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

 
We decided that the Plan does not have to pre-approve Hyalgan (J7321). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says the enrollee has not tried and failed one of the preferred step therapy drugs: Orthovisc or Supartz FX. The Plan states there is no indication the Plan's preferred agent(s) would likely 
be: less effective, and/or cause adverse effects for the enrollee. 
 
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 physician reviewer 
found the Plan requires a trial of drug Orthovisc OR Supartz FX, before they will approve the requested drug. 
In this case, the enrollee has not tried and failed the required drug(s). 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 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 Hyalgan (J7321).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision supply provided on February 17, 2023. 
   
You asked the Plan to pay for the vision supply. You say that your benefit allows one pair or eyeglasses up to 
$130 per year. You say you do not understand why your claim is denied. The Plan denied your request. The 
Plan says the benefit has been exhausted. 
 
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 one pair of eyeglasses every 12 months. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid $130 for eyewear on December 31, 2022, 
which is within the 12-month limitation and exhausted the benefit.  Based on this information, we decided that 
the Plan's rules for coverage of the vision supply have not been met. Therefore, we decided that the Plan does 
not have to pay for the vision supply provided on February 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the incontinence supplies.  
 
You asked the Plan to pre-approve incontinence supplies. You say that you would like reconsideration because 
the requested incontinence supplies are medically necessary. The Plan denied your request. The Plan says the 
requested incontinence supplies are 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 the incontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (PCD) described by 
code E0652 and a full leg appliance described by code E0667 from an out-of-network 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 requested provider in this case is not a network provider with the Plan. 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 these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a pneumatic compression device (PCD) described by code E0652 and a full leg appliance described by code 
E0667 from an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), intraoral-
complete series of radiographic images (D0210), panoramic radiographic image (D0330), and the 2D 
oral/facial photographic images (D0350 x 4) provided on February 16, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the services provided 
has already been exhausted. Additionally, a 2D oral/facial photographic image 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, certain limitations apply. The record 
shows your benefit for the comprehensive oral evaluation, intraoral-complete series of radiographic images, 
and the panoramic radiographic image provided was exhausted on date of service November 15, 2021. 
Specifically, a comprehensive oral evaluation is covered once every 3 year calendar years. You previously 
received this service on November 15, 2021, less than three years prior, which was paid for by the Plan.  
Additionally, the Plans contract states that one full mouth or panoramic radiographic image is covered every 
five calendar years. You previously received a full mouth x-ray on November 15, 2021; less than five years 
prior, which was paid for by the Plan. Therefore, you have exhausted the allowable benefit for these services.  
Lastly, a 2D oral/facial photographic image is not a covered benefit. Therefore, we decided that the Plan does 
not have to pay for the comprehensive oral evaluation (D0150), intraoral-complete series of radiographic 
images (D0210), panoramic radiographic image (D0330), and the 2D oral/facial photographic images  
(D0350 x 4) provided on February 16, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occupational therapy and speech language therapy 
services billed with codes 97530, 97162, 97166, and 97110 for February 7, 2022, to February 28, 2022. 
 
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 were billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that outpatient rehabilitation claims must be billed with the 
GN, GO, or GP modifier.  
 We looked at the file and Medicare rules. The file shows that the claim was billed with mismatched GN, GO, 
or GP modifiers. Based on this information, we decided that Medicare rules for coverage of these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the occupational therapy and speech 
language therapy services billed with codes 97530, 97162, 97166, and 97110 for February 7, 2022, to February 
28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lab testing (0117U) provided on January 25, 2022
 . 
 
You asked the Plan to pre-approve the lab testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the code billed is not eligible for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that procedure code 0117U is non-Covered for 
pharmacogenomic testing. 
 
We looked at the file and Medicare rules. The billed code is non-covered under Medicare rules for this 
procedure. Based on this information, we decided that Medicare rules for coverage of the lab testing have not 
been met. Therefore, we decided that the Plan does not have to pre-approve lab testing (0117U) provided on 
January 25, 2022 .
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pulmozyme (J7639). 
 
You asked the Plan to pre-approve Pulmozyme. 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 Pulmozyme. 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 Pulmozyme is medically reasonable and necessary or safe and 
effective for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Pulmozyme have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Pulmozyme (J7639).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility evaluation provided on October 24, 2022. 
 
You asked the Plan to pay for a nursing facility evaluation. You say that this was medically necessary and 
should be covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a nursing facility 
evaluation provided on October 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cystoscopy. 
 
You asked the Plan to pre-approve cystoscopy. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested services 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 cystoscopy. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee erectile dysfunction that was treated with inflatable penile prosthesis that has been 
replaced three times. The enrollee now reports that the prosthesis is "broken'. The enrollee has a history of 
prostate cancer treated with radical prostatectomy more than 20 years ago. Cystoscopy is not medically 
reasonable and necessary in this case. The records do not mention a specific reason for cystoscopy such as difficulty voiding or hematuria.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cystoscopy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve cystoscopy.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuous glucose monitor (CGM), supplies and accessories. 
 
You asked the Plan to pre-approve the CGM, supplies and accessories. You say that the enrollee has Dumping 
syndrome which is the cause of the hypoglycemia and requires multiple sugar checks per day. The Plan denied 
your request. The Plan says that the enrollee does not meet the medical necessity criteria. 
 
The Plan must follow 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 the CGM, supplies and accessories. Our 
reviewer says that the CGM, supplies and accessories are medically necessary. Our physician reviewer found 
the enrollee is having low blood glucose sugar and the libre is medically indicated to prevent low blood glucose 
sugar and warn them of the lows so they can eat before it gets dangerously low. This is the case even though 
the enrollee is not taking diabetes medications. 
 
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 CGM, supplies and accessories have been met. Therefore, we decided that 
the Plan has to pre-approve a continuous glucose monitor (CGM), supplies and accessories.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services at the in-network benefit level.  
 
You asked the Plan to pre-approve physician's services at the in-network benefit level. The Plan denied your 
request. The Plan says the enrollees Evidence of Coverage clearly states out-of-network providers will be 
approved at the in-network benefit level if there are not any in-network providers that can provide the specialist 
care. The Plan has identified nine providers with the same specialty that are in-network with the Plan. The 
enrollee can continue to utilize his out-of-network benefits as previously done per claims history. 
 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 requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services at the in-network benefit level.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a portable chest x-ray provided on December 28, 2022. 
 
You asked the Plan to pay for a portable chest x-ray. You say that this service was 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a portable chest x-ray 
provided on December 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on August 29, 
2022. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the services should be covered. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for subsequent nursing 
facility care provided on August 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasonic guidance for needle placement, the trigger 
point injections, and the propofol injection provided on January 4, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the ultrasonic guidance, the trigger point injections, and the propofol injection. 
You say that these services were medically necessary. The Plan denied your request. The Plan says enrollees 
must receive their care from 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
items/services at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the ultrasonic guidance for needle placement, the 
trigger point injections, and the propofol injection provided on January 4, 2023, by an out-of-network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for covid-19 testing provided on January 31, 2023, to February 
07, 2023. 
 
You asked the Plan to pay for covid-19 testing. You say that this is supported in the records. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for covid-19 testing 
provided on January 31, 2023, to February 07, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for covid-19 testing provided on January 20, 2023. 
 
You asked the Plan to pay for covid-19 testing. You say that this testing was 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for covid-19 testing 
provided on January 20, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the nuclear medicine study, and the iodine 
1-123 ioflupane injection provided on December 27, 2022. 
 
You asked the Plan to waive the cost sharing for the nuclear medicine study, and the injection. You say that 
you do not agree with the cost sharing. 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 $75 
copayment for Medicare-covered radiological diagnostic services, which includes nuclear studies, performed in 
a physicians office or at a free-standing facility (such as a radiology center or medical clinic), and a 20% 
coinsurance for each Medicare-covered medical supply. 
 
You have been asked to pay a $75 copayment for the nuclear medicine study. You have also been asked to pay 
a $592.32 coinsurance for the injection ($2961.60 allowed amount x .20 = $592.32). These items/services fall 
within the outpatient diagnostic tests and therapeutic services and 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 waive the cost sharing for the nuclear medicine study, and the iodine 1-123 ioflupane injection 
provided on December 27, 2022.