Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller harness (E2313), expandable 
controller (E2377), Light Emitting Diode (LED) lights and indicators (K0108), and LED expandable remote 
with lights (K0108). 
 
You asked the Plan to pre-approve an expandable controller harness, expandable controller, LED lights and 
indicators, and LED expandable remote with lights. You say that you would like the documentation provided to 
be reconsidered for the K0861 base and all recommended components needed to meet the enrollee's current 
medical, mobility, and functional needs. The Plan denied your request. The Plan says although there are three 
approved power options on this wheelchair (tilt, recline, and elevating leg rests), there is not a medical need to 
control these power options through the joystick. The Plan also says the LED lights and indicators and LED 
expandable remote with lights do not serve a medical purpose, and cannot be covered as they are not 
reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
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 expandable controller harness, 
expandable controller, LED lights and indicators, and LED expandable remote with lights. 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 left hemiplegia and partial paraplegia. The enrollee has normal 
functioning of the right arm. Our reviewer found that the expandable controller and associated electronics not 
medically necessary as the enrollee has adequate strength to manage standard power drives. Our physician 
reviewer also found that LED lights and indicators (K0108) and LED expandable remote with lights (K0108) 
are not necessary to meet the enrollees needs.  
 
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 expandable controller harness, expandable controller, LED lights and 
indicators, and LED expandable remote with lights have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an expandable controller harness (E2313), expandable controller (E2377), Light 
Emitting Diode (LED) lights and indicators (K0108), and LED expandable remote with lights (K0108).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for hearing aids (V5251) provided on June 13, 2023. 
 
You asked the Plan to pay for hearing aids. You say that you have enclosed the invoice, a photocopy of the 
cancelled check as well as the check information on the bank statement.  The Plan denied your request. The 
Plan says that the claim is being upheld as proof of payment, specifically the receipt, has not been received. 
The Plan also says the member was made aware of this on December 7, 2023. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan pays for 
hearing aids up to 2 vendor specific hearing aids every year (1 per ear, per year). 
 
We looked at the file, and the Plan's rules. The Plan rules say that the Plan covers up to 2 vendor specific 
hearing aids every year (1 per ear, per year). The Plan contract also say that the benefit is limited to the Plan 
vendor specific hearing aids, which come in various styles and colors. The Plan contract also says the enrollee 
must pay $599 per advance aid or $899 per premium aid. For the record, the contract does not say that the 
enrollee must submit a receipt as proof of payment. The EOC does not provide any information stating 
anything is required for payment for the hearing aids. Specifically, the Plan says the enrollee was made aware 
of proof of payment on December 7, 2023. No where in the contract is there any information stating the 
enrollee is responsible to provide any type of specific proof of payment. Therefore, since the contract does not 
specify the type of proof of payment the enrollee is required to submit, there is no way to verify whether or not 
the enrollee failed to submit the correct documentation. Based on this information, we decided that the Plan's 
rules for coverage of hearing aids have been met. Therefore, we decided that the Plan has to pay for hearing 
aids (V5251) provided on June 13, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ozempic. 
 
You asked the Plan to pre-approve the medication. You say that this is medically necessary for the enrollee. 
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 Ozempic.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqvio (J1306). 
 You asked the Plan to pre-approve Leqvio. You say that this is the most appropriate therapy for the enrollee. 
You say that the enrollee's LCL cholesterol is greater than 70 despite statin use. You also say that given the 
signs of end organ damage with memory impairment; it is necessary to administer this agent in this clinical 
setting. The Plan denied your request. The Plan says the enrollee has not tried and failed one of the preferred 
drugs, Praluent or Repatha, for at least 12 weeks. 
 
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 Leqvio. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation indicates that the 
enrollee has not tried and failed the preferred drugs. The reviewer also found that there is no documentation 
provided indicating that the Plans required drugs would likely be less effective and/or likely have adverse 
effects for the enrollee. Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Leqvio have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Leqvio (J1306).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for an office visit provided on June 16, 2023, by an OON provider.  
 
You asked the Plan to pay for an office visit. You say that you did not request prior authorization because you 
were affected by your recovery from a fall. The Plan denied your request. The Plan says that you must receive 
your care from a 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 includes a Point-of-Service option which 
allows you to receive all Plan covered services from non-network providers. 
 
The Plan contract says you may receive all Plan covered services from non-network providers. Therefore, we 
decided that the Plan has to pay for an office visit provided on June 16, 2023, by an OON provider. Please 
note: you will have to pay a higher cost sharing than what you pay when using in-network providers. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a core build-up (D2950), and a crown (D2740) provided on 
August 9, 2023. 
 
You asked the Plan to pay for the dental services. You say that you believe this dental work should be covered. 
The Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service October 17, 2022. Therefore, we decided that the Plan does not have to pay for a core build-up (D2950), and a crown (D2740) 
provided on August 9, 2023.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve GAZYVA (obinutuzumab). 
 
You asked the Plan to pre-approve GAZYVA. You say that the drug is needed for treatment The Plan denied 
your request. The Plan says that the requested drug is not reasonable and medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve GAZYVA. Our reviewer says that the 
enrollee's condition is not FDA labeled. Our physician reviewer found based on literature obinutuzimab is 
approved as a single agent for the enrollees condition low grade B cell lymphoma. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of GAZYVA have been met. Therefore, we decided that the Plan has to pre-
approve GAZYVA (obinutuzumab).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH admission is medically 
necessary. The Plan denied your request. The Plan says the enrollee's medical needs are being met in the 
current acute setting, and the LTACH would add no additional services. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving with current treatment and should only require 
short-term additional acute care hospital services that can safely be provided at the current facility until more 
stable and appropriate for transfer to a lower level of care soon. The enrollee does not require LTACH services that are not already available at the current facility. There are no services at the LTACH that the enrollee 
requires that are not already available and covered at the current facility. Transfer to the LTACH is not 
medically necessary as it would not be clinically advantageous. Completion of treatment at the current facility 
is 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided 
on December 27, 2022, to January 7, 2023. 
 
You asked the Plan to waive the copayment for SNF. You say that you disagree with 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 $0 
copayment per day for days 1-20 and a $75 copayment per day for days 21-100 for skilled nursing facility 
(SNF) care.  
 
 You have been asked to pay a $0 copayment per day for days 1-20 and a $75 copayment per day for days 21-
100 for SNF. The total amount for 11 days is $825 ($75 x 11 = $825), however you are only being asked to pay 
$615 which is less than the required amount. This item/service falls within the skilled nursing facility (SNF) 
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 skilled nursing facility (SNF) 
care provided on December 27, 2022, to January 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided on 
September 20, 2023. 
 
You asked the Plan to pay for the panoramic radiographic image. You say that the image was taken because of 
an emergency tooth extraction and was ordered by your oral surgeon. You also say that the area which the 
tooth needed to be extracted was precarious and care needed to be taken. The Plan denied your request. The 
Plan says your benefit for the panoramic radiographic image 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 panoramic radiographic image was exhausted on date of service November 4, 2021. 
Therefore, we decided that the Plan does not have to pay for the panoramic radiographic image (D0330) 
provided on September 20, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the SNF care is medically necessary since the 
enrollee is not able to return home. The Plan denied your request. The Plan says the documentation does not 
show that you have completed your full course of care in the inpatient rehabilitation facility (IRF). 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there are no identifiable skilled nursing service needs, but there are identifiable 
skilled therapy service needs. The beneficiary does not require skilled nursing or therapy services on a daily 
basis. This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a 
skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting an expedited appeal and attached 
medical records for reconsideration. The Plan denied your request. The Plan says the IRF services requested do 
not meet the requirements for approval.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Although the 
enrollee needs physical and occupational therapy and could tolerate the therapy in the IRF, the complexity of 
their condition doesnt require an IRF stay and care can be provided in a lower level.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stereotactic body radiation therapy (SBRT). 
 
You asked the Plan to pre-approve SBRT. You say that this is needed to make sure all of your cancer is gone. 
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 SBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on National Comprehensive Cancer Network (NCCN) guidelines, American Society for 
Radiation Oncology (ASTRO) consensus statements, and model policy, SBRT is not an accepted standard of 
care for the adjuvant treatment of breast cancer. Simply because it is a standard of care for a treatment to be 
delivered in 5 fractions does not necessary the use of - and billing for - SBRT versus standard intensity-modulated radiation therapy with image guidance. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve stereotactic body radiation therapy (SBRT).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral leg injection of sclerosant. 
 
You asked the Plan to pre-approve bilateral leg injection of sclerosant. You say that the enrollee has 3 mm 
varicosities, which are very focally tender. You say that the enrollee has pain, heaviness and edema that are 
interfering with her quality of life despite trying Ace wrap, compression stockings and elevation. The Plan 
denied your request. The Plan says the medical records received do not show that the enrollee's veins are 
greater than 4mm in diameter. The medical records also do not show that 6 weeks of conservative treatment has 
been tried once it is resolved. 
 
The Plan follows Medicare rules. Medicare rules say that bilateral leg injection of sclerosant 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 bilateral leg injection of sclerosant. Our 
reviewer says that the requested bilateral leg injection of sclerosant is not considered medically reasonable and 
necessary in this case. Our physician reviewer found the veins do not meet size criteria as, to be considered 
medically necessary per coverage criteria, the veins in question must be 4mm in diameter or greater. 
Furthermore, it is unclear from the medical record that the veins in question are causing the patient lifestyle 
limiting symptoms as she has numerous conditions that are often related to leg pain including diabetes, 
fibromyalgia, generalized osteoarthritis, lumbosacral radiculopathy, and rheumatoid arthritis. The coverage 
criteria are not met and the documentation does not sufficiently support that the procedure in question will have 
a substantial impact on the patient's quality of life. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bilateral leg injection of sclerosant have not been met. Therefore, we decided 
that the Plan does not have to pre-approve bilateral leg injection of sclerosant.