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

 
We decided that the Plan does not have to pay for the aqueous shunt prosthesis (L8612), aqueous shunt 
(66180), sterile Cefuroxime injection (J0697), Dexamethasone (J1100), Lidocaine injection (J2001), and 
Midazolam hydrochloride (J2250) provided on February 28, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the aqueous shunt prosthesis, aqueous shunt, sterile Cefuroxime, 
Dexamethasone, Lidocaine, and Midazolam hydrochloride. You say that you attempted to obtain an 
authorization and were advised by a representative that no prior authorization was required. The Plan denied 
your request. The Plan says these services were rendered by a non-participating provider and the Plan did not 
authorize any services. The Plan also says that there is no referring provider involved in 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 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 
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 aqueous shunt prosthesis (L8612), aqueous 
shunt (66180), sterile Cefuroxime injection (J0697), Dexamethasone (J1100), Lidocaine injection (J2001), and 
Midazolam hydrochloride (J2250) provided on February 28, 2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services (J3411, J3415, J3490, and J7999) 
provided on October 20, 2021. 
 
You asked the Plan to pay for the injection services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 We looked at the file, the Plan's contract and Medicare rules. In this case, medications are pre-mixed and would 
not be reported separately. Therefore, we decided that the Plan does not have to pay for the injection services 
(J3411, J3415, J3490, and J7999) provided on October 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the Monovisc injection and arthrocentesis provided on 
February 8, 2022. 
 
You asked the Plan to pay for the Monovisc injection and arthrocentesis. You say that part of the claim was 
denied because physician assistants aren't listed with the Plan. You say that the claim should be corrected and 
paid. The Plan denied your request. The Plan says the claim processed 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 20% 
coinsurance for Medicare Part B drugs at an in-network PCP's office, specialist's office or pharmacy. Your 
contract with the Plan clearly says that you must pay a $50 copayment for provider and professional services at 
an in-network specialist's office. 
  You have been asked to pay a total of $318.86 for the Monovisc injection and arthrocentesis.  
 
Service Allowed Amount Cost Share Member Liability Plan Paid 
Monovisc Injection $1,344.32 20% $268.86 $1,075.46 
Arthrocentesis $85.62 $50 $50 $35.62 
TOTAL:   $318.86 $1,111.08 
 
The Monovisc injection falls within the "Medicare Part B Prescription Drugs" benefit category. The 
arthrocentesis 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 
and the correct amount was paid by 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 pay more for the Monovisc 
injection and arthrocentesis provided on February 8, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychotherapy office visit provided on January 31, 2022. 
 
You asked the Plan to pay for a psychotherapy office visit. You say that the service was provided with no 
adequate time frame to obtain authorization for the service. The Plan denied your request. The Plan says the 
out-of-network services were not authorized. 
 
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 a psychotherapy office visit provided on January 
31, 2022 by an OON provider.
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 you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 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 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a diagnosis of age-related osteoporosis without current pathological fracture. The 
documentation does not contain documentation of trial and failure of zoledronic acid. The documentation does 
not support that zoledronic acid would likely be less effective, and/or would likely have adverse effects for the 
enrollee in this case. Therefore, the enrollee does not meet criteria for the requested drug. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for full series of x-rays (D0210) provided by a participating 
provider March 25, 2022. 
 
You asked the Plan to pay for full series of x-rays. You say that you would like the Plan to pay for this. The 
Plan denied your request. The Plan says the benefit limit for D0210 has already been met and 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 full series 
of x-rays every five years.  
 
We looked at the file and Medicare rules. Evidence was provided to show that D0210 was previously provided 
on May 10, 2019. Based on this information, we decided that the Plan's rules for coverage of full series of x-
rays have not been met. Therefore, we decided that the Plan does not have to pay for full series of x-rays 
(D0210) provided by a participating provider on March 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0230) and an unspecified preventative 
procedure (D1999), provided by a participating provider on January 26, 2022. 
 
You asked the Plan to pay for intraoral imaging and an unspecified preventative procedure. You say that you 
believe the Plan should pay for this. The Plan denied your request. The Plan says the services provided have 
been processed correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers one intraoral 
imaging every year. The Plan does not cover an unspecified preventative procedure. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of intraoral imaging have not been met. An unspecified preventative procedure is not a covered dental 
benefit. Therefore, we decided that the Plan does not have to pay for intraoral imaging (D0230) and an 
unspecified preventative procedure (D1999), provided by a participating provider on January 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom frame; two custom profile side guards; 
Bodypoint mobility bag; luggage carrier; two aluminum right removable side guards; two black Neoprene 
impact guards; and a catch all, 16 to 18-inch width (CPT code K0108). 
 
You asked the Plan to pre-approve the items. You say that due to hemicorpectomy with amputation 
translumbar level, you feel that is medically necessary for the ultralightweight wheelchair and wheelchair 
components or accessories. The Plan denied your request. The Plan says the items are not necessary. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured.  
 Therefore, we decided that the Plan does not have to pre-approve custom frame; two custom profile side 
guards; Bodypoint mobility bag; luggage carrier; two aluminum right removable side guards; two black 
Neoprene impact guards; and a catch all, 16 to 18-inch width (CPT code K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom power wheelchair. 
 
You asked the Plan to pre-approve a custom power wheelchair. You say that you have back pain. The Plan 
denied your request. The Plan says you do not meet criteria for the requested item. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 The file shows that your condition can be improved by a walker, cane or manual wheelchair. In addition, the 
custom power wheelchair at issue in this appeal is being requested for use outside of the home. Although this 
item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. This means that 
Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a custom power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for refractions (92015) provided March 10, 2022. 
 You asked the Plan to pay for the refractions. You say that this service should be covered. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
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. The Plan covers these services when performed by an optometrist as part of a routine vision exam. 
 
We looked at the file and the Plan's rules. This service was provided by an ophthalmologist and was not part of 
a routine vision exam. Based on this information, we decided that the Plan's rules for coverage of the 
refractions have not been met. Therefore, we decided that the Plan does not have to pay for refractions (92015) 
provided March 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 3, 2022. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration for the office 
visit. The Plan denied your request. The Plan says the out-of-network services were not authorized. 
 
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 an office visit provided by an OON provider on 
January 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for a vitrectomy recovery equipment chair provided 
on December 22, 2021. 
 
You asked the Plan to reimburse you for a vitrectomy recovery equipment chair. You say that you were told by 
your surgeon to order the requested item. You submitted the rental amount for 7 days right away hoping to be 
reimbursed as soon as possible only to receive a denied letter. You are asking for reconsideration as you say 
this is medically necessary for your surgery recovery. The Plan denied your request. The Plan says the provider 
is not under contract with the health plan and is not certified with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to reimburse you for a vitrectomy recovery 
equipment chair provided on December 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Testost Cyp. 
 
You asked the Plan to pre-approve Testost Cyp. 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 Testost Cyp.  
 
Benefits for Testost Cyp 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultrasound of the heart with color-depicted blood 
flow, rate, direction and valve function. 
 
You asked the Plan to pre-approve an ultrasound of the heart. You say that you require a repeat 
echocardiogram to assess the enrollee's current status so you can further manage his heart failure and prevent 
hospitalizations and/or mortality. The Plan denied your request. The Plan says the enrollee does not meet the 
criteria for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that ultrasound diagnostic procedures are subject to the 
criteria listed in the Medicare rules section. 
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an ultrasound of the heart. Our reviewer 
says that an ultrasound of the heart is not medically reasonable and necessary. Our physician reviewer found 
there has been no re-evaluation suggesting change in function or symptoms. There has been no recent change 
in medication. The enrollee's last echocardiogram was one year ago. Our reviewer found that the current 
guidelines consider repeat echocardiography at less than one year inappropriate under these circumstances. The 
guidelines do not specifically recommend a frequency for stable patients without change, nor do they 
recommend yearly testing. Our physician reviewer also found that the enrollee does not meet any of the 
nationally covered indications for coverage of an ultrasound of the heart with color-depicted blood flow, rate, 
direction and valve 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 an ultrasound of the heart have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an ultrasound of the heart with color-depicted blood flow, rate, direction and 
valve function.
Appeal type: DME/ Orthotics
Decision: Unfavorable

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

 
We decided that the Plan does not have to pre-approve expandable controller, including all related electronics 
and mounting hardware, upgrade provided at initial issue (CPT code E2377), harness for upgrade to 
expandable controller, including all fasteners, connectors and mounting hardware (CPT code E2313), 
electronic connection between wheelchair controller and two or more power seating system motors, including 
all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware 
(CPT code E2311) new push handle assy tru balance, bracked assy footplate width ext, and accessory assy rear 
(CPT code K0108 x3). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the DME is not necessary. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The push handles do not serve a medical purpose and are never covered by Medicare. The upgraded electronics 
(expandable controller, harness and electronic connector to 2 power options) are not medically necessary. They 
are necessary when there is a medical need to control power options through the joystick.  The notes do not show a medical need to control the power options through the joystick. The power options can 
be controlled using their own switches. These switches can be made any size without asking for a separate 
request. They can be made from material without asking for a separate request. All of this can be done without 
the need to use the joystick to control the power properly. The back cushion comes with mounting hardware. 
These cannot be covered separately. Therefore, we decided that the Plan does not have to pre-approve 
expandable controller, including all related electronics and mounting hardware, upgrade provided at initial 
issue (CPT code E2377), harness for upgrade to expandable controller, including all fasteners, connectors and 
mounting hardware (CPT code E2313), electronic connection between wheelchair controller and two or more 
power seating system motors, including all related electronics, indicator feature, mechanical function selection 
switch, and fixed mounting hardware (CPT code E2311) new push handle assy tru balance, bracked assy 
footplate width ext, and accessory assy rear (CPT code K0108 x3).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G Orthotic device (CPT code 
L8702). 
 
You asked the Plan to pre-approve the MyoPro Motion G Orthotic device. You say that the device is necessary. 
The Plan denied your request. The Plan says the enrollee's request is not medically necessary because the 
medical records provided for review from the enrollee's treating providers do not document failure of standard 
modalities and/or devices used in their rehabilitation that the MyoPro was recommended for the enrollee or if 
the MyoPro is the only device appropriate for the enrollee. The Plan states the medical records do not support 
medical necessity and whether this device meets but does not exceed their needs. The Plan states peer reviewed 
literature considers the use of robotic therapy for upper and lower extremity stroke rehabilitation to be 
investigational in nature with no long-term outcome data at this time. 
 
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 MyoPro Motion G Orthotic device. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the requested device is used for the upper extremity. It is an arm brace 
that is motorized and can help an individual with upper extremity weakness to move their arm and hand. The 
requested device has not been shown to be superior to other standard treatments for the medical condition. The studies do not indicate the MyoPro brace improves an individuals function or general health. The requested 
device is not medically 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 the MyoPro Motion G Orthotic device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the MyoPro Motion G Orthotic device (CPT code L8702).