Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya. 
 You asked the Plan to pre-approve Ilumya. You say that this drug is medically necessary. The Plan denied your 
request. The Plan says a trial of Enbrel, Humira, Otezla, or Skyrizi 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 Ilumya. Our reviewer says that Ilumya 
is not medically necessary. Our physician reviewer found the record shows no trial of the plan preferred drugs 
or any reason they would be 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 Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Ilumya.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transurethral waterjet ablation of the prostate (0421T). 
 
You asked the Plan to pre-approve transurethral waterjet ablation of the prostate. 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 follows Medicare rules. Medicare rules say that treatment for LUTS/BPH treatment will be 
considered reasonable and necessary when certain criteria 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 transurethral waterjet ablation of the 
prostate. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
enrollee does not meet the coverage criteria detailed in the LCD. Specifically, the records do not show a 
maximum urinary flow rate (Qmax) of =15 mL/s4 (voided volume greater than 125 cc). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transurethral waterjet ablation of the prostate have not been met. Therefore, we 
decided that the Plan does not have to pre-approve transurethral waterjet ablation of the prostate (0421T).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve a repeat Zilretta injection. 
 
You asked the Plan to pre-approve a repeat Zilretta injection. You say that you are extremely frustrated with 
this being consistently denied. You say that your doctor has provided all the necessary information. You also 
say that you feel your health is not being taken seriously. The Plan denied your request. The Plan says that 
there are not enough studies that show more than one dose of this drug will improve health conditions for your 
condition. 
 
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 a repeat Zilretta injection. Our reviewer 
says that the request for a repeat Zilretta injection is medically necessary. Our physician reviewer found repeat 
administration of Triamcinolone Acetonide Extended-release (TA-ER) using a flexible dosing schedule timed 
to patient response was well tolerated, with no radiographic evidence of cartilage impact. Both injections 
resulted in similar improvements in osteoarthritis (OA) symptoms across a broad spectrum of disease severity 
reflective of that seen in clinical practice. Therefore, the reviewer found that the requested use of Zilretta is 
approved by the Food and Drug Administration (FDA) for your condition. 
 
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 repeat Zilretta injection have been met. Therefore, we decided that the Plan 
has to pre-approve a repeat Zilretta injection.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on August 10, 2023, to August 31, 
2023. 
 
You asked the Plan to pay for physical therapy. You say that the records attached support these services. 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 physical therapy 
provided on August 10, 2023, to August 31, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vivistim Paired Vagus nerve stimulator. 
 
You asked the Plan to pre-approve a Vivistim Paired Vagus nerve stimulator. You say that this is necessary for 
the enrollee so that they can live a normal daily life. The Plan denied your request. The Plan says the clinical 
value and effectiveness of Vivistim Paired Vagus nerve stimulator in the setting of post-stroke residual 
weakness (unilateral) have not been demonstrated in the peer-reviewed literature. 
 
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 Vivistim Paired Vagus nerve 
stimulator. Our reviewer says that the requested Vivistim Paired Vagus nerve stimulator is not considered 
medically reasonable and necessary in this case. Our physician reviewer found the provided records do not 
indicate that the enrollee has medically refractory partial onset seizures for whom surgery is not recommended 
or for whom surgery has failed or the enrollee has treatment resistant depression. The reviewer also found that 
provided medical records and review of the current peer-reviewed medical literature do not document that use 
of the Vivistim Paired Vagus nerve stimulator has been shown in controlled studies in a CMS-approved journal 
to result in sustained long term health benefits in patients with weakness due to a stroke. Therefore, the 
reviewer found that the requested Vivistim Paired Vagus nerve stimulator 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 Vivistim Paired Vagus nerve stimulator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Vivistim Paired Vagus nerve stimulator.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on June 12, 2023. 
 
You asked the Plan to pay for physical therapy. You say that the enrollee does not have a primary care 
provider. 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 physical therapy 
provided on June 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) provided 
on July 24, 2023. 
 
You asked the Plan to pay for the topical application of fluoride varnish. You say that you were not notified 
that this provider was out-of-network when you went in for your dental work. You also say that in the past, the 
office was always in-network and all your dental work was covered. The Plan denied your request. The Plan 
says the service code D1206 rendered is not covered.  

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the topical 
application of fluoride varnish (D1206) provided on July 24, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 91 additional skilled nursing home health visits.  
You asked the Plan to pre-approve home health services. You say that the enrollee needs help administrating 
their daily insulin. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the submitted 
documentation does not specify any acute clinical status changes, medication or plan of care changes, or 
complex wounds that would be expected to require 91 home health skilled nursing visits additional to the 90 
approved visits 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 91 additional skilled nursing home health visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 2D oral imaging (D0350) provided on August 11, 2023. 
 
You asked the Plan to pay for D0350. You say that you would like the Plan to pay for this. The Plan denied 
your request. The Plan says the denied dental services are not covered benefits. 
 
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 pay for 2D oral 
imaging (D0350) provided on August 11, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for the non-physician provider services provided on July 
24, 2023. 
 
You asked the Plan to waive the coinsurance for the non-physician provider services. You say that you should 
not be held responsible. The Plan denied your request. The Plan says that 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 enrollees must pay a $0 copayment for physician/practitioner services, 
including doctor's office visits.  
 
The Plan says you must pay 20% coinsurance for the non-physician provider services. Based on the Plan 
contract, however, you cannot be asked to pay more than a $0 copayment for the non-physician provider 
services. Therefore, we decided that the Plan has to waive the coinsurance for the non-physician provider 
services provided on July 24, 2023.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cervical traction equipment (E0849) provided on July 1, 
2023. 
 
You asked the Plan to pay for the cervical traction equipment. You say that the item was medically necessary. 
The Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. There is no indication the item was discussed, needed, or ordered by the treating physician in the 
clinical records submitted. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for the cervical 
traction equipment (E0849) provided on July 1, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation, nerves innervating the 
sacroiliac joint, with image guidance (64625). 
 
You asked the Plan to pre-approve radiofrequency ablation, nerves innervating the sacroiliac joint, with image 
guidance. You say that this is medically necessary. The Plan denied your request. The Plan says this is not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that SIJ Denervation (also called Radiofrequency 
Ablation or RFA) is not considered reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance have not been 
met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation, nerves 
innervating the sacroiliac joint, with image guidance (64625).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant /abutment supported fixed denture for 
edentulous arch (D6115). 
 
You asked the Plan to pre-approve D6115. You say that you would like the Plan to approve this dental work. 
The Plan denied your request. The Plan says the requested dental service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, 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 an 
implant /abutment supported fixed denture for edentulous arch (D6115).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an intrauterine device (IUD) (58300). 
 You asked the Plan to pre-approve insertion of an IUD. You say that you want the Plan to approve this service. 
The Plan denied your request. The Plan says the procedure code 58300 has a Status Code of N and is therefore 
a non-covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
 
We looked at the file and Medicare rules. We find that procedure code 58300 has a status indicator of N on the 
Physician Fee Schedule. Based on this information, we decided that Medicare rules for coverage of insertion of 
an IUD have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an 
intrauterine device (IUD) (58300).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve T12 kyphoplasty (22513). 
 
You asked the Plan to pre-approve T12 kyphoplasty. You say that this is medically necessary. The Plan denied 
your request. The Plan says you do not meet the criteria for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be covered when specific criteria 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 T12 kyphoplasty. Our reviewer says 
that you do not meet criteria for coverage. Our physician reviewer found there is no documentation of the use 
of a back brace for fracture care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of T12 kyphoplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve T12 kyphoplasty (22513).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code E0849 provided on June 13, 2023. 
 
You asked the Plan to pay for procedure code E0849. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the documentation requirements have not been 
met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case as the date of service billed does not match the date of delivery. The record shows that the Plan made several attempts to obtain the 
necessary documentation without success. Therefore, we decided that the Plan does not have to pay for 
procedure code E0849 provided on June 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 81314 and 81345 
for June 6, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim for this molecular pathology testing did not include the required unique 
identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. 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 laboratory services billed with 
codes 81314 and 81345 for June 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

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

 
We decided that the Plan does not have to pay for procedure code G0260 provided on July 24, 2023. 
 
You asked the Plan to pay for procedure code G0260. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules also say that code G0260 should be reported with an imaging code specific to the imaging modality employed. 
 
We find that code G0260 has not been reported with a corresponding imaging code as required. Based on this 
information, we decided that Medicare rules for coverage of procedure code G0260 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code G0260 provided on July 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 28, 2023. 
 
You asked the Plan to pay for lab services. You say that the referring provider is in-network. 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 lab services provided on 
July 28, 2023.