Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Supartz FX. 
 
You asked the Plan to pre-approve the medication. You say that you do not use the Plans preferred drugs in 
your office. The Plan denied your request. The Plan says that step therapy requirements have not been met. 
 
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 criteria for coverage of Supartz FX have not been met. Our physician reviewer found that the Plan requires 
a trial of Monovisc, Orthovisc or Synvisc before they will approve the requested drug. In this case, the enrollee 
has not tried and failed the required drugs. There is no documentation provided indicating that the Plan's 
required drugs would likely be less effective 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 Supartz FX.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the injections of drug into the eye and the 
aflibercept injections provided from August 25, 2023, to September 22, 2023. 
 
You asked the Plan to waive the cost share for the injections of drug into the eye and the aflibercept injections. 
You say that you have been receiving injections in your eyes for the past four years. You say your doctor did 
not tell you that the new medication is very expensive.  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 a $15 
copayment for provider and professional services at an in-network specialist's office and 20% coinsurance for 
Medicare-covered Part B covered drugs at in-network specialist's office.  
 
You have been asked to pay a $15 copayment for the injections of drug into the eye on each date of service. 
You have been asked to pay $350.27 on each date of service which is 20% of the allowed amount for the 
aflibercept injections. The allowed amount is $1,751.34. ($1,751.34 x 20% = $350.27). The injection of the 
drug into the eye falls within the physician/practitioner services, including doctors office visits benefit 
category. The aflibercept injections fall within the Medicare Part B prescription drugs benefit category.  
 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the cost share for the injections of drug into the eye and the aflibercept 
injections provided from August 25, 2023, to September 22, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would recover quicker at an 
LTACH. The Plan denied your request. The Plan says the enrollee does not meet the requirements for LTACH 
services. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital being provided by the health Plan. Given there are offered alternatives, LTACH services are 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH 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 services are medically necessary for 
the enrollee's complex medical needs. The Plan denied your request. The Plan says when the enrollee is ready 
to leave the hospital they can receive this care in another setting, such as skilled nursing facility.  
 
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 record indicates that the enrollee has ongoing acute medical issues and still 
requires acute care services. The enrollee continues to receive acute care services, and these have not been 
denied. The medical record does not indicate that the enrollee requires services that they are not currently 
receiving but that would be available at the LTACH facility. The elements of the coverage rules are not 
satisfied. The requested service cannot be recommended. 
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency room visit provided by an out-of-network 
provider on July 17, 2023. 
 
You asked the Plan to pay for the emergency room visit. You say that the enrollee was seen for oral pain and 
was prescribed medications. The Plan denied your request. The Plan says the denial of payment for this service 
is correct, because the services involved show it involved the care, treatment, filling, removal or replacement of 
teeth or structures directly supporting the teeth. 
 
The Plan must follow Medicare rules. Medicare generally does not cover dental services.  
 
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 the emergency room visit. Our reviewer says 
that the requested items/services are considered medically reasonable but meet the Medicare dental rules. Our 
physician reviewer found the services provided were dental based on Medicare rules and definitions. The 
enrollee was diagnosed with a dental abscess related to a dental fracture and was referred to an oromaxillary 
facial surgeon for outpatient care. The record indicates the pain started with a fractured tooth. 
 
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 emergency room visit have not been met. Specifically, the services you are 
asking the Plan to pay for involve the care, treatment, filling, removal or replacement of the enrollees teeth or 
the structures directly supporting the enrollees teeth. These are dental services that are not covered or paid for 
by Medicare. Therefore, we decided that the Plan does not have to pay for an emergency room visit provided 
by an out-of-network provider on July 17, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One (J7326). 
 You asked the Plan to pre-approve Gel-One. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for the requested viscosupplement device. 
 
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 Gel-One. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the Plan requires a trial of Durolane, 
Monovisc, or Synvisc-One before they will approve the requested drug. In this case, the patient has not tried 
and failed the required drug(s). Our reviewer also found that there is no documentation provided indicating that 
the Plan's required drug(s) would likely be less effective and/or likely have adverse effects for the patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One (J7326).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676), a segmental 
gradient pressure pneumatic appliance, half leg (E0673) and a segmental pneumatic appliance for use with 
pneumatic compressor, trunk (E0656) provided on March 30, 2023. 
 
You asked the Plan to pay for a pneumatic compression device and garments. You say that you disagree with 
the denial and request reconsideration. The Plan denied your request. The Plan says items that are used for a 
preventative service or function are excluded from coverage. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676), a segmental gradient pressure pneumatic appliance, half leg 
(E0673) and a segmental pneumatic appliance for use with pneumatic compressor, trunk (E0656) provided on 
March 30, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from July 5, 2022, to July 7, 
2022. 
 You asked the Plan to pay for the home health services. You say that you did not receive notification that the 
Plan was changing the requirement for NOAs. The Plan denied your request. The Plan says the NOA was not 
received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is July 5, 2022. The NOA was not received by the Plan until November 3, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from July 5, 2022, to July 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound, abdominal aorta, real time with image 
documentation, screening study for abdominal aortic aneurysm (AAA) (76706) provided February 16, 2023. 
 
You asked the Plan to pay for the diagnostic service. You say that CPT 76706 was billed with diagnosis 
Z87.891 which is a billable code. Please review the information provided to reconsider payment. The Plan 
denied your request. The Plan says this should be billed with the appropriate code for these services.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 76706 is ultrasound, abdominal aorta, real time with 
image documentation, screening study for abdominal aortic aneurysm (AAA). 
 
We asked our coder 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 the diagnostic service. Our reviewer says that the services at 
issue in this case are not supported by the medical records. Our reviewer found the documentation consists of 
an addendum to a radiology report that clarifies measurements of the common iliac arteries. There is no 
mention of the aorta or a description of a screening ultrasound. The documentation does not contain a radiology 
report supporting 76706. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the diagnostic service have not been met. Therefore, we decided that the Plan 
does not have to pay for the ultrasound, abdominal aorta, real time with image documentation, screening study 
for abdominal aortic aneurysm (AAA) (76706) provided February 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inhalation of nitrous oxide (D9230) provided on 
September 11, 2023. 
 You asked the Plan to pay for the dental service. You say that you cannot imagine having these procedures 
done without nitrous oxide. You say that you would not be able to get through them due to the pain. You also 
say that in anticipation of 2 additional denials, all three procedures should be considered for coverage. The Plan 
denied your request. The Plan says this service is not a covered benefit. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the service at issue in this case is not 
among those covered under this benefit. Additionally, the record shows that the treatment plan indicates that 
this service would not be covered. Therefore, we decided that the Plan does not have to pay for the inhalation 
of nitrous oxide (D9230) provided on September 11, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Genvisc. 
 You asked the Plan to pre-approve Genvisc. You say that traditional Medicare does not require failure of any 
injections prior to the use of Genvisc. The Plan denied your request. The Plan says the enrollee has not tried 
and failed the alternatives.  
 
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 Genvisc. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found based on the medical records provided 
there is no indication that the enrollee has tried and failed the required drugs Durolane, Gelsyn-3, and 
Synvisc/Synvisc-One. Based on the medical records provided and the Medicare-approved major drug 
compendia there is no indication that the plan's required drugs would likely be less effective 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 Genvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Genvisc.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the home sleep test (HST) (G0399) 
provided on August 18, 2023. 
 
You asked the Plan to waive the deductible for the HST. You say that you spoke to the provider prior to the 
issue, and you were assured there would be no cost to you. You also say that you were very clear that if you 
would be responsible for any out-of-pocket amount, that you would not be able to do the testing. 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. Your 
contract with the Plan says that there is a $600 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies.  
 
 
 
 
 The item or service you asked the Plan to waive the deductible for falls within the outpatient diagnostic tests 
and therapeutic services and supplies benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $600 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies. The $0 copay for home based sleep studies only applies after the $600 
deductible is met. This cost sharing is a contractual obligation that had not been met at the time the HST was 
received on August 18, 2023. Therefore, we decided that the Plan does not have to waive the deductible for the 
home sleep test (HST) (G0399) provided on August 18, 2023.  
 
Your complaint about the misinformation you received and the issues you have had with the providing 
company 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) (64635, 64636). 
 
You asked the Plan to pre-approve the RFA. You say that the 2 previous diagnostic branch blocks you received 
had produced a significant amount of pain relief. You say that you would like an additional procedure done for 
more pain relief and for a longer period of time. You also say that you have cut back on walking and stair 
climbing due to your chronic pain. The Plan denied your request. The Plan says the requested RFA are not 
medically reasonable or necessary. 
 
The Plan follows Medicare rules. Medicare rules say that thermal radiofrequency destruction of cervical, 
thoracic, or lumbar paravertebral facet joint (medial branch) nerves are considered medically reasonable and 
necessary after the patient has had at least two (2) medically reasonable and necessary diagnostic MBBs, with 
each one providing a consistent minimum of 80% sustained relief of primary (index) pain. 
 
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 RFA. Our reviewer says that the requested RFA is not medically necessary. Our physician reviewer found there is no documentation of at least 
two (2) medically reasonable and necessary diagnostic medial branch blocks, with each one providing a 
consistent minimum of 80% sustained relief of primary (index) pain (with the duration of relief being 
consistent with the agent used). Therefore, the reviewer found that the requested RFA 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 the RFA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve radiofrequency ablation (RFA) (64635, 64636).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic supplies provided on June 27, 2023. 
 
You asked the Plan to pay for the diabetic supplies. You say that you would like the request reconsidered, the 
medical records and waiver of liability are attached. The Plan denied your request. The Plan says you are not 
enrolled in Medicare as a durable medical equipment supplier. Therefore, the claim was 
denied. 
 
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 pay for the diabetic supplies provided on June 
27, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer (J1439). 
 You asked the Plan to pre-approve Injectafer. You say that you are requesting Injectafer because the guidelines 
now include Injectafer as one of the recommended intravenous irons. The Plan denied your request. The Plan 
says this request does not meet the Plan's Part B step therapy criteria for the requested drug. 
 
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 Injectafer. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the Plan requires a trial of Infed and 
Venofer before they will approve the requested drug. In this case, the patient has not tried and failed the 
required drugs. Our reviewer also found that there is no documentation provided indicating that the Plan's 
required drugs would likely be less effective and/or likely have adverse effects for the patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer (J1439).