Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for an ultrasound, abdominal aorta, real time with image documentation, 
screening study for abdominal aortic aneurysm (code 76706) provided on October 26, 2022. 
 
You asked the Plan to pay for the ultrasound, abdominal aorta, real time with image documentation, screening 
study for abdominal aortic aneurysm. You say that the ultrasound, abdominal aorta, real time with image 
documentation, screening study for abdominal aortic aneurysm was medically necessary. The Plan denied your 
request. The Plan says that the ultrasound, abdominal aorta, real time with image documentation, screening 
study for abdominal aortic aneurysm does not meet the coverage criteria in the Medicare Claims Processing 
Manual Chapter 18 - Preventive and Screening Services, Section 110.2. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 pay for the ultrasound, abdominal aorta, real time 
with image documentation, screening study for abdominal aortic aneurysm. Our reviewer says that the 
requested ultrasound, abdominal aorta, real time with image documentation, screening study for abdominal 
aortic aneurysm is considered medically reasonable and necessary in this case. Our physician reviewer found 
that the documentation supports the medical necessity of the study in question. The enrollees obesity renders 
physical examination unhelpful for this condition. The enrollee has hypertension, is a former smoker, and 
documentation of both abdominal pain and back pain. As the enrollee has risk factors for and potentially 
symptoms of an abdominal aortic aneurysm, evaluation with abdominal aortic duplex is both reasonable and 
medically necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the ultrasound, abdominal aorta, real time with image documentation, screening 
study for abdominal aortic aneurysm have been met. Therefore, we decided that the Plan has to pay for an 
ultrasound, abdominal aorta, real time with image documentation, screening study for abdominal aortic 
aneurysm (code 76706) provided on October 26, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a rest home visit provided on November 25, 2022, by an 
OON provider. You asked the Plan to pay for the home visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says that this service is not covered when received by an out-of-
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 Plan contract also says that the enrollees POS benefit does 
not apply to an out-of-network home visit. 
 
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 
item/service 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 a rest home visit provided on November 25, 2022, 
by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous spacer device (X-Stop). 
 
You asked the Plan to pre-approve an interspinous spacer device (X-Stop). You say that an interspinous spacer 
device (X-Stop) is medically necessary. The Plan denied your request. The Plan says the requested interspinous 
spacer device (X-Stop) is experimental and investigational. 
 
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 interspinous spacer device (X-Stop). 
Our reviewer says that the requested interspinous spacer device (X-Stop) is not considered medically 
reasonable and necessary. Our physician reviewer found that the X-Stop device is experimental. More research 
is needed. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an interspinous spacer device (X-Stop) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an interspinous spacer device (X-Stop).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Gelsyn-3 (J7328). 
 You asked the Plan to pre-approve Gelsyn-3. You say that Gelsyn-3 is a medical necessity for the enrollee. The 
Plan denied your request. The Plan says step-therapy rules for coverage of Gelsyn-3 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 Gelsyn-3. Our reviewer says that 
treatment with Gelsyn-3 is not medically reasonable and necessary in this case. Our physician reviewer found 
that the Plan requires a trial of drugs Orthovisc or Supartz FX before they will approve the requested drug. The 
case record does not contain documentation of trial and failure of Orthovisc or Supartz FX. The documentation 
does not support that Orthovisc or Supartz FX would likely be less effective and/or would likely have adverse 
effects for the enrollee 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 Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Gelsyn-3 (J7328).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 7 additional physical therapy visits.

You asked the Plan to pre-approve physical therapy visits.. You say that you do not have steadiness in your feet
and have had a cerebral ischemic attack. The Plan denied your request. The Plan says 7 additional physical
therapy visits are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.

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 physical therapy visits. Our reviewer
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the
enrollee's condition. Our physician reviewer found that you have chronic functional loss and requires a
repetitive exercise program. However, you have an established home exercise program in which you do not
follow consistently. Therefore, continued input from a skilled therapist is not medically necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of physical therapy visits. have not been met. Therefore, we decided that the Plan
does not have to pre-approve 7 additional physical therapy visits.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zoledronic Acid. 
 
You asked the Plan to pre-approve Zoledronic Acid. You say that the requested Zoledronic Acid is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested 
Zoledronic Acid. 
 
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 Zoledronic Acid. Our reviewer says 
that the enrollee does not meet criteria for the requested Zoledronic Acid. Our physician reviewer found the 
record indicates that the enrollee has a diagnosis of osteopenia and systemic lupus. The Food and Drug 
Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare 
approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's 
clinical situation. The noted condition is not one which is enumerated in the rules for which coverage may be 
available. The elements of the coverage criteria are not satisfied. The requested service cannot be 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zoledronic Acid have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Zoledronic Acid.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontic - porcelain for tooth #19 (D6240) and retainer 
crown -porcelain for tooth #20 (D6750). 
 
You asked the Plan to pre-approve a pontic and retainer crown for teeth # 19 and #20. You say that this is 
medically necessary for the enrollee. The Plan denied your request. The Plan says this is not medically 
necessary because the treatment is on teeth with poor or questionable prognosis. 
 
 
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. The Plan covers a pontic and 
retainer crown for teeth # 19 and #20 when the services are medically necessary and reasonable.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a pontic and retainer crown for teeth # 
19 and #20. Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
documentation provided does not meet the criteria for coverage for a fixed bridge replacing missing tooth #19 
with a pontic (D6240) using tooth #20 as an abutment retainer (D6750). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a pontic and retainer crown for teeth # 19 and #20 have not been met. 
Therefore, we decided that the Plan does not have to pre-approve pontic - porcelain for tooth #19 (D6240) and 
retainer crown -porcelain for tooth #20 (D6750).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion procedure (22869 C1821). 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that the enrollee meets the medical 
necessity outlined in the criteria. The Plan denied your request. The Plan says Interspinous decompression 
systems (without fusion) for the treatment of spine pain or spinal stenosis are unproven and not medically 
necessary due to insufficient evidence of efficacy. 
 
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 Vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex spacer device is experimental. More research is needed. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex Superion procedure (22869 C1821).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prosthetic services to be provided by an OON provider. 
 
You asked the Plan to pre-approve prosthetic services. You say that you are requesting reconsideration of the 
denied authorization. The Plan denied your request. The Plan says that the requested items are not covered 
when received by an out-of-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 contract 
also says that the enrollees POS benefit does not apply to out-of-network prosthetic 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 
prosthetic services to be provided by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Modafinil. 
 
You asked the Plan to pre-approve the medication. You say that you disagree with the denial. 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 Modafinil.   
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat lumbar sacral interlaminar epidural steroid 
injection (ESI) (62323). 
 
You asked the Plan to pre-approve the injection services. You say that without this injection you will be unable 
to walk and have no quality of life.  The Plan denied your request. The Plan says repeat lumbar sacral interlaminar epidural steroid injection (ESI) 
is not medically necessary because the enrollee had 7 weeks of 80% pain relief. 
 
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 injection services. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record show that the patient did not have a total of 3 months of pain relief from 
the first injection. 
 
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 injection services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve repeat lumbar sacral interlaminar epidural steroid injection (ESI) (62323).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Procrit or Epogen (J0885). 
 You asked the Plan to pre-approve Procrit or Epogen. You say that Procrit or Epogen are a medical necessity 
for the enrollee. The Plan denied your request. The Plan says step-therapy rules for coverage of Procrit or 
Epogen 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 Procrit or Epogen. Our reviewer says 
that Procrit or Epogen are not medically reasonable and necessary in this case. Our physician reviewer found 
that the Plan requires a trial of drugs Aranesp or Retacrit before they will approve the requested drugs. The 
case record does not contain documentation of trial and failure of Aranesp or Retacrit. The documentation does 
not support that Aranesp or Retacrit would likely be less effective and/or would likely have adverse effects for 
the enrollee 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 Procrit or Epogen have not been met. Therefore, we decided that the Plan does 
not have to pre-approve treatment with Procrit or Epogen (J0885).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided on June 14, 2021, to July 29, 
2021. 
 
You asked the Plan to pay for the inpatient hospital care provided. You say that the claim was billed correctly 
and should be paid. The Plan denied your request. The Plan says this is a hospital claim audit. Insufficient 
medical records were submitted for review. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the inpatient hospital care provided 
have been met. Specifically, the complete medical records for all dates of service have not been submitted for 
review. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided on June 
14, 2021, to July 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repatha Sureclick. 
 
You asked the Plan to pre-approve the medication. You say that you disagree with the denial. 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 Repatha Sureclick.   
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block. 
 
You asked the Plan to pre-approve a genicular nerve block. You say that a genicular nerve block is medically 
necessary. The Plan denied your request. The Plan says a genicular nerve block 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 a genicular nerve block. Our reviewer 
says that the requested genicular nerve block is not considered medically reasonable and necessary. Our 
physician reviewer found that genicular nerve blocks and genicular nerve radiofrequency ablation are 
considered investigational and not medically necessary for the treatment of chronic knee pain, including, but 
not limited to any of the following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to 
knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not candidates for knee replacement surgery. The review has determined that the requested genicular nerve block is 
not medically reasonable or necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete denture - maxillary (D5110). 
 
You asked the Plan to pre-approve complete denture - maxillary. You say that this should be covered. The Plan 
denied your request. The Plan says this is not a covered service. 
 
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 
complete denture - maxillary (D5110).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6533. 
 
You asked the Plan to pre-approve the compression stockings. The Plan denied your request. The Plan says you 
do not meet the statutory definition of a dressing. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are 
noncovered because they do not meet the statutory definition of a surgical dressing.   
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6533.