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

 
We decided that the Plan does not have to pre-approve the Sprint peripheral nerve stimulation (PNS) device 
(64555). 
 
You asked the Plan to pre-approve the Sprint PNS device. You say that the denial for this procedure is 
unwarranted and unsupported. The Plan denied your request. The Plan says implantable peripheral nerve 
stimulators for chronic pain are still being studied to see if this treatment is reasonable and necessary. There is 
a lack of literature evaluating long-term efficacy and adverse events associated with implantable PNS devices. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. There is lack of evidence to support PNS over traditional treatment 
of chronic low back pain. There is a lack of literature evaluating long-term efficacy and adverse events 
associated with implantable PNS devices. Based on this information, we decided that Medicare rules for coverage of the Sprint PNS device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the Sprint peripheral nerve stimulation (PNS) device (64555).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tub transfer bench (also known as a shower chair). 
 
You asked the Plan to pre-approve a shower chair. You say that hygiene is an important part of your medical 
care and this item is needed to prevent urine burns and allow salve to be applied. The Plan denied your request. 
The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a tub transfer bench (also known as a 
shower chair).
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for neurophysiological monitoring rendered on September 21, 2022. 
 
You asked the Plan to pay for the services. You say that there is an emergency exclusion on the plan, and this 
claim falls under that category. The Plan denied your request. The Plan says that the neurosurgeon informed the 
patient prior to surgery that there would likely be no recovery of lower extremity neurological function, 
therefore monitoring would not change outcome. 
 
The Plan must follow Medicare rules. Medicare rules say that intraoperative neuromonitoring can be covered 
for spinal instrumentation requiring pedicle screws or distraction.  
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 services. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found that the services can be covered as part of spinal instrumentation requiring pedicle screws or 
distraction. In this case, the records provided for review otherwise demonstrated that as part of the enrollee's 
surgical stabilization procedure they underwent pedicle screw placement. In as much the requested services 
would have fallen within the scope of those for which Medicare covers the service. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
neurophysiological monitoring rendered on September 21, 2022.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that this benefit would greatly help the enrollee. 
The Plan denied your request. The Plan says the criteria for eligibility have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle libre 14-day. 
 
You asked the Plan to pre-approve a therapeutic CGM and supplies. You say that you need the continuous 
glucose monitor (CGM) system as soon as possible. The Plan denied your request. The Plan says the request is 
denied because you do not have documentation of history of problematic hypoglycemia. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 a therapeutic CGM and supplies. Our 
physician reviewer found that you are not taking insulin and have no low blood sugar was documented, and 
you are not on medication that should cause low blood sugar; therefore, the criteria for a CGM are not met. 
 
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 therapeutic CGM and supplies have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Freestyle libre 14-day.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee orthosis (L1852). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no new documentation of new injury or surgery to the knee. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there has not been any recent injury or surgery to the knee. There is no knee instability documented 
on examination. 
 
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 a knee orthosis (L1852).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower prosthesis rotational unit (L5999). 
 
You asked the Plan to pre-approve the lower prosthesis rotational unit. You say that this item is medically 
necessary. The Plan denied your request. The Plan says the code requested for this item is incorrect. 
 
The Plan must follow Medicare rules. Medicare rules say that DME MACs and the Pricing, Data Analysis, and 
Coding (PDAC) contractor are responsible for assigning individual DMEPOS products to HCPCS code 
categories for billing Medicare. Manufacturers and other entities do not have similar authority to assign their 
own code determinations to specific products. 
 
We looked at the file and Medicare rules. The code requested (L5999) is not associated with the item being 
requested. Per the DME PDAC, K1022 is the correct code. Based on this information, we decided that 
Medicare rules for coverage of the lower prosthesis rotational unit have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a lower prosthesis rotational unit (L5999).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to approve a routine transportation trip for 57 miles. 
 
You asked the Plan to approve these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the request exceeds the mileage limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation for up to 50 miles per one-way trip. 
 
We looked at your request, the records in the case file, and the rules. The file request is for a one-way trip of 57 
total miles. This exceeds the 50 mile limit for one-way trips. Based on this information, we decided that the 
Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does 
not have to approve a routine transportation trip for 57 miles.
Appeal type: Drugs
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 this drug is medically necessary. The Plan denied 
your request. The Plan says a trial of Orthovisc, Synvisc, or Monovisc is required before alternatives can be 
considered. 
 
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 
Genvisc is not medically necessary. Our physician reviewer found the records show no trial of the plan 
preferred drugs, or any reason they would be unsafe or ineffective. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental 
pneumatic appliances (E0673) provided December 6, 2022. 
 
You asked the Plan to pay for the pneumatic compression device and appliances. You say that this device was 
provided for use during the patient's surgery. The Plan denied your request. The Plan says equipment used in a 
facility for a procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental pneumatic appliances (E0673) 
provided December 6, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo. 
 You asked the Plan to pre-approve Vabysmo. You say that Vabysmo is medically necessary. The Plan denied 
your request. The Plan says a trial of Bevacizumab is required first. 
 
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 Vabysmo. Our reviewer says that 
Vabysmo is not medically necessary. Our physician reviewer found the records show no trial of the plan 
preferred drug, or any reason it would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vabysmo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vabysmo.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for the oxygen concentrator, single delivery port (E1390) 
purchased October 21, 2022. 
 
You asked the Plan to reimburse for the oxygen equipment. You say that at the time, the doctor advised you to 
start using oxygen. Your family took it upon themselves to shop for you. They were anxious and did not 
consider the protocol and neither did you. 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 $2,882.00 for Durable Medical Equipment (DME) and Related Supplies.  
 
You have been asked to pay $2,882.00 for the oxygen equipment. Per Medicare, an Oxygen concentrator 
(E1390) is considered a rental item, meaning it must be rented and cannot be purchased. This item/service falls 
within the Durable Medical Equipment (DME) and Related Supplies 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 reimburse for the oxygen concentrator, single delivery port (E1390) purchased October 21, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for medical services provided on October 29, 2022. 
 
You asked the Plan to reimburse you for the medical services. You say that these services should be covered 
under your worldwide benefit. The Plan denied your request. The Plan says the services are not covered under 
your Plan. 
 The Plan must follow Medicare rules. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to 
reimburse you for medical services provided on October 29, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zilretta. 
 You asked the Plan to pre-approve Zilretta. You say that this is medically necessary. The Plan denied your 
request. The Plan says 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 Zilretta. Our reviewer says that the 
criteria for coverage of Zilretta have not been met. Our physician reviewer found the Plan requires a trial of 
intra-articular steroids before they will approve Zilretta. The submitted records do not contain documentation 
of trial and failure of intra-articular steroids. The records also do not support that intra-articular steroids would 
likely be less effective or have adverse effects 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 Zilretta have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Zilretta.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided in the emergency 
department on December 30, 2022, and December 31, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that you were transported by ambulance for 
an emergency visit to a hospital and you did now know what was given to you as you couldnt really talk or 
walk. The Plan denied your request. The Plan says the medication is not covered as a medical benefit under the 
Plan. 
 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 pay for self-administered drugs provided 
in the emergency department on December 30, 2022, and December 31, 2022.  
 
Benefits for the self-administered drugs 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 the implantation of the hypoglossal nerve stimulator 
64582, C1787, C1767, C1778. 
 
You asked the Plan to pre-approve the surgical procedure. You say that this is not an adequate denial based on 
the enrollee's need for care and needs to be appealed for a full review of the clinicals. The Plan denied your 
request. The Plan says the implantation of the hypoglossal nerve stimulator is not reasonable or necessary at 
this time. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The rules states that hypoglossal nerve neurostimulation is 
considered not medically reasonable and necessary when any of the following contraindications are present: 
BMI equal to or greater than 35. The enrollee's body mass index (BMI) is documented as 39 in some areas and 
41.96 in others. Based on this information, we decided that Medicare rules for coverage of the surgical 
procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
implantation of the hypoglossal nerve stimulator 64582, C1787, C1767, C1778.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hip brace. 
 
You asked the Plan to pre-approve the brace. You say that this is often used to provide support after surgery 
and to prevent or reduce the severity of injuries. The Plan denied your request. The Plan says there are no 
surgery plans at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the brace. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that detailed documentation regarding a trial and failure of recent, reasonable, comprehensive, less 
invasive conservative care measures is not evident. The documentation only supports a cortisone injection 
having been trialed. Additionally, there is no indication that she is to undergo a surgical procedure. There are limited large-scale, long-term references showing the safety and efficacy of the requested brace in this clinical 
setting. No compelling rationale is presented or extenuating circumstances noted to support the medical 
necessity of this request as an exception. Therefore, the requested hip brace, in this case, 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 brace have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a hip brace.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G (L8702). 
 
You asked the Plan to pre-approve the MyoPro Motion G. You say that this submission addresses each of the 
Plan's reasons for denial and reviews the enrollee's medical necessity for the device. The Plan denied your 
request. The Plan says this item is considered experimental and investigational. There is insufficient evidence 
of its effectiveness in those with stroke and hemiparesis. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the MyoPro Motion G have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the MyoPro Motion G (L8702).