Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint injection. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says the documentation shows that the provocative testing is negative. 
 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. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, there is no documentation of at least three positive findings with provocative 
maneuvers: FABER, Gaenslen, Thigh Thrust or Posterior Shear, Sacroiliac (SI) Compression, SI Distraction 
and Yeoman Tests, or a minimum of four weeks of conservative therapies. The review has determined that the 
enrollee does not meet all of the requirements of the LCD for coverage. 
 
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 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sacroiliac joint injection.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B coverage criteria for Prolia. 
 
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 Prolia. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the provided records do not indicate that 
the enrollee has tried and failed the Plan's preferred step one alternative. The record does not indicate that the 
enrollee has a contraindication to, or would have an adverse effect from the Plan's preferred step one 
alternative. Our reviewer found that the elements of the coverage criteria are not satisfied. Our physician 
reviewer also found that 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of temozolomide. 
 
You asked the Plan to pre-approve temozolomide. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee is enrolled in clinical trial A092104; therefore, the Plan is not 
responsible for coverage. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve temozolomide as part of a clinical trial. The Plan does not cover 
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-
approve use of temozolomide.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller, harness, electronic 
connection, and attendant control system for a power wheelchair. 
 
You asked the Plan to pre-approve expanded controller assembly and attendant control. You say that you are 
appealing this denial. The Plan denied your request. The Plan says these components exceed the enrollee's 
medical needs. 
 
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 expanded controller assembly and attendant control. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the enrollee has adequate strength to manage the 
wheelchair's standard power drives and an attendant control is not medically necessary when the wheelchair is 
designed with enrollee controls. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of expanded controller assembly and attendant control have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an expandable controller, harness, electronic 
connection, and attendant control system for a power wheelchair.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a denosumab injection provided on July 
05, 2023. 
 
You asked the Plan to waive the coinsurance for a denosumab injection. You say that this cannot be the correct 
amount. Please sort through this and reprocess. 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for a denosumab injection. This item/service falls within the 
Medicare Part B prescription drugs 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. The total you owe is $290.28, this is less than the full $504 total ($2,520 x 20% 
= $504). Therefore, we decided that the Plan does not have to waive the coinsurance for a denosumab injection 
provided on July 05, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 You asked the Plan to pre-approve Prolia. You say that the patient does not have hypocalcemia and is not going 
to be using Xgeva with Prolia. You also say that the patient has not tried Reclast, but would prefer starting 
Prolia first as an injection rather than infusion. The Plan denied your request. The Plan says the patient has not 
had a trial of Reclast which is required prior to Prolia being approved. 
 
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 Prolia. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the case file does not contain 
documentation of trial and failure of the required drug, Reclast. Our reviewer also found that the 
documentation does not support that Reclast would likely be less effective, and/or would likely have adverse 
effects for the patient 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99214) provided on August 24, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the service at issue was 
not billed with the required modifier to allow separate payment within the global surgery period. 
 
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM 
services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 20611 
provided on August 24, 2023. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the services (99214) provided on 
August 24, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the arthrocentesis (20610) provided on July 
27, 2023. 
 
You asked the Plan to waive the copayment for the arthrocentesis (20610). You say that there should not be a 
cost share. 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 for outpatient surgery. 
 
You have been asked to pay a $325 copayment for the arthrocentesis (20610). This item/service falls within the 
outpatient surgery 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. You were asked to pay $256.54 out of the $325 copayment. Therefore, we decided that the Plan 
does not have to waive the copayment for the arthrocentesis (20610) provided on July 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visits provided on July 25, 2023, 
to August 02, 2023. 
 
You asked the Plan to waive the copayment for the office visits. You say that there should not be a cost share. 
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 $60 
copayment for Physician/Practitioner services, including doctors office visits. 
 
You have been asked to pay a $60 copayment for the office visits. This item/service falls within the 
Physician/Practitioner services, including doctors office visits 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 office visits provided on July 25, 2023, to August 02, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 You asked the Plan to pre-approve a ventilator. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says the documentation does not support that you have been considered for, 
or failed treatment with, positive airway pressure such as continuous positive airway pressure (CPAP) and bi-
level positive airway pressure (BiPAP). 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not 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 a ventilator. Our reviewer says that the 
requested ventilator is not medically necessary. Our physician reviewer found the provided records show that 
you have been diagnosed with chronic obstructive pulmonary disease (COPD), pulmonary hypertension, heart 
failure with preserved ejection fraction, and coronary artery disease. The forced expiratory volume (FEV1) was 
36% of predicted in January 2023.  The records show that you were hospitalized in November with an 
exacerbation, and an arterial blood gas was consistent with mild chronic carbon dioxide (CO2) retention. There 
is no diagnosis of thoracic restrictive disease or neuromuscular disease. The records do not show that you have 
tried and failed bilevel positive airway pressure therapy. Therefore, the reviewer found that the requested 
ventilator 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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator (E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facial feminization surgery (15774, 15773, 21159, 
67900, 21175). 
 
You asked the Plan to pre-approve the cosmetic surgery. You say that you have jumped through all of the 
hoops you were told you needed to jump through to get this procedure done. You also say that this procedure is 
medically necessary due to your significant gender dysphoria. The Plan denied your request. The Plan says 
cosmetic surgery is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 cosmetic surgery. Our reviewer says 
that the requested facial feminization surgery is not medically necessary. Our reviewer found the record indicates that the enrollee has gender dysphoria and has had previous facial surgery in 1988 following a 
gunshot wound. The record provided does not document that the requested service is required for the prompt 
repair of accidental injury or to improve the functioning of a malformed body member or for the diagnosis or 
treatment of an illness or injury. Therefore, the reviewer found that the requested facial feminization surgery 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 the cosmetic surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facial feminization surgery (15774, 15773, 21159, 67900, 21175).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit with an opted-out physician on April 25, 2023. 
 
You asked the Plan to pay for physician services. You say that it was the Plan's responsibility to process the 
payment correctly. The Plan denied your request. The Plan says that they mistakenly overpaid you. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for an office 
visit with an opted-out physician on April 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound guided radiation therapy (US-IGRT). 
 
You asked the Plan to pre-approve US-IGRT. You say that the enrollee needs this to monitor lesions and depth 
for skin cancer. The Plan denied your request. The Plan says the requested services are 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 US-IGRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has skin cancer. When treating skin cancers, there is generally not a need for IGRT 
unless deep structures are being treated. Certainly, using ultrasound on a daily basis is not unreasonable to offer 
but not necessary. The device itself is FDA approved for use with ultrasound though that in and of itself does not mean that daily imaging is necessary but simply that the device was designed to incorporate this 
functionality. Therefore, to bill for daily simple simulations and/or IGRT for a technology for which need has 
not been established by published data or supported by consensus guidelines (many of which recommend 
against treatment with these devices in general- citations below) is not necessary. Daily IGRT would not be 
furnished in accordance with accepted standards of medical practice. Therefore, the enrollee does not meet 
criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of US-IGRT have not been met. Therefore, we decided that the Plan does not have 
to pre-approve ultrasound guided radiation therapy (US-IGRT).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block (64454). 
 
You asked the Plan to pre-approve the nerve block. You say that you want to appeal this denial. 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 nerve block. Our reviewer says that 
the requested genicular nerve block is not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is considered experimental therapy. It is the subject of ongoing clinical 
trials. Therefore, the reviewer found that the requested nerve block 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 nerve block have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a genicular nerve block (64454).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the hospital stay provided on May 31, 
2023, to June 01, 2023. 
 
You asked the Plan to waive the coinsurance for the hospital stay. You say that you should not have to pay a 
cost share. 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 10% 
coinsurance for Outpatient Surgery and Other Medical Services Providedat Hospital Outpatient Facilities and 
Ambulatory SurgicalCenters. 
 
You have been asked to pay 10% coinsurance for the hospital stay. This item/service falls within the Outpatient Surgery and Other Medical Services Providedat Hospital Outpatient Facilities and Ambulatory SurgicalCenters 
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 coinsurance for the hospital stay provided on 
May 31, 2023, to June 01, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 18 home health skilled nursing visits (G0299). 
 You asked the Plan to pre-approve home health services. You say that the services are necessary. 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 
documentation does not support that the enrollee requires additional skilled nursing services to provide 
treatment that is medically necessary. The enrollee does not require additional skilled nursing services to 
effectively provide treatment, care, and/or services in order to improve the members condition, perform a 
maintenance program to maintain the enrollees condition and/or prevent deterioration. The enrollee has been 
medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The 
requested home health services are 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 18 home health skilled nursing visits (G0299).