Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture services (97810). 
 
You asked the Plan to pre-approve the acupuncture services. You say that the services are medically necessary. 
The Plan denied your request. The Plan says rules for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that treatments may be provided by a physician in 
accordance with state requirements, or by physician assistants, nurse practitioners/clinical nurse specialists, and 
auxiliary personnel if they meet certain licensure requirements. Auxiliary personnel furnishing acupuncture 
must be under the appropriate level of supervision of a physician, physician assistant, or nurse 
practitioner/clinical nurse specialist. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the services are not being provided by or under the supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist. Therefore, we 
decided that the Plan does not have to pre-approve acupuncture services (97810).
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 SNF admission is medically necessary. The Plan 
denied your request. The Plan says you do not meet criteria for SNF care and the services you require, such as 
additional therapy services, can be safely received in a different setting such as at home with home health, in 
residential care, or at home with close follow-up with your doctor. 
 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 daily 
skilled services are not necessary. Our physician reviewer found that you do not have daily skilled nursing 
needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not 
have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 
skilled nursing facility (SNF) setting. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses (V2020, V2303, V2750) purchased on 
January 12, 2022. 
 
You asked the Plan to pay for the eyeglasses. You say that you were told you had a $300 benefit allowance for 
these services, and the provider applied this amount to your cost, and you paid the rest. You do not understand 
what is denied. The Plan denied your request. The Plan says you have used your full eyewear benefit on the 
date in question, and you are responsible for the charges that exceeded the $300 allowance. 
 
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 up to $300 every calendar year. 
 
We looked at the file and the Plan's rules. Based on the documentation provided, the Plan applied the full $300 
allowance at the time of services. The amount denied in this case is the $254 which exceeded the allowance. 
Please note that if you paid this at the time of service, you are not responsible for any additional amount, but 
you are also not entitled to reimbursement for this amount. The Plans denial notice is not a bill. Therefore, we 
decided that the Plan does not have to pay for the eyeglasses (V2020, V2303, V2750) purchased on January 12, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT 
code(s): 22869 and 22870). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to 
insufficient evidence of efficacy. 
 
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 items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertilfex device is experimental. More research is needed to show safety and efficacy. 
 
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 the Vertiflex superion device placement surgery (CPT code(s): 22869 and 22870).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you have no one at home to help you and are at risk 
of falling again. The Plan denied your request. The Plan says based on Medicare guidelines, the requested IRF 
services do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you are medically stable and do not need physical medicine and rehabilitation physician close supervision 3 times per week (at a minimum) for the ongoing management of any active or 
acute exacerbations of chronic medical conditions. You have no rehabilitation nursing needs identified or 
documented in the record. You do not need 3 hours a day five days a week of IRF therapies with 
interdisciplinary management. The complexity of your nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient rehabilitation stay with an interdisciplinary approach to rehabilitation care. 
While you may benefit from physical therapy and occupational therapy, your rehabilitation needs can be 
addressed at a low intensity alternate setting such as in a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 the enrollee is receiving appropriate care at the present acute care hospital. 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. The requested LTACH service are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that the requested Euflexxa is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for Euflexxa. 
 
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 Euflexxa. Our reviewer says that the 
enrollee does not meet criteria for Euflexxa. Our physician reviewer found the enrollee is with osteoarthritis of bilateral shoulders. She has previously received injections of hyaluronate products (Euflexxa series) in both 
shoulders in May 2020 and December 2020. Her provider has recommended Euflexxa 10mg/ml injections for 
bilateral shoulders. According to the coverage criteria, repeat hyaluronate injections for the shoulder are limited 
to a single repeat course. The enrollee has already had one repeat injection of hyaluronate products into each 
shoulder. The review has determined that the enrollee does not meet criteria for Euflexxa. 
 
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 Euflexxa.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Laboratory services provided on December 14, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Laboratory services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and it was determined 
these services were 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 Laboratory services provided on December 14, 
2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hydrocodone/acetominophen. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
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 
hydrocodone/acetominophen.  
 Benefits for these services 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the criteria for coverage are not met. 
 
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 treat with insulin three 
or more times per day or use an insulin pump. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Genetic Testing provided on October 12, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Genetic Testing. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and it was 
determined these services were 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 Genetic Testing provided on October 12, 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 domiciliary services provided on November 26, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for domiciliary services. You say that that it isn't your responsibility to obtain prior 
authorization. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 domiciliary services provided on November 26, 
2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography angiography (CTA) scan of the 
abdominal aorta. 
 
You asked the Plan to pre-approve CTA scan of the abdominal aorta. You say that this imaging service is 
medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. 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 CTA scan of the abdominal aorta. Our 
reviewer says that the requested imaging services is not medically reasonable and necessary. Our physician 
reviewer found at issue is the medical appropriateness and necessity of CTA of the abdominal aorta. Your 
physician has expressed a need for cardiac evaluation and a stress test has been ordered. Clinical guidelines for 
the use of CTA of the abdominal aorta have not been met based on review of the submitted clinical 
documentation. As a result, at this time CTA of the abdominal aorta would not be considered medically 
reasonable and necessary in your clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CTA scan of the abdominal aorta have not been met. Therefore, we decided that 
the Plan does not have to pre-approve computed tomography angiography (CTA) scan of the abdominal aorta.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nplate (CPT code J9999) and Opdualag 
(Nivolumab/Relatlimab-RMBW) (CPT code J2796). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessity for the 
enrollees skin cancer. The Plan denied your request. The Plan says the use of this drug/regimen is not 
reasonable and necessary. The Plan states the documentation does not support that the enrollee has: an accepted 
medical indication for Opdualag (nivolumab + relatlimab). The Plan states the use of this drug in the enrollee's 
case requires: Opdualag be used as first-line systemic therapy for cutaneous melanoma. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 medication. Our physician reviewer 
found Nplate is indicted for patients with idiopathic thrombocytopenic purpura, whose degree of 
thrombocytopenia and clinical condition increases the risk for bleeding. The documentation does not support 
that the enrollee has idiopathic thrombocytopenic purpura. Nivolumab/relatlimab-rmbw is not approved by the 
US FDA for the treatment of patients with metastatic uveal melanoma.  The use of Nivolumab/relatlimab-rmbw is not supported by one of the major drug compendia or by clinical 
research that appears in a CMS-approved medical journal for the treatment of patients with metastatic uveal 
melanoma. There is insufficient information to support that Nivolumab/relatlimab-rmbw is safe and effective 
and otherwise reasonable and necessary for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Nplate (CPT code J9999) and Opdualag (Nivolumab/Relatlimab-RMBW) (CPT code 
J2796).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the prostate biopsy (55700), the Midazolam 
hydrochloride injection (J2250), and the Ceftriaxone sodium injection (J0696) provided on November 1, 2021. 
 
You asked the Plan to waive the cost share. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the cost share has been applied correctly to the 
services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare Part B covered drugs rendered by an in-network provider. Additionally, you must 
pay a $40 copayment for surgery services rendered by an in-network specialists office.   
You have been asked to pay $40.53 ($40 + .13 + .40). This amount includes a $40 copayment for the surgery 
service rendered by an in-network specialists office. This amount includes the Plan allowed amount of  
$.65 x 20% coinsurance=$.13 for the Medicare-covered Part B drug injection provided. Additionally, this 
amount includes the Plan allowed amount of $2.00 x 20% coinsurance=$.40 for the other Medicare-covered 
Part B drug injection provided. 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 cost share for the prostate biopsy (55700), 
the Midazolam hydrochloride injection (J2250), and the Ceftriaxone sodium injection (J0696) provided on 
November 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rexulti 2MG tablet. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says Rexulti 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 Rexulti 2MG tablet.  
 Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.