate knee response. It will help the 
enrollee participate in high impact activities. The physician documentation does not support that this enrollee 
requires this advanced knee for running, high impact activities, or his functional level. The enrollee was noted 
to use a four-wheeled walker. It is not clear that he will be unable to ambulate without a walker or cane after 
his new prosthesis, which would not be consistent with a K3 level ambulatory function. 
 
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 items have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an advanced knee and foot feature.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PureWick urine collection system. 
 
You asked the Plan to pre-approve incontinence supplies. You say that severe incontinence wakes you 3 or 
more times a night to urinate. The PureWick allows you to stay in bed without worry of injury from a fall while 
attempting o go to the bathroom. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve PureWick urine collection 
system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more towards the medical eye exam and the eye refraction 
provided on April 12, 2022. 
 
You asked the Plan to pay more towards the medical eye exam and the eye refraction. You say that you should 
not have to pay the $30 copayment because you did not see a specialist. You say the refraction should be billed 
to the eye insurer. The Plan denied your request. The Plan says this cost sharing was charged 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 $30 
copayment for each visit to a specialist, such as an ophthalmologist or optometrist, for Medicare-covered 
benefits and eye refractions are only covered during a routine exam.  
 
You have been asked to pay a $30 copayment for the medical eye exam. The medical eye exam falls within the 
vision care benefit category. The record shows the provider is considered a specialist. You have also been 
asked to pay $42 for the eye refraction. The record shows the eye refraction was done during a medical eye 
examination. This means that you have been asked to pay the correct amount based on your contract with the 
Plan. Therefore, we decided that the Plan does not have to pay more towards the medical eye exam and the eye 
refraction provided on April 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
and supplies (K0553, K0554). 
 
You asked the Plan to pre-approve a Freestyle Libre CGM and supplies. You say that you disagree with the 
denial. The Plan denied your request. The Plan says the enrollee does not meet coverage criteria for the 
requested items. 
 
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 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 a Freestyle 
Libre CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre continuous glucose monitor (CGM) and supplies (K0553, K0554).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cala Trio nerve stimulator device and supplies. 
 
You asked the Plan to pre-approve Cala Trio nerve stimulator device and supplies. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the requested device is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that electric nerve stimulation use in the treatment of 
motor function disorders is not proven and therefore, not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Cala Trio nerve stimulator device and supplies have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Cala Trio nerve stimulator device and supplies.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81439). 
 
You asked the Plan to pre-approve genetic testing. You say that the test is medically necessary. The Plan 
denied your request. The Plan says the requested service is not medically necessary. Medicare has determined 
that testing for cardiomyopathy is not a medically necessary test. 
 
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 genetic testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a 7-year-old son with syncope. The provider has recommended the enrollee get 
genetic testing and if she is positive, her son will be tested. Medicare states that testing would be performed to 
confirm an established diagnosis or on individuals already diagnosed with cardiomyopathy to identify family 
members at risk. The determination of medical necessity must be tailored to the individual enrollee and their 
unique clinical scenario. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genetic testing (81439).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve golimumab (J1602). 
 
You asked the Plan to pre-approve golimumab. You say that the requested medication is medically necessary 
for the enrollee. The Plan denied your request. The Plan says the requested medicine is not medically 
necessary. 
 
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.  
 
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 golimumab. Our reviewer says that the 
requested drug, golimumab, is not medically necessary. Our physician reviewer found the provided records 
indicate the enrollee had a negative hepatitis B surface antigen test result from November 2021. The reviewer 
found there is no evidence of a negative chest x-ray. The reviewer found that with the negative test result in 
November 2021, it is reasonable and necessary to require a negative chest x-ray result before approving 
coverage for the golimumab. Therefore, the requested drug is not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of golimumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve golimumab (J1602).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pneumatic compression device (E0651) and 
segmental pneumatic appliance (E0667) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the pneumatic compression device and appliance. You say that you are the 
exclusive provider in the State of Arizona for the Lymphapress product. Please review the attached 
documentation for an appeal for reconsideration of an in-network GAP for the enrollee. The Plan denied your 
request. The Plan says enrollees must receive their medical services from an in-network provider with the 
exception being urgent or emergent services. Non-emergent services with non-contracted providers require 
prior authorization before services being rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the pneumatic compression device (E0651) and segmental pneumatic appliance (E0667) to be provided by an 
out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on March 28, 2022. 
 
You asked the Plan to pay for psychotherapy. You say the service was medically necessary. The Plan denied 
your request. The Plan says the provider must attempt to consult the attending or primary care physician about 
the services furnished and document the consent or declination date to consultations, and the date of 
consultations in the patients medical record. There was no documentation of contact in the patient record. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for psychotherapy provided on March 28, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee is not ready to be discharged. The Plan 
denied your request. The Plan says the record does not show that the enrollee requires daily skilled nursing or 
skilled therapy in a SNF setting 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that daily skilled services are not required. There is no documentation that the 
enrollee requires services on an inpatient basis, only in a skilled nursing facility setting. Records support that 
services in the home with home health care or in a long-term care facility on a part time basis are more 
appropriate 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the medical records provided there is no documentation that you require the 
services on an inpatient basis, only in a skilled nursing facility setting. Records do not support that services in 
the long-term care facility on a part time basis are not appropriate 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve saline syringes (A4216). 
 
You asked the Plan to pre-approve the syringes. You say that the supplies are medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that supplies for the routine intermittent irrigations of 
a catheter will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. The requested syringes are for use for routine catheter irrigations. 
Based on this information, we decided that Medicare rules for coverage of the syringes have not been met. 
Therefore, we decided that the Plan does not have to pre-approve saline syringes (A4216).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Budesonide for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that other therapies were not effective for the enrollee. 
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 Budesonide 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: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve eight (8) home physical therapy visits. 
 
You asked the Plan to pre-approve home health services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that that there is no documentation of an active or acute chronic 
condition that would necessitate a new program. 
 
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 home health services. Our reviewer 
says that eight (8) home physical therapy visits are medically reasonable and necessary. You have functional 
impairments and would continue to require the professional assessment and treatment of a physical therapist for 
durable medical equipment evaluation and safety of mobility. Our physician reviewer found that your condition 
meets Medicare criteria for eight (8) home physical therapy visits. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have been met. Therefore, we decided that the Plan has to 
pre-approve eight (8) home physical therapy visits.  
 
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.