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

 
We decided that the Plan does not have to pre-approve Steglatro 15mg tablets. 
 
You asked the Plan to pre-approve the Steglatro tablets. You say that this medication is medically necessary. 
The Plan denied your request. The Plan says this oral drug is not covered by 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 Steglatro 15mg tablets.  
 
 
 Benefits for the Steglatro tablets 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 a Freestyle Libre continuous glucose monitor sensor kit. 
 
You asked the Plan to pre-approve a Freestyle Libre continuous glucose monitor sensor kit. You say that this is 
necessary because finger pricking is causing the enrollee significant pain. The Plan denied your request. The 
Plan says the requirements for coverage have not been 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 the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
Freestyle Libre continuous glucose monitor have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Freestyle Libre continuous glucose monitor sensor kit.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Simponi Aria for the enrollee. 
 
You asked the Plan to pre-approve Simponi Aria. You say that this is medically necessary. The Plan denied 
your request. The Plan says that the enrollee does not have any stated contraindications to the preferred 
products. 
 
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 Simponi Aria. Our reviewer says that 
Simponi Aria is not medically reasonable and necessary for the enrollee. The enrollee has rheumatoid arthritis. 
The requested medication is a new start. The provided records do not indicate that the enrollee has tried and 
failed the plan's preferred alternatives, Humira, Enbrel, Xeljanz or Rinvoq. The record does not provide a 
sufficient medical rationale that the enrollee has a contraindication to or would have an adverse effect from the 
Plan's preferred alternatives. Our physician reviewer found that the enrollee's condition does not meet step 
therapy criteria for Simponi Aria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Simponi Aria have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Simponi Aria for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right knee surgery including arthroscopy with 
meniscectomy medial or lateral including meniscal shaving (29881, 29880, 29882). 
 
You asked the Plan to pre-approve right knee surgery. You say that this is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the requested surgery does not satisfy the 
coverage criteria. 
 
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 right knee surgery. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that this 76-year-old male enrollee was being treated for medial meniscus tear, right 
knee; primary osteoarthritis of right knee. He presented with persistent and ongoing right knee pain. He had 
been treated in the past for osteoarthritis that was noted to be moderate and tricompartmental.  
 
 Magnetic resonance imaging of the knee dated December 29, 2021, showed a complex medial meniscus tear of 
the body and posterior horn; grade III chondromalacia of the medial femorotibial joint with a few tiny foci of 
grade IV chondromalacia; few small foci of patella grade IV chondromalacia. Exam reveals posteromedial joint 
line tenderness, mild lateral joint line tenderness. Trace effusion is noted. Range of motion is 0-135 with pain. 
Medial McMurrays is positive. 
 
In this case, there is limited published, large-scale, long-term peer-reviewed literature that shows this request to 
be an effective and/or safe treatment for the noted pathology. Studies do not support meniscectomy procedures 
in the presence of significant osteoarthrosis/osteoarthritis. There has been no significant change as the 
exam/objective findings have not changed from January 12, 2021, to the most recent exam of February 10, 
2022. There is no compelling rationale presented or extenuating circumstances noted to support the medical 
necessity of this request as an exception. Therefore, the request for right knee surgery, arthroscopy with 
meniscectomy medial or lateral including meniscal shaving (29881, 29880, 29882), is not medically reasonable 
or 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 right knee surgery have not been met. Therefore, we decided that the Plan does 
not have to pre-approve right knee surgery including arthroscopy with meniscectomy medial or lateral 
including meniscal shaving (29881, 29880, 29882).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost-share for the colonoscopy with biopsy (45380) 
provided on October 12, 2021. 
 
You asked the Plan to reduce the cost-share for the colonoscopy. You say that you expected your share of the 
cost would be closer to $120 for these services. The Plan denied your request. The Plan says this claim was 
processed correctly, and your cost-share was assessed in accordance with your contract. 
 
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 says that there is a $250 deductible 
which applies to outpatient surgery services. In addition, your contract states that you must pay a $100 
copayment for each outpatient surgery visit.  
 
 
 You have been asked to pay a $100 copayment and a $247.75 deductible. The Plan has followed Medicare 
rules by clearly disclosing in the contract that there is a $250 deductible which applies to outpatient surgery 
services. Documentation shows that you had paid $2.25 toward your deductible prior to the services in 
question, and $247.75 was applied to the cost of the colonoscopy. After the deductible was met, there was a 
remaining balance on the colonoscopy. The colonoscopy with biopsy is classified as an outpatient surgical 
procedure, which requires a $100 copayment. 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 reduce the cost-share for the 
colonoscopy with biopsy (45380) provided on October 12, 2021.  
 
Your complaint about potential misinformation or missing information from a Plan representative 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient therapeutic services provided on May 10, 
2021. 
 
You asked the Plan to pay for the outpatient therapeutic services. You say that these treatments were 
necessitated due to emergency conditions created by vertigo. The Plan denied your request. The Plan says the 
provided documentation does not support that the services were urgent or emergent in nature. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the outpatient therapeutic services 
provided on May 10, 2021. have not been met. Specifically, the file does not indicate that medical records were 
provided to substantiate the claim that the services you received in a foreign country were urgent or emergent 
in nature. Therefore, we decided that the Plan does not have to pay for the outpatient therapeutic services 
provided on May 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest for lung 
cancer screening (71271). 
 
You asked the Plan to pre-approve a CT scan of the chest. You say that the requested CT scan of the chest is 
medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not 
meet criteria. 
 
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 CT scan of the chest. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee is above the age 
threshold. While the enrollees smoking history qualifies at 30 pack years, he is currently symptomatic with an 
unexplained cough. A diagnostic CT scan of the chest may be indicated if a request is made for this. 
 
 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT scan of the chest have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a computed tomography (CT) scan of the chest for lung cancer screening (71271).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug test (G0481) rendered by the out-of-network (OON) 
provider on February 22, 2021. 
 
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 drug test (G0481) rendered by the out-of-network (OON) provider on February 22, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two additional resin-based composites - four or more 
surfaces or involving incisal angle (anterior) (D2335) provided November 3, 2021. 
 
You asked the Plan to pay for the two filings. You say that you didn't know you needed a total of 4 fillings until 
the dentist was doing the first 2 and were unaware that the additional fillings would not be covered. The Plan 
denied your request. The Plan says you have exceeded the frequency limit for this service. 
 
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 two filings 
per calendar year. 
 
 
 We looked at the file and Medicare rules. The Plan provided documentation showing that 2 fillings were 
covered on November 3, 2021. Based on this information, we decided that the Plan's frequency limit for 
coverage of the fillings has been exceeded. Therefore, we decided that the Plan does not have to pay for the 
two additional resin-based composites - four or more surfaces or involving incisal angle (anterior) (D2335) 
provided November 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 72 filters per year (six per month) for a continuous 
positive airway device (CPAP). 
 
You asked the Plan to pre-approve the extra filters. You say that this is medically necessary due to needing to 
replace the filters once every five days, due to the buildup of each filter. The Plan denied your request. The 
Plan says quantities of supplies greater than those described in the policy as the usual maximum amounts will 
be denied as not reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CPAP filters are covered at a rate of two per 
month and 24 per year. 
 
The request for six filters per month and 72 per year exceeds the covered limits for CPAP filters. Based on this 
information, we decided that Medicare rules for coverage of the extra filters have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 72 filters per year (six per month) for a continuous positive 
airway device (CPAP).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Lupron. 
 
You asked the Plan to pre-approve Lupron. You say that you only use Lupron in their office. The Plan denied 
your request. The Plan says the denial of authorization for this drug is correct, because the Plan requires a trial 
of Eligard before it will approve Lupron. 
 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 Lupron. Our reviewer says that the 
enrollee does not meet the Medicare criteria for a step therapy exception for Lupron. Our physician reviewer 
found the enrollee has not tried and failed the Plan's preferred drug of Eligard. The record does not show that 
this drug would likely be less effective and/or have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Lupron have not been met. Therefore, we decided that the Plan does not have to 
pre-approve use of Lupron.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 
You asked the Plan to pre-approve Evenity. You say that this is medically necessary. The Plan denied your 
request. The Plan says that you do not have any stated contraindications to the preferred products. 
 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 Evenity. Our reviewer says that Evenity 
is not medically reasonable and necessary. The Plan requires a trial of Prolia or Reclast before they will 
approve the requested drug. In this case, you have not tried and failed one of the required drugs. There is no 
documentation provided indicating that the Plan's required drugs would likely be less effective and/or likely 
have adverse effects for you. Our physician reviewer found that your condition does not meet step therapy 
criteria for Evenity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute 
setting. 
 
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. 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 acute care hospital where he 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. Our physician reviewer found that the enrollee's condition does not meet Medicare 
criteria for LTACH services. 
 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oxygen concentrator provided on October 11, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for an oxygen concentrator. You say that the Plan told you no authorization was 
required so the claim should be paid. The Plan denied your request. The Plan says the rendering provider is an 
out-of-network provider with no approved authorization. Also, the service rendered by the provider 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 an oxygen concentrator provided on October 11, 
2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve a PET scan. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 a PET scan. Our reviewer says that the 
requested PET scan is not medically reasonable and necessary. Our physician reviewer found in this case, the 
requested PET scan is not for an oncologic indication. Per NCD 220.6.20 the requested type of scan (beta 
amyloid PET) is not covered. The request is not otherwise part of a clinical study approved by CMS. This 
ultimately does not meet Medicare criteria for coverage. 
 
 
 
 
 
 
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transportation of portable x-ray equipment and personnel to 
home or nursing home (R0070) provided on August 26, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the portable x-ray services. You say that these services were of medical necessity 
to prevent choking and aspiration risk. The Plan denied your request. The Plan says enrollees must receive 
their medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 transportation of portable x-ray equipment and 
personnel to home or nursing home (R0070) provided on August 26, 2021 by an out-of-network (OON) 
provider.