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

 
We decided that the Plan does not have to pay for telehealth services provided on March 31, 2023. 
 
You asked the Plan to pay for the telehealth services. You say that the patient was in a nursing home at the 
time services were rendered. You say that since your company has an exclusive contract with the facility, your 
doctors are the only providers who will treat the patients and the nursing home does not allow your doctors to 
visit in person and instead to render service to the patients via teleconference. The Plan denied your request. 
The Plan says telehealth services must be rendered by a participating network provider. 
 
The Plan contract says certain telehealth services, including consultation, diagnosis, and treatment by a 
physician or practitioner for patients in certain rural areas or other locations approved by Medicare. If you 
choose to get one of these services by telehealth, you must use a network provider who offers the service by 
telehealth. 
 
We looked at the file and the Plans rules. The file shows that the services were not provided by a network 
provider who offers telehealth services. Based on this information, we decided that the Plans rules for coverage of the telehealth services have not been met. Therefore, we decided that the Plan does not have to pay 
for telehealth services provided on March 31, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the echocardiography provided on August 3, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the echocardiography. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says this service is available with in-network providers. 
 
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 echocardiography provided on August 3, 2023, 
by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Accu-Chek guide strips. 
 
You asked the Plan to pre-approve the Accu-Chek guide strips. The Plan denied your request. The Plan says 
you have not tried and failed all preferred blood glucose testing products. The prescriber has not indicated the 
preferred products are inappropriate for you. 
 The Plan must follow Medicare rules. Medicare rules say that Plans may limit coverage to certain brands of 
products and this plan only covers Ascensia and LifeScan branded products  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Accu-Chek guide strips have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Accu-Chek guide strips.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate services (20939). 
 
You asked the Plan to pre-approve the bone marrow aspirate services. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says the request 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 the bone marrow aspirate services. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that bone marrow aspirate is considered experimental/investigational for 
use as bone graft material and 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 bone marrow aspirate services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve bone marrow aspirate services (20939).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compressor, non-segmental pneumatic appliance 
for use with pneumatic compressor, half leg, and orthotic(s) management and training (E0650, E0666, 97760) 
provided from April 30, 2023 to May 19, 2023. 
 
You asked the Plan to pay for a pneumatic compressor, half leg non-segmental pneumatic appliance, and 
orthotic(s) management and training. You say that the services are necessary. The Plan denied your request. 
The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that pneumatic compression devices are covered when 
specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for a pneumatic compressor, half leg non-
segmental pneumatic appliance, and orthotic(s) management and training. Our reviewer says that the services 
were not medically necessary. Our physician reviewer found the enrollee underwent a total knee arthroplasty 
on April 28, 2023. Clinical documentation dated May 11, 2023, indicated that the enrollee was participating in 
home health physical therapy and using a walker to ambulate. The enrollee was using knee high compression 
stockings and aspirin post-operatively. The requested non-segmental compression device was requested for the 
prevention of post-operative deep venous thrombosis (DVT), which is not covered per the coverage criteria. 
There is no medical history of lymphedema. 
 
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 pneumatic compressor, half leg non-segmental pneumatic appliance, and 
orthotic(s) management and training have not been met. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compressor, non-segmental pneumatic appliance for use with pneumatic compressor, half 
leg, and orthotic(s) management and training (E0650, E0666, 97760) provided from April 30, 2023 to May 19, 
2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from May 5, 2023, 
through May 6, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient hospital care provided was 
not medically necessary.  
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 pay for these services. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee presented to the hospital requesting detoxification from tramadol. She reported 
the last use of this medication as two days prior. She reported headache, diarrhea, chills, and diaphoresis. The 
enrollee had tachycardia and high blood pressure on evaluation. The laboratory results were unremarkable 
except for slight leukocytosis. She was admitted for opiate withdrawal and a possible urinary tract infection 
based on an abnormal urinalysis. However, the enrollee was not experiencing breathing difficulty or nausea. 
Her vital signs returned to normal at the time of admission and her withdrawal symptoms were resolved for the 
course of the hospital stay. It was not expected that the enrollee would have required inpatient services that 
would have likely crossed two midnights based on the presentation and she was not at risk of an adverse event.  
 
We looked at this physician's review, the file, and Medicare rules. 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 pay for the acute inpatient hospital care provided from May 5, 2023, through May 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on July 28, 2023. 
 
You asked the Plan to pay for the lab testing. You say that you are requesting reconsideration for the services 
provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the lab testing provided 
on July 28, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for out-of-network physical therapy visits 
provided on June 20, 2023, to July 13, 2023. 
 
You asked the Plan to waive the coinsurance for out-of-network physical therapy visits. You say that you feel 
you have been billed incorrectly for this service. You already paid a copayment at each visit. The Plan denied 
your request. The Plan says this cost sharing was charged 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 50% 
coinsurance for outpatient rehabilitation services. 
 
You have been asked to pay 50% coinsurance for out-of-network physical therapy visits. This item/service falls 
within the outpatient rehabilitation services 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. The total you owe is $70 ($92.52 + $46.37 + $46.37 + $46.37 + $46.37 = 
$278). Therefore, we decided that the Plan does not have to waive the coinsurance for out-of-network physical 
therapy visits provided on June 20, 2023, to July 13, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an Ankle foot orthosis (L1960) and addition (L2275). 
 
You asked the Plan to pre-approve an Ankle foot orthosis (L1960) and addition (L2275). You say that the 
requested custom fabricated ankle foot orthosis (L1960) is medically necessary. The Plan denied your request. 
The Plan says that the enrollee does not meet criteria for the requested custom fabricated ankle foot orthosis 
(L1960).  
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 an Ankle foot orthosis (L1960) and 
addition (L2275). Our reviewer says that the enrollee meets criteria for the requested custom fabricated ankle 
foot orthosis (L1960).  Our physician reviewer found the enrollee has chronic foot drop, will benefit 
functionally and the impairment is expected to be present for more than 6 months. 
 
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 Ankle foot orthosis (L1960) and addition (L2275) have been met. Therefore, 
we decided that the Plan has to pre-approve an Ankle foot orthosis (L1960) and addition (L2275).  
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer (ferric carboxymaltose). 
 You asked the Plan to pre-approve the medication. You say that the records provided support medical 
necessity. The Plan denied your request. The Plan says the enrollee has not tried and failed preferred 
medications. 
 
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 the medication. Our reviewer says that 
the requested medication does not meet the requirements for step therapy guidelines. Our physician reviewer 
found based on the medical records provided there is no indication that the enrollee has tried and failed the 
required drugs. There is no indication that the plan's required drugs would likely be less effective and/or likely 
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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Injectafer (ferric carboxymaltose).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vacuum-assisted socket system (VASS) (L5781). 
 
You asked the Plan to pre-approve a vacuum-assisted socket system (VASS) (L5781). You say that the 
requested vacuum-assisted socket system (VASS) (L5781) is medically necessary. The Plan denied your 
request. The Plan says the requested vacuum-assisted socket system (VASS) (L5781) 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 vacuum-assisted socket system 
(VASS) (L5781). Our reviewer says that the requested vacuum-assisted socket system (VASS) (L5781) is not 
medically necessary. Our physician reviewer found the enrollee has a transtibial amputation and poorly fitting 
socket. The requested VASS is not medically necessary as the socket system has not been shown to improve 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 a vacuum-assisted socket system (VASS) (L5781) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a vacuum-assisted socket system (VASS) 
(L5781).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rituxan and diphenhydramine. You asked the Plan to 
pre-approve Rituxan and diphenhydramine. You say that there is no patient advocacy program to assist the 
enrollee with a copayment for Ruxience or Riabni. You say if the enrollee does not receive patient assistance, they cannot afford the medication and will not be able to receive treatment.  The Plan denied your request. The 
Plan says the requested drug regimen is subject to a step therapy requirement. The unmet criteria are that the 
enrollee cannot use Ruxience (rituximab-pvvr) or Riabni (rituximab-arrx).  
 
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 Rituxan and diphenhydramine. Our 
reviewer says that the requested drugs are not medically necessary. Our physician reviewer found that there is 
no indication that the enrollee has tried and failed the required drug(s). Our physician also says there is no 
indication that the Plan's required drug(s) would likely be less effective and/or likely 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 Rituxan and diphenhydramine have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Rituxan and diphenhydramine.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (62323). 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that the pain relief from the injections 
do not last the full three months and the pain is unbearable. The Plan denied your request. The Plan says you do 
not meet the criteria for the requested procedure to be approved. 
 
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 epidural steroid injection. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you have lumbar radiculopathy. Imaging shows spinal stenosis. The injections are 
described as providing 100% pain relief, but the relief does not last 3 months. You have had physical therapy 
and home exercise. The LCD criteria requires 3 months of 50% pain relief. This was not met and therefore, the 
request is deemed not medically reasonable and 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 epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection (62323).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Orthotic Device. 
 
You asked the Plan to pre-approve a MyoPro Orthotic Device. You say that the requested MyoPro Orthotic 
Device is medically necessary.  The Plan denied your request. The Plan says the requested MyoPro Orthotic 
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 MyoPro Orthotic Device. Our 
reviewer says that the requested MyoPro Orthotic Device is not medically necessary.  Our physician reviewer 
found the device has not been recommended to improve self-care activity. The American Heart Association 
recommends the device as an adjunct to standard rehabilitation. The device has minimal impact on self-care 
such as dressing, bathing, toileting, and feeding. It is not reliably effective for persons with a stroke more than 1 year old and has been tested on individuals with some passive range of motion and active range of motion in 
the shoulder. Patients with significantly increased tone have been excluded from trials based on Ashworth 
scores. At this time, the device is not medically necessary, not the standard of care and not shown to be reliably 
at least as effective as the standard of care. The American Heart Association does not recommend the device 
for the proposed purpose.  
 
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 MyoPro Orthotic Device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro Orthotic Device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on August 29, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
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 services at issue in this appeal. 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 the services provided on August 29, 2023, by an out-of-network 
(OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the catheter placement procedure provided on July 27, 2023. 
 
You asked the Plan to pay for the catheter placement procedure. You say that you are requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the catheter placement 
procedure provided on July 27, 2023.