Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6531. 
 You asked the Plan to pre-approve the compression stockings. You say that you are appealing the denial of the 
pre-service request for gradient compression stockings. The Plan denied your request. The Plan says there is no 
documentation that the enrollee has a qualifying wound present. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6531 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code 
A6531.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for outpatient diagnostic testing provided on 
November 9, 2021, and a pulse oximetry provided on November 15, 2021. 
 
You asked the Plan to waive the cost share for outpatient diagnostic testing and a pulse oximetry. You say that 
you were under the assumption that since testing was done during an office visit you would only be responsible 
for the $35 copayment. You also say that the office should have used an in-network oxygen company. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $35 copayment for a routine x-ray service. The Plan contract also says that enrollees must pay a 
$150 copayment for other outpatient diagnostic testing. The contract also says if you receive additional 
services, cost sharing for those services may apply.  
 
The record shows these claims were approved, and there is a cost sharing amount. You have been asked to pay 
the allowed amount of $24.45, which is less than the $35 copayment for a chest x-ray on November 9, 2021. 
You have also been asked to pay the allowed amount of $43.64, which is less than the $150 copayment for a 
spirometry test on November 9, 2021. You have also been asked to pay the allowed amount of $55.63, which is 
less than the $150 copayment for a diffusing capacity test on November 9, 2021. You have been asked to pay a 
total of 99.27 on this claim ($43.64 copayment + $55.63 copayment = $99.27). You have also been asked to 
pay the allowed amount of $36.33, which is less than the $150 copayment for a pulse oximetry test on 
November 15, 2021. An x-ray, a spirometry test, a diffusing capacity test, and a pulse oximetry test fall within 
the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that the 
enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a 
contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan 
does not have to waive the cost share for outpatient diagnostic testing provided on November 9, 2021, and a 
pulse oximetry provided on November 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sensor, invasive (e.g., subcutaneous), disposable, for use 
with interstitial continuous glucose monitoring system, one unit = 1 day supply (A9276). 
 
You asked the Plan to pre-approve sensor for non-therapeutic continuous glucose monitor. You say that the 
medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says 
this item is not a covered benefit because you are requesting supplies for a non-therapeutic device which is not 
covered under Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Services related to non-covered services are not covered under 
Medicare. Based on this information, we decided that Medicare rules for coverage of sensor for non-therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve sensor, invasive (e.g., subcutaneous), disposable, for use with interstitial continuous glucose 
monitoring system, one unit = 1 day supply (A9276).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 10, 2021. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says there are no 
out-of-network benefits. 
 
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 physician's services provided on March 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ankle orthosis and accessories. 
 
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 medical records do not indicate the required conditions for coverage. 
 
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 records do not support necessity of a custom orthosis. Based on the medical records provided, there 
is no documentation that the enrollee's right ankle requires stabilization for medical reasons. 
 
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 an ankle orthosis and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient treatment provided on April 20, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient treatment. You say that you were told you did not need an 
authorization and you submitted the claim to get a not covered denial. The Plan denied your request. The Plan 
says the rendering provider is an out-of-network provider and there was no referral from an in-network 
provider or an approved authorization. Also, the service rendered was not urgent or emergent. 
 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 had network providers 
available who could have provided the items/services at issue in this appeal. 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 outpatient treatment provided on April 20, 
2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sphenopalatine ganglion block (64999). 
 
You asked the Plan to pre-approve sphenopalatine ganglion block. You say that the enrollee has persistent 
debilitating symptoms that interfere with their daily functions. The Plan denied your request. The Plan says this 
procedure is considered investigational and experimental as there is currently insufficient evidence to 
recommend this procedure as safe and effective for migraine pain. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of sphenopalatine ganglion block have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sphenopalatine ganglion block (64999).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network 
(OON) provider on January 27, 2022.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
 
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 office visit (99214) rendered by the out-of-network (OON) provider on January 27, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a hip x-ray provided on December 10, 
2021. 
 
You asked the Plan to waive the copayment for a hip x-ray. You say that the doctor took a picture of your hip 
in his office, and you were not sent to any lab for an x-ray. 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 $50 
copayment for in-network x-ray.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay 
$30, which is less than the $50 copayment for a hip x-ray. A hip x-ray falls within the Outpatient Diagnostic 
Tests and Therapeutic Services and Supplies 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 hip x-ray provided on December 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an oncology specialist office visit provided 
on May 11, 2021. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you refuse to pay the 
copayment due to your experience with the doctor. 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 $30 
copayment for a specialist office visit.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$30 copayment for a specialist office visit. A specialist office visit falls within the Physician/Practitioner Services, Including Doctors Office Visits benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for an oncology specialist office visit provided on May 11, 2021.  
 
Your complaint about the way the doctor spoke to you during your appointment is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve computed tomography (CT) scan of the colon. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary, due to a failed 
colonoscopy five years ago. The Plan denied your request. The Plan says that it is not evident that a standard 
colonoscopy could not be attempted given the successful flexible sigmoidoscopy. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 scan. Our reviewer says that the 
requested scan is medically reasonable and necessary. Our physician reviewer found the muscular hypertrophy 
and segmental thickening noted on the prior CT can be expected to still be present. Despite the successful 
sigmoidoscopy to 45 cm, the exact length of colon where the prior abnormal stricture was noted is impossible 
to correlate to the level noted at direct visualization. It is reasonable to assume a repeat attempt of direct 
colonoscopy 5 years later may well be unsuccessful due to the scarring, narrowing and angulation note 
previously. It makes the most sense to follow with a CT colonoscopy especially as a baseline was established 5 
years ago. 
 
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 scan have been met. Therefore, we decided that the Plan has to pre-approve 
computed tomography (CT) scan of the colon.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zilretta (J3304). 
 
You asked the Plan to pre-approve Zilretta. You say that Zilretta is medically necessary. The Plan denied your 
request. The Plan says a trial of dexamethasone injection and methylprednisolone injection is required before 
alternatives can be considered. 
 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 Zilretta. Our reviewer says that Zilretta 
is not medically necessary. Our physician reviewer found the record does not a show a trial of the plan 
preferred drugs or any reason they would be unsafe or ineffective 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 Zilretta have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Zilretta (J3304).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram (ECG) provided on 
December 3, 2021. 
 
You asked the Plan to waive the copayment for the ECG. You say that you should only be responsible for the 
$45 specialist copayment. 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 $30 
copayment for non-radiological diagnostic tests, including ECG/EKG's.  
 
You have been asked to pay $14.74, which is less than the $30 copayment for the ECG. Please note that the test is separate from the office visit charge and is subject to the appropriate copayment. The ECG falls within the 
Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for an electrocardiogram (ECG) provided on December 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient treatment provided on March 23, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient treatment. You say that you were told you did not need an 
authorization and you submitted the claim to get a not covered service denial. The Plan denied your request. 
The Plan says the rendering provider is an out-of-network provider and there was no referral from an in-
network provider or an approved authorization. Also, the service rendered was not urgent or emergent. 
 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 had network providers 
available who could have provided the items/services at issue in this appeal. 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 outpatient treatment provided on March 23, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient office visit provided on November 19, 2021. 
 
You asked the Plan to pay for a new patient office visit. The Plan denied your request. The Plan says Medicare 
will not cover Evaluation / Management services rendered by a Chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for a new patient office visit provided on November 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex device. 
 
You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically 
necessary. The Plan denied your request. The Plan says the requested Vertiflex device is not medically 
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 a Vertiflex device. Our reviewer says 
that the requested Vertiflex device is not medically necessary. Our physician reviewer found the enrollee was 
being treated for spinal stenosis, lumbar region with neurogenic claudication. He presented with chronic low 
back pain. The pain has just recently started worsening. He noted 2 days of 100% pain relief with the right L4 
transforaminal epidural steroid injection. The lumbar exam reveals pain with extension at 10 degrees. There is 
tenderness to palpation of the right paraspinal. Facet loading is positive on the right. 
 
Current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the gold standard of lumbar laminectomy. There is a lack of large 
volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees medical 
condition as discussed above. 
 
There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception to guidelines. Therefore, the requested Vertiflex Superion interspinous device at 
L4-5 is not medically reasonable or 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 a Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Vertiflex device.