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

 
We decided that the Plan does not have to pre-approve treatment with Prolia (J0897).  
You asked the Plan to pre-approve Prolia. You say that Prolia is a medical necessity for the enrollee. The Plan 
denied your request. The Plan says step-therapy rules for coverage of Prolia 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 Prolia. Our reviewer says that treatment 
with Prolia is not medically reasonable and necessary in this case. Our physician reviewer found that the Plan 
requires a history of osteoporotic fracture or a trial of zoledronic acid before they will approve the requested 
drug. In this case, the enrollee has no history of osteoporotic fracture and has not tried and failed the required 
drug. The Plans required drug would not 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Prolia (J0897).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the core buildup, including any pins when 
required (D2950) provided on May 25, 2023. 
 
You asked the Plan to issue reimbursement for this dental item. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says this dental item 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 Plan's coverage rules apply in this case.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the item provided in this case is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to issue 
reimbursement for the core buildup, including any pins when required (D2950) provided on May 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4239 provided on August 3, 2023. 
 
You asked the Plan to pay for procedure code A4239. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the provider is not enrolled in the Medicare 
program. 
 
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 procedure code A4239 provided on 
August 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone graft (D3428) for tooth #4, #5, and #12. 
 
You asked the Plan to pre-approve the dental services. You say that you are having trouble eating and you 
would like the Plan to cover the dental services. The Plan denied your request. The Plan says the denial of 
authorization for these services is correct, because the bone graft is not covered by the Plan. 
 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
bone graft (D3428) for tooth #4, #5, and #12.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet injections by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are available from 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 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 Plan has network providers available who are capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve facet injections by an out-of-network (OON) 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positioning belt (E0978), width extension foot plates 
(K0108), and Q-logic 3 joystick (K0108). 
 
You asked the Plan to pre-approve positioning belt, foot plates, and Q-logic 3 joystick. You say that this is 
medically necessary for the enrollee. The Plan denied your request. The Plan says the requested joystick is 
included in the requested controller. The Plan says that positioning belt is included in the approved power 
wheelchair. The Plan also says the footplate extension is miscoded and cannot 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 positioning belt, foot plates, and Q-
logic 3 joystick. Our reviewer says that the requested positioning belt, foot plates, and Q-logic 3 joystick are 
not considered medically reasonable and necessary in this case. Our physician reviewer found the records show 
that the approved power wheelchair includes a positioning belt, foot plates and joystick. Therefore, the 
reviewer found that the requested positioning belt, foot plates, and Q-logic 3 joystick are 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 positioning belt, foot plates, and Q-logic 3 joystick have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a positioning belt (E0978), width extension 
foot plates (K0108), and Q-logic 3 joystick (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device to be provided by an 
out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the pneumatic compression device. You say that this item is medically 
necessary. The Plan denied your request. The Plan says there are network providers available. 
 
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 Plan has network providers available who are capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) We found no exception that would require the Plan to pre-approve these items/services. 
Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device to be 
provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of a Barostim Neo system. 
 
You asked the Plan to pre-approve implantation of a Barostim Neo system. You say that the requested 
procedure is medically necessary to treat the enrollee's diagnosis. The Plan denied your request. The Plan says 
the procedure does not meet the criteria necessary for approval. 
 
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 implantation of a Barostim Neo system. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that there remains an absence of randomized, blinded clinical studies 
examining long-term clinical outcomes establishing the value of Barostim Neo in patient management. As a 
result, at this time the Barostim Neo system would not be considered medically reasonable and necessary in 
this enrollee's clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of implantation of a Barostim Neo system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve implantation of a Barostim Neo system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the personal emergency response system (PERS) 
(S5161). 
 
You asked the Plan to pre-approve the personal emergency response system. You say that you are appealing 
this denial for the PERS Unit because this is medically needed for you and your doctor agrees that this is 
medically needed for you. The Plan denied your request. The Plan says this device is not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the personal emergency response system (PERS) (S5161).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies.  
 
You asked the Plan to pre-approve incontinence supplies. You say that you feel that the enrollee should be 
approved for diapers. Purchasing these will take away from the enrollee's food and other needs. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with multiple
power options (K0861) and accessories for the enrollee.

You asked the Plan to pre-approve a Group 3 PWC with multiple power options and accessories. You say that
these items are medically necessary. The Plan denied your request. The Plan says that the enrollee does not
have medical need for multiple power options available with K0861 group 3 power wheelchair.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for a Group 3 PWC
with multiple power options and accessories. Our Medical Director states that the enrollee has a medical
history that included coronary artery disease, congestive heart failure, hypertension, prostate cancer, and
chronic kidney disease. The plan was to provide the enrollee with a new tilt in space midwheel drive motorized
wheelchair with padded seat belt, trunk support, left lateral thigh support, adjustable head support, and
motorized leg rest. The available clinical documentation in the case file does not support that this enrollee
qualified for a Group 3 power wheelchair with multiple power options. Our Medical Director found that the
enrollee's condition does not meet criteria for coverage of a Group 3 PWC with multiple power options and
accessories.

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 PWC with multiple power options and accessories have not been
met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC)
with multiple power options (K0861) and accessories for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve podiatry services to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve podiatry services. You say that you need the services of a podiatrist on a 
regular basis. You also say that the approved podiatry office is a 25 minute drive from your home. The Plan 
denied your request. The Plan says the requested services can be received by a network provider. 
 
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 Plan has network providers available who are capable of providing the items/services at issue in this appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) We found no exception that would require the Plan to pre-approve these items/services. 
Therefore, we decided that the Plan does not have to pre-approve podiatry services to be provided by an out-of-
network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87529 billed for date of service April 5, 
2023. 
 
You asked the Plan to pay for the billed service. The Plan denied your request. The Plan says the billed code is 
not supported. 
 
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 87529 is infectious agent detection by nucleic acid (DNA 
or RNA); Herpes simplex virus, amplified probe technique. We find that CPT code 87529 is not supported in the medical record. The records provided do not show that this service was provided. Based on this information, we decided that Medicare rules for coverage of the billed service have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 87529 billed for date of service April 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dermatology services provided on September 19, 2023. 
 
You asked the Plan to pay for the dermatology services. You say that you listed the incorrect primary care 
provider when you saw the dermatologist. 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 dermatology services provided on September 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a re-evaluation post-operative office visit (D0171) provided 
on September 8, 2023. 
 You asked the Plan to pay for the dental service. You say that you do not agree with the denied dental services. 
The Plan denied your request. The Plan says the denial of authorization for these services is correct, because 
the re-evaluation post-operative office visit is not covered by the Plan. 
 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a re-
evaluation post-operative office visit (D0171) provided on September 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the  nursing facility care provided on June 07, 2023, to June 
26, 2023. 
 
You asked the Plan to pay for the  nursing facility care. You say that the assisted living facility is responsible to 
obtain prior authorization for all of their patients. 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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  nursing facility care provided on June 07, 2023, to June 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 03, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that these services were medically necessary. 
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 Plan had network providers available who were capable of providing the items/services at issue in this appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 laboratory services provided on August 03, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2310). 
 
You asked the Plan to pre-approve an electronic connection. You say that based on the specialty wheelchair 
evaluation that was ordered by the enrollee's physician on October 4, 2023, you are asking that the denial be 
reconsidered for the power tilt. The Plan denied your request. The Plan says since the enrollee is able to the 
control of the power options with their own switches, there is no need to control the power option through the 
joystick. 
 
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 an electronic connection. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested electrical accessories are not medically necessary as the enrollee does 
have use of the upper extremity and can operate and control the power options using the switches that are 
included in the basic wheelchair. Our reviewer also found that there is not a medical need for the upgraded 
electronics. 
 
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 electronic connection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection (E2310).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation (D4921) for the upper right quadrant 
provided on August 3, 2023. 
 
You asked the Plan to pay for the dental services. You say that the provider did not let you know that they were 
an out-of-network provider, and you would have rescheduled or skipped the visit. The Plan denied your 
request. The Plan says your benefit for the requested item or service has already been exhausted. 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, certain limitations apply. The record 
shows the Plan paid for the gingival irrigation (D4921) for the upper right quadrant on February 7, 2023; 
therefore, your benefit for the requested item or service was exhausted on the date of service of February 7, 
2023. Therefore, we decided that the Plan does not have to pay for the gingival irrigation (D4921) for the upper 
right quadrant provided on August 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) coded E0675 and 
half leg appliance coded E0673 billed for August 28, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that claims for E0675 will be denied as not 
reasonable and necessary.  
 
We looked at the file and Medicare rules. The services at issue are a PCD coded E0675. These services are 
denied by Medicare as not medically necessary. Given that the E0675 PCD is not covered, the half leg 
appliance billed with code E0673 is also not covered. Therefore, we decided that the Plan does not have to pay 
for the pneumatic compression device (PCD) coded E0675 and half leg appliance coded E0673 billed for 
August 28, 2023.