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

 
We decided that the Plan does not have to pre-approve liposuction by the Tri-Sculpt Body Contouring 
technique. 
 
You asked the Plan to pre-approve liposuction by the Tri-Sculpt Body Contouring technique. You say that this 
is not a cosmetic procedure, this will be done to correct the side effects of hormone therapy conducted in June 
2020. You say that the doctor recommends the procedure as you are in cardiovascular danger if the side effects 
of fat tissue are not corrected. The Plan denied your request. The Plan says this procedure is cosmetic in nature 
and will be provided by a provider who does not participate in Original Medicare that cannot bill medical 
claims. 
 
  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 liposuction by the Tri-Sculpt Body 
Contouring technique. Our reviewer says that the elements of the coverage criteria are not satisfied, and the 
requested service is not recommended. Our physician reviewer found the record provided does not indicate that 
the service requested is required for the prompt repair of accidental injury or to improve the functioning of a 
malformed body member. The record does not indicate that the service requested is to diagnose or treat an 
illness or injury or to improve the functioning of a malformed body member. The record provided also does not 
establish medical necessity and reasonableness, as defined by Medicare rules. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of liposuction by the Tri-Sculpt Body Contouring technique have not been met. 
Therefore, we decided that the Plan does not have to pre-approve liposuction by the Tri-Sculpt Body 
Contouring technique.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kerendia. 
 
You asked the Plan to pre-approve Kerendia. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for 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 Kerendia.  
 Benefits for Kerendia 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 use of Euflexxa. 
 You asked the Plan to pre-approve Euflexxa. You say that you need Euflexxa to be covered. The Plan denied 
your request. The Plan says the denial of authorization for this drug is correct, because the documentation does 
not show that you have not had a positive response to conservative therapies. 
 
The Plan follows Medicare rules. Medicare rules state that viscosupplementation with a drug such as Euflexxa 
may be covered if certain 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 Euflexxa. Our reviewer says that you 
do not meet the Medicare criteria for Euflexxa. Our physician reviewer found you have X-Ray findings of 
osteoarthritis. However, the record does not indicate that you have failed at least 3 months of conservative non-
pharmacologic therapy or that conservative therapy is contraindicated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Euflexxa.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the radiofrequency ablation of the sacroiliac joint. 
 
You asked the Plan to pre-approve the radiofrequency ablation of the sacroiliac joint. You say that the left 
sacroiliac nerves were blocked on October 26, 2021, providing 100% pain relief. You say that her pain has 
been refractory to conservative measures and clinical trials show favorable responses to sacroiliac joint 
radiofrequency ablation. The Plan denied your request. The Plan says radiofrequency ablation of the sacroiliac 
joint is not covered as it is considered investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that radiofrequency ablation used for sacro-iliac joint 
pain is considered not medically necessary/investigational whether performed using traditional, cooled, or 
pulsed radiofrequency.   We looked at the case file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the radiofrequency ablation of the sacroiliac joint have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the radiofrequency ablation of the sacroiliac joint.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies. 
 
You asked the Plan to pre-approve a CGM and supplies. You say that you are having trouble obtaining blood 
from your fingers because of poor circulation. The Plan denied your request. The Plan says that you are only 
taking one insulin injection per day. 
 
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 you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM) and supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ophthalmology services. 
 
You asked the Plan to pre-approve the requested services. You say that none of the providers can treat your 
condition. The Plan denied your request. The Plan says your eye case must be provided by the assigned POD. 
 Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case.  
 
We looked at the file and the Plan's rules. The requested provider is not one of your POD doctors. There are 
providers available for the services at issue in this case. Based on this information, we decided that the Plan's 
rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve ophthalmology services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional hours of personal care services per week. 
 
You asked the Plan to pre-approve the additional hours of personal care services. You say that you are left on 
three days a week without any personal care for dinner and bedtime. The Plan denied your request. The Plan 
says the assessment does not support the additional 4 hours of personal care services per week to manage your 
activities of daily living. 
 
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 the additional hours of personal care 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 additional hours of personal care services per week.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Insulin Lispro. 
 
You asked the Plan to pre-approve Insulin Lispro. The Plan denied your request. The Plan says this medication 
falls under the pharmacy (drug) benefit. 
 
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 Insulin Lispro.  
 
  Benefits for Insulin Lispro 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150), and intraoral 
radiographic images (D0210). 
 
You asked the Plan to pre-approve a comprehensive oral evaluation, and intraoral radiographic images. You 
say that you had to switch providers and the requested services are medically necessary. The Plan denied your 
request. The Plan says the services are covered benefits, but you have exceeded the frequency limit of one 
every 3 Plan years. 
 
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. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a comprehensive oral evaluation, and intraoral radiographic images have not been met. 
Specifically, the record shows that you had exceeded the frequency limit for these services on May 28, 2020. 
Therefore, we decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150), 
and intraoral radiographic images (D0210).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergent transport trips. 
 
You asked the Plan to pre-approve additional non-emergent transport trips. You say that the services are 
necessary. The Plan denied your request. The Plan says the enrollee exhausted their established twenty-four 
(24) one-way trips. 
 
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.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. The enrollee exhausted their 
established twenty-four (24) one-way trips. Therefore, we decided that the Plan does not have to pre-approve 
additional non-emergent transport trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies (K0553), 
provided on April 22, 2021. 
 
You asked the Plan to pay for the CGM supplies. You say that the items were medically necessary. The Plan 
denied your request. The Plan says there was not a valid physician order. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order. There is no evidence the treating physician ordered these 
items. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) 
supplies (K0553), provided on April 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided necessitating admission to a LTACH. The 
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at 
the LTACH that are not available at the present setting where she is currently receiving care. There are no 
services available at the LTACH that the enrollee requires that are not available at the health care setting being 
offered by the health plan. 
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial denture and a denture relining to be provided 
by a participating provider. 
 
You asked the Plan to pre-approve a partial denture and a denture relining. You say that your dentures kept 
breaking. You say that you need these dentures fixed. The Plan denied your request. The Plan says the benefit 
limit for the requested dental work 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 a partial 
denture and a denture relining when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. Evidence was provided to show that the medical rules for the 
requested dental services have already been met. Based on this information, we decided that the Plan's rules for 
coverage of a partial denture and a denture relining have already been met. Therefore, we decided that the Plan 
does not have to pre-approve a partial denture and a denture relining to be provided by a participating provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve manual therapy techniques (97140), moderate 
complexity physical therapy evaluation (97162), high complexity physical therapy evaluation (97163), and re-
evaluation of physical therapy established plan of care (97164) to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve the manual therapy techniques, physical therapy evaluations, and re-
evaluation of physical therapy established plan of care. You say that you recommend that this enrollee only be 
seen by you. The Plan denied your request. The Plan says the enrollee must use network providers to get 
medical care and services when there are network providers available. The Plan also says that the records show 
no medical need as to why the enrollee cannot get this physical therapy from a provider in the Plan's network. 
 
  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 
manual therapy techniques (97140), moderate complexity physical therapy evaluation (97162), high 
complexity physical therapy evaluation (97163), and re-evaluation of physical therapy established plan of care 
(97164) 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 services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve home health services. You say that you are in urgent need of home services 
The Plan denied your request. The Plan says there are in network providers available to provide these services. 
 
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 
home health services to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fasenra Pen injection. 
 
You asked the Plan to pre-approve Fasenra. You say that the enrollee has not tolerated the approved product 
well. You also say that the enrollee has previously tried Fasenra and had success. The Plan denied your request. 
The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are 
covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered 
under Medicare 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 Fasenra Pen injection.  
 Benefits for Fasenra 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical stent, unspecified removable prosthodontic 
procedure, modification of removable prosthesis following implant surgery, cone beam - both jaws, and 
surgical placement of mini implant - Tooth #22, #25, #25, #27. 
 
You asked the Plan to pre-approve a surgical stent, unspecified removable prosthodontic procedure, 
modification of removable prosthesis following implant surgery, cone beam - both jaws, and surgical 
placement of mini implant - Tooth #22, #25, #25, #27. You say that the services are necessary. The Plan denied 
your request. The Plan says the requested services are not a covered 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 a surgical stent, unspecified removable 
prosthodontic procedure, modification of removable prosthesis following implant surgery, cone beam - both 
jaws, and surgical placement of mini implant - Tooth #22, #25, #25, #27.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve plastic surgery services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that multiple medical therapies have been tried in 
the past. The Plan denied your request. The Plan says the services can be provided within the network. 
 
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 
plastic surgery services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cervical collar (L0180), provided on April 5, 2021. 
 
You asked the Plan to pay for the cervical collar. You say that the items are medically necessary. The Plan 
denied your request. The Plan says the documentation submitted did not indicate the provider discussed the 
need for the billed supply code 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order or relevant medical records which support medical 
necessity for the supplies provided in this case. There is no indication the treating physician discussed the need for this item or that it is medically necessary. The record shows that the Plan made several attempts to obtain 
the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the 
cervical collar (L0180), provided on April 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve OON services. You say that the service is sleep apnea treatment. The Plan 
denied your request. The Plan says services are available from providers in the network. 
 
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.  
 
We looked at the file, and Medicare rules. Dental services are only covered when provided by a Plan provider. 
Based on this information, we decided that the Plan's rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pre-approve dental services to be provided by an out-of-network 
provider.