Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction provided on September 11, 2023. 
  
You asked the Plan to pay for the refraction. You say that you are entitled to this service under your plan.  You 
say that you were evaluated for issues involving your vision that could not be evaluated in routine vision care. 
The Plan denied your request. The Plan says the refraction is not a covered benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers refractions when provided as a part of a routine eye examination. 
 
We looked at the file and the Plan's rules. Specifically, the refraction was provided during a medical eye 
examination. Based on this information, we decided that the Plan's rules for coverage of the refraction have not 
been met. Therefore, we decided that the Plan does not have to pay for the refraction provided on September 
11, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit. 
 
You asked the Plan to pre-approve Retacrit. 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 must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Retacrit. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the review has determined that the 
documentation does not support that the Retacrit is medically reasonable and necessary or safe and effective 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 Retacrit have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Retacrit.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. You asked the Plan to pre-approve Prolia. You 
say that the requested drug is medically necessary. The Plan denied your request. The Plan says the requested drug is subject to step therapy and is covered when the criteria are met. The unmet criteria are: the enrollee has 
a history of osteoporotic fracture OR has tried or cannot use zoledronic acid.  
 
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 Prolia. Our reviewer says that the 
requested drug is not medically necessary. Our physician reviewer found that the record indicates the enrollee 
has age related osteoporosis without osteoporotic fracture. The requested medication is a new start. The 
provided records do not indicate that the enrollee has tried and failed the Plan's preferred step one alternative. 
The record does not indicate that the enrollee has a contraindication to or would have an adverse effect from 
the Plan's preferred step one alternative. The elements of the coverage criteria are not satisfied.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the hearing aids provided on March 21, 2023. 
 
You asked the Plan to pay more for the hearing aids. You say that you are requesting reimbursement for the 
$2,948.00 that you paid towards hearing aids. 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 25% 
coinsurance for out-of-network hearing aids, then any amount over $1,000 every three years for hearing aids.  
 
You have been asked to pay 25% of the allowed amount coinsurance for one of the hearing aids. The allowed 
amount is $1,000. ($1,000 x 25% = $250). Please note, the Plan paid the remaining $750 for this hearing aid. The contract says you are responsible for any remaining amount. The remaining amount for the second hearing 
aid is $2,698. ($2,698 + $250 = $2,948). The hearing aids fall within the mandatory supplemental hearing 
benefits 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 pay more for the hearing aids provided on March 21, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Sprint peripheral nerve stimulator (PNS) device 
(64555). 
 
You asked the Plan to pre-approve a Sprint PNS device. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 Sprint PNS device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the SPRINT PNS device is experimental for chronic pain. More research is needed. 
 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 Sprint PNS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Sprint peripheral nerve stimulator (PNS) device (64555).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
  You asked the Plan to pre-approve a home ventilator system. You say that the enrollee has been treated with 
BiPAP therapy for the last few years and have been complaint. You say that a simpler device has already been 
considered, utilized, and proven to be insufficient to adequately ventilate the enrollee. The Plan denied your 
request. The Plan says a home ventilator is not medically necessary for this patient because their needs can be 
met with an alternative device such as a BiPAP device with average volume-assured pressure support 
(AVAPS).  
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 home ventilator system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that the enrollee's 
hospital documentation shows improvement with AVAPS. Also, the enrollee would likely benefit from BiPAP 
with AVAPS, given the documentation and data provided. Additionally, the sleep study also confirms benefit 
from BiPAP therapy.  
 
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 home ventilator system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
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 enrollee cannot be adequately cared 
for with the current medical condition at a lower level of care and is stable and ready to transfer to LTACH. 
The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and is 
currently unstable for transfer to an LTACH. 
 
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. 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. Given there are offered alternatives, LTACH 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a salpingo-oophorectomy and a hysterectomy. 
 
You asked the Plan to pre-approve a salpingo-oophorectomy and a hysterectomy. You say that the enrollee has 
postmenopausal bleeding and a thickened heterogeneous endometrium at 19 millimeters(mm). You say that a 
cervical polyp was present that was benign and attempts at sampling the endometrium was unable to capture an 
adequate specimen. The Plan denied your request. The Plan says a salpingo-oophorectomy and a hysterectomy 
are 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 salpingo-oophorectomy and a 
hysterectomy. Our reviewer says that a salpingo-oophorectomy and a hysterectomy is not medically necessary. 
Our physician reviewer found that due to the thickened endometrium on the ultrasound and postmenopausal 
bleeding, the standard of care is to obtain endometrial sampling. Furthermore, a dilation and curettage 
hysteroscopy are indicated to rule out hyperplasia and malignancy prior to any definitive treatment. Therefore, 
a hysterectomy with bilateral salpingo-oophorectomy is not medically necessary at this time and appropriate 
definitive treatment will depend on biopsy results. 
 
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 salpingo-oophorectomy and a hysterectomy have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a salpingo-oophorectomy and a hysterectomy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has not been provided a prior 
opportunity at an IRF level of care with intense therapy and medical oversight. The Plan denied your request. 
The Plan says the enrollee's condition does not meet all the requirements for inpatient rehabilitation admission. 
The Plan says services may be provided at a lower level of care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The medical 
records support a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. It is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ROMA (Oncology (ovarian), biochemical assays of two 
proteins (CA-125 and HE4), utilizing serum, with menopausal status, algorithm reported as a risk score) 
(81500). 
 
You asked the Plan to pre-approve ROMA. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
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 ROMA. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found serologic biologic assays for tumor markers are not standard of care for a simple ovarian cyst less than 10 cm with no other risk factors or positive findings. Therefore, ROMA testing is not medically 
indicated in this enrollee at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ROMA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve ROMA (Oncology (ovarian), biochemical assays of two proteins (CA-125 and HE4), utilizing 
serum, with menopausal status, algorithm reported as a risk score) (81500).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the primary repair of tendon on the back of the leg to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the primary repair of tendon on the back of the leg. You say that the out-of-
network provider has more available time at the out-of-network facility as well as ankle surgery privileges at 
the facility where the equipment and staffing will be readily available. The Plan denied your request. The Plan 
says the requested provider is out-of-network, and the surgery can be provided at the in-network level. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The provider at issue in this case is not a network provider with the Plan. 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 primary repair of tendon on the back of the leg. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the surgery for tendon repair may be 
safely and effectively performed in plan by a fellowship trained surgeon. There is no need for an out-of-
network referral. 
 
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 primary repair of tendon on the back of the leg have not been met.  
 
The Plan has network providers available who can provide the items/services at issue in this appeal. We found 
no exception that would require the Plan to pre-approve the primary repair of tendon on the back of the leg. 
Therefore, we decided that the Plan does not have to pre-approve the primary repair of tendon on the back of 
the leg to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the records do not show the enrollee needs to be seen by a 
rehabilitation physician three times per week or that you need an 
intensive team for care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The medical 
records support a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. It is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service August 25, 
2023.  
 You asked the Plan to pay for procedure code 86077. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service August 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extra battery for a portable oxygen concentrator 
(POC). 
 
You asked the Plan to pre-approve an extra battery for a POC. You say that the item is necessary. The Plan 
denied your request. The Plan says an extra set of batteries for a POC is not covered. A battery is included with 
your POC and can be recharged. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an extra battery for a POC have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an extra battery for a portable oxygen concentrator (POC).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power 
options (tilt, seat elevator) and accessories. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair with multiple power options. You say that this 
is medically necessary for the enrollee. The Plan denied your request. The Plan says there is not a medical need 
to control two or more power options though the joystick. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with multiple power 
options and accessories. 
 
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 Group 3 power wheelchair with 
multiple power options. Our reviewer says that the requested Group 3 power wheelchair with multiple power 
options is not medically necessary. Our physician reviewer found the provided records do not document that 
power tilt and recline or a ventilator which is mounted on the wheelchair are being requested. The provided 
records only document a request for power tilt and a power seat elevator. These features are not documented in 
the Local Coverage Determination (LCD) Wheelchair Options/Accessories L33792 as requiring a multiple 
power option base. Therefore, the reviewer found that the requested Group 3 power wheelchair with multiple 
power options 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 a Group 3 power wheelchair with multiple power options have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple 
power options (tilt, seat elevator) and accessories.