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

 
We decided that the Plan does not have to pre-approve Percutaneous Vertebroplasty and Vertebral 
Augmentation Procedure: Kyphoplasty. 
 
You asked the Plan to pre-approve a Kyphoplasty. You say that the requested Kyphoplasty is medically 
necessary. The Plan denied your request. The Plan says the requested Kyphoplasty is not medically necessary.  
 
The Plan follows Medicare rules. Medicare rules say that a Kyphoplasty is covered when the criteria listed in 
the Medicare rules section of this decision are met.  
 
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 Kyphoplasty. Our reviewer says that 
the requested Kyphoplasty is not considered medically necessary in this case. Our physician reviewer found 
this enrollee was being treated for wedge compression fracture of the first lumbar vertebra. The enrollee 
presented status post a fall. The exam reveals the enrollee is quite sore at the thoracolumbar junction around the 
flank area. The enrollee presented with a computed tomography (CT) findings of an acute L1 
burst/compression fracture. However, detailed documentation is not evident regarding worsening pain. There is 
no indication of a progression of the body height loss, kyphotic deformity, or a severe impact on her daily 
activities. Moreover, there is CT corroboration of retropulsion. Therefore, the requested Percutaneous Vertebroplasty and Vertebral augmentation Procedure-Kyphoplasty does not meet the Medicare LCD coverage 
criteria. 
 
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 Kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Percutaneous Vertebroplasty and Vertebral Augmentation Procedure: Kyphoplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services rendered on January 11, 2023. 
 
You asked the Plan to pay for the services. You say that this was required to keep the patient stable during the 
procedure. The Plan denied your request. The Plan says there are no extraordinary circumstances which would 
require anesthesia. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that monitored anesthesia care (MAC) was not indicated for this procedure. The enrollee did not have any unstable medical conditions, difficult airways, current problems with drug/alcohol abuse, or any other 
specific indication for a separate anesthesia provider. 
 
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 pay for anesthesia services rendered on January 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental crown-porcelain fused to high noble metal for 
tooth number 12 (D2750). 
 
You asked the Plan to pre-approve this dental item. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says your benefit for the requested item 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 was exhausted on date of service June 25, 2021.  
 
 
 
Specifically, the Plans contract states that a dental crown is covered every five years per tooth. You previously 
received a dental crown for tooth number 12, less than five years prior, which was paid for by the Plan. 
Therefore, you have exhausted the allowable benefit for this dental item. Therefore, we decided that the Plan 
does not have to pre-approve a dental crown-porcelain fused to high noble metal for tooth number 12 (D2750).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Renflexis. 
 
You asked the Plan to pre-approve Renflexis. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Renflexis. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has a diagnosis of moderate to severe Crohn's disease. The Food and Drug 
Administration has not stated that the requested drug, as prescribed, 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, 
as prescribed, in the enrollee's clinical situation.  Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Renflexis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Renflexis.
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 you have hypoglycemia which the CGM should be 
covered. The Plan denied your request. The Plan says the Medicare criteria was not met. 
 
The Plan follows 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. Our reviewer says that the 
CGM coverage criteria is not met. Our physician reviewer found that the record indicates that the enrollee has 
diabetes. The record provided does not indicate that the enrollee is being treated with insulin or has problematic 
hypoglycemia as defined by the Medicare rules. The elements of the coverage criteria are not satisfied. The 
requested service is not 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 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
November 24, 2022, to December 2, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were unaware of 
the copayment. 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 $325 
copayment per day for days 1-5 of an inpatient hospital stay.  
 
 
 You have been asked to pay a total of $1,625, which is a $325 copayment per day for days 1-5 of the inpatient 
hospital stay ($325 copayment x 5 days = $1,625). You have not been charged a copayment beyond day five. 
This item/service falls within the inpatient hospital care 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 the inpatient hospital stay provided from November 24, 2022, to December 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement power wheelchair. 
 
You asked the Plan to pre-approve a replacement power wheelchair. You say that your current power scooter 
does not work. The Plan denied your request. The Plan says that your current equipment is less than five years 
old and there is no evidence that it cannot be repaired. 
 
The Plan must follow Medicare rules. Medicare rules say that that equipment which the beneficiary owns or is 
a capped rental item may be replaced in cases of loss or irreparable damage. The rules also say that replacement 
due to wear is not covered during the reasonable useful lifetime of the equipment. During the reasonable useful 
lifetime, Medicare does cover repair up to the cost of replacement (but not actual replacement) for medically 
necessary equipment owned by the beneficiary. 
 
We looked at the file and Medicare rules. The record shows you received your current equipment in November 
2022. The record also shows that your equipment can be repaired. Therefore, we decided that the Plan does not 
have to pre-approve a replacement power wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service February 9, 
2023.  
 You asked the Plan to pay for procedure code 86077. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service February 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on March 2, 2023. 
 
You asked the Plan to waive the copayment for an office visit. You say that you should not have a copayment. 
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 $10 
copayment for each covered visit in an outpatient location with a primary care provider. This copayment will 
apply if you receive services that address a medical condition during the same office visit as an annual visit. 
 
 You have been asked to pay a $10 copayment for an office visit. This item/service falls within the 
physician/practitioner 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 
an office visit provided on March 2, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the walker and does not have to pay for the 
walker accessories provided on January 11, 2023. You asked the Plan to waive the cost share for the walker and to pay for the accessories. You say that this is too 
much to pay for a walker. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
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 20% 
coinsurance for in-network durable medical equipment. 
 
The brakes and pouch for your walker do not serve a purpose that is primarily medical in nature. These items 
are available to the general public and would be helpful even to those who are not sick or injured. Therefore, 
we decided that the Plan does not have to pay for the brakes and the pouch provided on January 11, 2023. 
 
You have been asked to pay $19.41, which is 20% coinsurance of the allowed amount for the walker. This 
item/service falls within the in-network durable medical equipment 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 walker provided on January 11, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF visit provided from January 5, 2023, 
to February 9, 2023. 
 
You asked the Plan to waive the copayment for a SNF visit. You say that you were unaware of the copayment 
for the SNF visit and are having financial hardship. 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 $0 copayment per day for days 1 to 20 and a $196 copayment per day for days 21 to 100 for SNF 
care.  
 The enrollee has been asked to pay $2,940 for a SNF visit ($196 per day x 15 days = $2,940). This item/service 
falls within the SNF care 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 a 
SNF visit provided from January 5, 2023, to February 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on December 15, 2022. 
 
You asked the Plan to pay for the psychotherapy. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that the health Plan requires utilization of network providers when 
possible and available and requires authorization for certain services. No medical necessity for an 
out-of-network provider, such as an urgent or emergency situation, has been documented. There is no network 
deficiency for these services and alternate network providers were found. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for psychotherapy provided on December 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oral nutritional supplement (B4152). 
 
You asked the Plan to pre-approve oral nutritional supplement (B4152). You say that you are a cancer patient 
who depends on this product. The Plan denied your request. The Plan says this is not a covered benefit 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve oral nutritional supplement (B4152).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from  
November 26, 2022, through November 29, 2022. 
 
 
  
 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient hospital care provided was 
not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 these services. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee presented to the emergency department (ED) on November 26, 2022 with 
hypothermia, lethargy, confusion, and concern for seizure activity in the field prior to arrival. She was warmed 
and given fluids. The workup revealed an abnormal urinalysis suggestive of a urinary tract infection but no 
leukocytosis was noted in the blood. She was treated with intravenous antibiotics and Keppra. The seizure was 
likely due to hypothermia. Her vital signs were stable following initial fluids/treatment and upon transfer to the 
intensive care unit without new seizure events and with improved mentation. There was insufficient evidence 
for sepsis or shock as she responded to initial treatment with fluids and had no leukocytosis. It was not 
expected that the enrollee would require hospital care that would likely cross two midnights based on the 
provided documentation.  
 
We looked at this physician's review, the file, and Medicare rules. 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 acute inpatient hospital care provided from November 26, 2022, through November 29, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Creon. 
 
You asked the Plan to pre-approve the medication. You say that you are appealing with supporting records. 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 Creon.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular nerve block. 
 
You asked the Plan to pre-approve the genicular nerve block. You say that you fell and re-injured your left 
knee and now have problems walking and putting any amount of weight on it.  The Plan denied your request. 
The Plan says the 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 the genicular nerve block. Our reviewer 
says that the enrollee does not meet the coverage criteria. Our physician reviewer found that you have a history 
of chronic right and left knee pain due to osterarthiristis. Also, you have been treated with medications and 
have received corticosteroid injections. However, genicular nerve blocks and genicular nerve radiofrequency 
ablations are considered investigational and not medically necessary for the treatment of chronic knee pain, 
including degenerative joint disease; osteoarthritis of the knee; a treatment prior to knee replacement or as a 
treatment for individuals who are not candidates for knee replacement surgery. Therefore, the request for the 
genicular nerve block of the left knee is not medically reasonable and 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 genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the genicular nerve block.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Euflexxa. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has a diagnosis of chronic pain in her left knee which has not responded to oral 
anti-inflammatory medication and intra-articular corticosteroid injection. An MRI demonstrated patellofemoral 
advanced full-thickness chondral loss and high-grade chondromalacia of the medial femoral condyle. Euflexxa 
is not FDA-approved for chondromalacia. The use of Euflexxa is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Therefore, the enrollee 
does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.