Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pneumatic compression device and the accessories 
to be provided by an OON provider.  
 
You asked the Plan to pre-approve the compression device and accessories. You say that the items are 
medically necessary. The Plan denied your request. The Plan says this service is not approved. 
 
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 contract 
says the enrollees POS benefit only applies to covered routine dental services. 
 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 
the pneumatic compression device and the accessories to be provided by an OON provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc. 
 You asked the Plan to pre-approve Synvisc. You say that Synvisc is medically necessary. The Plan denied your 
request. The Plan says a trial of Gel-One and Euflexxa 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 Synvisc. Our reviewer says that 
Synvisc is not medically necessary. Our physician reviewer found the records do not show a trial of the plan 
preferred drugs, or any reason they are 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 Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Synvisc.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the robotic prostate procedure and surgery to take out 
the prostate (51999 and 55866). 
 
You asked the Plan to pre-approve the services. You say that your hemoglobin level is currently low, and you 
are experiencing pain, dizziness, fatigue, and bleeding. You state that when you experience bleeding, the blood 
accumulates in the urethra and your primary care physician has to prescribe your antibiotics to avoid infections. 
The Plan denied your request. The Plan says there is no documentation that you suffer from cancer.  
 
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 items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found Current Procedural Terminology (CPT) 51999 (laparoscopic procedure of the bladder and CPT 55866 (laparoscopic removal of the prostate for cancer) are not medically reasonable and necessary in this case. 
The records show that the procedure desired for the enrollee is a simple laparoscopic prostatectomy for BPH 
which is CPT 55867. 
 
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 the robotic prostate procedure and surgery to take out the prostate (51999 and 55866).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Evenity injection. 
 
You asked the Plan to pre-approve an Evenity injection. You say that the requested injection is medically 
necessary. The Plan denied your request. The Plan says the enrollee did not meet the step therapy requirements. 
 
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 injections. Our physician reviewer 
found that the Plan requires a trial of Forteo before they will approve Evenity. Our physician reviewer found 
that based on the medical records provided there is no indication that the enrollee has tried and failed the 
required drug. Our physician reviewer found that there is no indication that the Plans required drug 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 an Evenity injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Evenity injection.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ongentys. 
 
You asked the Plan to pre-approve the medication. You say that the requested drug is needed by the enrollee. 
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 pre-approve Ongentys.  Benefits for the medication 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 Kerecis Omega3 (Q4158). 
 
You asked the Plan to pre-approve the Kerecis Omega3. You say that the medical records support the medical 
necessity. The Plan denied your request. The Plan says the records do not show that the wound has failed to 
respond to four weeks of standard wound care.  
 
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 Kerecis Omega3. Our reviewer says 
that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided records in this case document wound measurements from May 3, 2023 of 12cm x 
5cm x 0.1cm through May 23, 2023 of 11.5cm x 3.7cm x 0.1cm.  
 Records also document bilateral lower extremity peripheral arterial disease as of April 5, 2023 with plans to 
perform an arteriogram and treat as needed to improve inflow and outflow of the bilateral lower extremities. 
No documentation has been provided that this procedure was performed and current records show non-palpable 
lower extremity pulses. The current standard of care for use of skin substitutes for wound care is to document 
30 days of lack of healing with standard wound care and to document no significant arterial disease preventing 
healing. Provided records only contain wound measurement over a 20 day period and records do not clarify the 
vascular status of this patients lower extremity arterial supply.  
 
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 Kerecis Omega3 have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Kerecis Omega3 (Q4158).
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 stay is medically necessary. The Plan denied 
your request. The Plan says your records do not show that your rehabilitation needs are complex and that you 
need to be seen three (3) times per week for evaluation of functional and medical goals and progress. The Plan 
states you do not need an intensive team for your care. The Plan states the services you need can be provided 
safely in other settings, for example, a skilled nursing facility, home with home health services or home with 
outpatient therapy. 
 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 Health Plans denial should be upheld. You do not require the intensity of 
services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative 
services and regular physician evaluation. 
 
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 the vascular consultation to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve the consultation. You say that the consultation is medically necessary. The 
Plan denied your request. The Plan says this service is not approved. 
 
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 item/service at issue in this appeal. We found no exception that would require 
the Plan to pre-approve the item/service. Therefore, we decided that the Plan does not have to pre-approve the 
vascular consultation to be provided by an OON provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Durysta (J7351). 
 You asked the Plan to pre-approve Durysta. You say that Durysta is a medical necessity for the enrollee. The 
Plan denied your request. The Plan says step-therapy rules for coverage of Durysta 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 Durysta. Our reviewer says that 
Durysta is not medically reasonable and necessary in this case. Our physician reviewer found that the Plan 
requires a trial of at least two ophthalmic prostaglandins and two ophthalmic products from two different 
pharmacological classes before they will approve the requested drug. The enrollee has open angle 
glaucoma. The requested drug is a new start. The provided records do not indicate that the enrollee has tried 
and failed the Plan's preferred step-one alternatives. 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 alternatives. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Durysta have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Durysta (J7351).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a new patient office visit provided on 
February 24, 2023. 
 
You asked the Plan to waive the copayment for a new patient office visit. You say that you think that this 
service should be covered. 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 $35 
copayment for in-network Medicarecovered physician specialist services. 
 
You have been asked to pay a $35 copayment for a new patient office visit. This item/service falls within the 
in-network Medicarecovered physician specialist services 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 copayment for a new patient office visit provided on February 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says the enrollee must receive their care from a network provider (for more 
information about this, see Section 2 of Chapter 3). In most cases, care the enrollee receives from an out-of-
network provider (a provider who is not part of the plans network) will not be 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 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 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the specialist services to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve the specialist services. You say that you would like to see the same provider 
again. The Plan denied your request. The Plan says this service is not approved. 
 
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 
the specialist services to be provided by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital admission. 
 
You asked the Plan to pre-approve inpatient hospital admission. You say that the services are medically 
necessary. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. Medicare rules say that if coverage under a Medicare 
Advantage (MA) plan begins while the beneficiary is an inpatient in a hospital facility, payment for inpatient 
services until the date of the beneficiary's discharge is made by the previous MA organization, or Original 
Medicare, as appropriate. 
 
The enrollee ended Medicare Hospice benefits on June 27, 2023. Coverage under the MA plan began again on 
July 1, 2023. The payer on the date of admission would still cover the whole stay. Therefore, we decided that 
the Plan does not have to pre-approve inpatient hospital admission.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that you would like a third opinion. The Plan denied 
your request. The Plan says this is available in-network. 
 
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 
an office visit 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary for 
the enrollee's care.  The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient 
acute care and does not require transfer to a 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 appears to be improving with current treatment and should only require 
short-term additional acute care services that can safely be provided at the current facility until appropriate for 
a lower level of care soon. The enrollee does not require services at the LTACH that are not already available 
at the current facility.  
 
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 waive the cost share for the biopsy procedure provided on February 
3, 2023. 
 
You asked the Plan to waive the cost share for the biopsy. You say that you had met your deductible prior to 
this service. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1,000 deductible which applies to in-network outpatient surgery and 
other medical services provided at hospital outpatient facilities. Your contract with the Plan also clearly says 
that you must pay a $295 copayment for in-network Medicare-covered surgery. 
 
 
 The record shows you had not met the deductible prior to this service. You have been asked to pay $1,000, 
which satisfies the deductible for the biopsy. The item or service you asked the Plan to waive the cost share for 
falls within the outpatient surgery and other medical services provided at hospital outpatient facilities benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 
deductible which applies to outpatient surgery and other medical services provided at hospital outpatient 
facilities. This cost sharing is a contractual obligation that had not been met at the time the biopsy was received 
on February 3, 2023.  
 
You have also been asked to pay a $295 copayment for the biopsy. This item/service falls within the outpatient 
surgery and other medical services provided at hospital outpatient facilities benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the cost share for the biopsy procedure provided on February 3, 2023.