Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 17 additional fractions of intensity-modulated radiation 
therapy (IMRT). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is 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 the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the additional 17 fractions of IMRT are not medically reasonable and necessary in this 
case. The records do not show that the additional 17 fractions are medically necessary. The originally approved 
28 fractions of IMRT are medically adequate in this case.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 17 additional fractions of intensity-modulated radiation therapy (IMRT).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture and mandibular partial 
denture (D5211, D5212). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. 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 your benefit for the requested item or service was exhausted on date of service June 04, 2019 (D5211) 
and April 22, 2019 (D5212). Therefore, we decided that the Plan does not have to pre-approve a maxillary 
partial denture and mandibular partial denture (D5211, D5212).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the items denied correctly as you do not meet the clinical 
requirements to be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not have diabetes, 
use insulin or have a history of problematic hypoglycemia, had an in-person visit with their treating physician 
to evaluate their diabetes control and to determine whether the criteria for coverage have been met.  Based on 
this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 50 additional routine transportation trips (A0130). 
 
You asked the Plan to pre-approve the 50 additional routine transportation trips. You say that it is a medical 
necessity for the enrollee to receive the additional transportation tips until year end. The Plan denied your 
request. The Plan says the enrollee has used 36 of the 36 allowed one-way trips.  
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 36 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve 50 
additional routine transportation trips. Based on this information, we decided that you have exhausted the Plan 
maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to 
pre-approve 50 additional routine transportation trips (A0130).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic injection services provided on March 23, 2023. 
 
You asked the Plan to pay for diagnostic injection services. You say that the records attached support the 
services provided. 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 diagnostic injection 
services provided on March 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 24 additional routine transportation trips. 
 
You asked the Plan  to pre-approve the 24 additional routine transportation trips. You say that the medical 
necessity for transportation is due to the enrollee's prostate cancer. You also say that the enrollee needs 24 
round trip visits. The Plan denied your request. The Plan says the enrollee has already exhausted this yearly 
benefit.  
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve 24 
additional routine transportation trips. Based on this information, we decided that the enrollee has exhausted 
the Plans maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does 
not have  to pre-approve 24 additional routine transportation trips.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on December 
30, 2022. We also decided that the Plan does not have to pay for the ambulance mileage provided on December 
30, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transport and pay for the ambulance mileage. 
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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $250 copayment for each one-way Medicare-covered  ambulance transport and $250 for each non-
Medicare covered ambulance stabilization when there is no transport. The Plan contract also says that 
ambulance - mileage for ambulance transport beyond nearest facility or to/from facility preferred by member 
and/or family is not a covered service. 
 
The enrollee has been asked to pay $233.65 which is less that the standard $250 copayment for the ambulance 
transport, and $2,478.00 for the non-covered charges for the ambulance mileage. This leaves the enrollee with 
a liability of $2,711.65 ($233.65 + $2,478.00 = $2,711.65). The ambulance transport falls within the ambulance 
services benefit category, and the ambulance mileage falls within the service not covered by Medicare benefit 
category. This means that the enrollee has been asked to pay the correct amount based on the contract with the 
Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for ambulance transport and pay for 
the ambulance mileage  provided on December 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3020).  
 
You asked the Plan to pre-approve these items. You say that you are requesting reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says these items are not a covered benefit for your condition. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3020).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 81226, 81240, 81241 and 
81328 provided November 10, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that you believe that the treatment sought is 
medically necessary to treat the enrollee based on the enrollee's medical condition. The Plan denied your 
request. The Plan says there is a more appropriate lab panel CPT code that should be billed when one or more 
CPT codes are included in the same panel.  
 
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, we find that CPT code 81226, 81240, 81241 and 81328 is not supported in the medical record. 
Specifically, there is a more appropriate lab panel CPT code that should be billed when one or more CPT codes 
are included in the same panel. There's a more appropriate CPT code (81455) that should be used to bill for the 
service provided. Based on this information, we decided that Medicare rules for coverage of the laboratory 
service have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
coded as 81226, 81240, 81241 and 81328 provided November 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. 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 your benefit for the requested item or service was exhausted on date of service May 10, 2021. Therefore, 
we decided that the Plan does not have to pre-approve a crown (D2740).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Syfovre 15 mg/0.1 mL intravitreal solution every 4 
weeks. 
 
You asked the Plan to pre-approve Syfovre 15 mg/0.1 mL intravitreal solution every 4 weeks. 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 Syfovre 15 mg/0.1 mL intravitreal 
solution every 4 weeks. Our reviewer says that the services are not medically necessary. Our physician 
reviewer found information from the provider shows he requested every 4-week dosing which exceeds the 
coverage limits. The plan has approved a frequency of every 60-day dosing. There is no documentation 
provided indicating medical necessity for the requested increased dosing. The review has determined that the 
documentation does not support that the requested dose of Syfovre is medically reasonable or necessary for the enrollee. The documentation does not support that the requested dose of Syfovre is 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 Syfovre 15 mg/0.1 mL intravitreal solution every 4 weeks have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Syfovre 15 mg/0.1 mL intravitreal solution 
every 4 weeks.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Darzalex Faspro (J9144). 
 
You asked the Plan to pre-approve the drug. You say that the requested drug is medically necessary for the 
enrollee's treatment. The Plan denied your request. The Plan says the requested use of this drug is not approved 
by the Food and Drug Administration (FDA) for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found this drug is not 
approved as first line therapy for the enrollee's condition. Its use is not supported by one of the major drug compendia, or by clinical research that appears in a CMS-approved medical journal. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Darzalex Faspro (J9144).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan. 
 
You asked the Plan to pre-approve Hyalgan. You say that Hyalgan is medically necessary for this patient. The 
Plan denied your request. The Plan says use of this drug is not medically necessary. 
 
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 Hyalgan. Our reviewer says that 
Hyalgan is not medically necessary in this case. Our physician reviewer found there is no documentation of an 
intraarticular steroid injection. More conservative measures for knee pain are needed before Hyalgan can be 
considered 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 Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hyalgan.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa injections. 
 You asked the Plan to pre-approve the Euflexxa injections. You say that the enrollee would benefit from this 
treatment.  The Plan denied your request. The Plan says there is no reason given that the preferred agents 
cannot be tried. 
 
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 Euflexxa injections. Our reviewer 
says that the requested Euflexxa is not reasonable and necessary based on step therapy rules.  Our physician 
reviewer found the enrollee is a 70-year-old female with a history of bilateral knee pain due to bilateral primary 
osteoarthritis of the knee. The enrollee's provider has recommended viscosupplementation therapy with 
Euflexxa. The enrollee has not trialed one of the preferred viscosupplement treatments such as Orthovisc or 
Supartz. The documentation does not outline contraindications or reasons these medications were not 
considered or that the plan's additional 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 the Euflexxa injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Euflexxa injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with single power 
option and power tilt seating system. 
 
You asked the Plan to pre-approve the Group 3 PWC requested. You say that it is felt that the requested PWC 
and accessories are necessary.  The Plan denied your request. The Plan says since power tilt seating is not 
needed, the requested PWC base code cannot be approved. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 PWC with a single power option may only 
be covered when the enrollee meets criteria for a power tilt or power recline seating system. 
 
 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 Group 3 PWC requested. Our 
reviewer says that the requested PWC base cannot be approved as the power tilt seating system does not meet 
criteria.  Our physician reviewer found the enrollee has multiple sclerosis with markedly impaired ambulation. 
She does not use a catheter, have spasticity which impairs her positioning, or have high risk for skin 
breakdown. As such, the requested power tilt feature is not medically necessary based on LCD guidelines. 
 
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 Group 3 PWC requested have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with single power option and power tilt 
seating system.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for code 87634-59 billed for date of service December 1, 2022. 
 
You asked the Plan to pay for code 87634-59. You say that you followed all appropriate testing guidelines, and 
this service should be covered. The Plan denied your request. The Plan says that the use of the 59 modifier for 
code 87634-59 is not supported by the medical record. This code is considered part of code 87798 and cannot 
be separately reimbursed. The Plan has agreed to pay for codes U0005, 87502, 87541-59, 87581-59, and 
87798-59, so those codes are not in dispute. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for code 87634-59 Our reviewer says that the 
use of the 59 modifier to allow for separate payment of code 87634 is supported by the medical record. Our 
physician reviewer found the medical records do support the use of procedure 86734, as respiratory panel was 
performed. Code 87798 is a Not Otherwise Specified code, where 86734 is more specific for the panel 
performed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 87634-59 have been met. Therefore, we decided that the Plan has to pay 
for code 87634-59 billed for date of service December 1, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you were independent and active before coming to 
the hospital. The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
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 that you do not have complex nursing or rehabilitation needs. While the medical 
record supports 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. There is not a 
reasonable expectation that you 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 IRF admission and services.