Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
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 the requested drug is medically necessary. The Plan 
denied your request. The Plan says the requested drug is subject to the Plan's step therapy requirements. 
 
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 Euflexxa. Our reviewer says the 
requested drug is not medically necessary. Our physician reviewer found that the enrollee has not trialed one of 
the preferred viscosupplemental treatments such as, Orthovisc, Synvisc/Synvisc-One, or Monovisc.  Step 
therapy, as outlined by the Plan, requires that one of these be trialed first. The documentation does not outline 
contraindications or reasons these medications were not considered or that the Plan's additional required drug 
would likely be less effective and/or likely have adverse effects for the enrollee. Without the support of the 
documentation, step therapy criteria has 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an acupuncture service provided on January 4, 2022. 
 
You asked the Plan to pay for an acupuncture service. You say that you are appealing the denial of the date of 
service - January 4, 2022, for untimely filing. The Plan denied your request. The Plan says you must submit 
your claim to them within 12 months for medical services or items. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for an acupuncture service was not filed until February 27, 2023. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for an acupuncture service provided on January 4, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from April 1, 2023, to 
April 30, 2023. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you were advised by the facility that 
the Plan would cover the cost of the stay in full. 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 $0 
copayment for days 1 to 20 and a $196 copayment per day for days 21 to 100 for SNF care.  
 
 You have been asked to pay $1,960 copayment for a SNF stay ($196 per day x 10 days = $1,960). This 
item/service falls within the 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 a 
SNF stay provided from April 1, 2023, to April 30, 2023.
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 a CGM. You say that you would like the Plan to reconsider their denial. The 
Plan denied your request. The Plan says the enrollee does not meet criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
has a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Boost High Protein Nutritional Drinks. 
 
You asked the Plan to pre-approve Boost High Protein Nutritional Drinks. The Plan denied your request. The 
Plan says the documentation provided does not meet the criteria for coverage. The Plan also says the 
documentation submitted provides no additional information that justifies this request. 
 
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 Boost High Protein Nutritional Drinks.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 22, 2022. 
 You asked the Plan to pay for the office visit. You say that the services are not hospice related. The Plan denied 
your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for an office visit provided on February 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5261) purchased on 
February 20, 2023. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable as 
they were purchased from an out-of-network provider.  
 
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 only when purchased from the Plans select hearing aid provider.   
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract states that hearing aids are only 
covered when purchased from the Plans select hearing aid provider. However, the hearing aids in this case 
were purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids (V5261) purchased on February 20, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve the home health services. You say that you are not able to get out of bed 
alone, go to the bathroom alone, or dress yourself due to the surgery to your arm. You also say that you want 
Medicare to pay for your sitter since you cannot care for yourself. The Plan denied your request. The Plan says 
this type of care is considered to be custodial care and is part of your activities of daily living. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. You asked the Plan to pre-approve home health services. Based on 
this information, we decided that Medicare rules for coverage of the home health services have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we 
decided that the Plan does not have to pre-approve home health services.
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 this treatment is the only option that will help you 
walk again. The Plan denied your request. The Plan says the IRF services you are requesting 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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. There is not a reasonable expectation that you will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 10, 2023. 
 You asked the Plan to pay for the office visit. You say that the claim was denied as a non-contract provider, 
and you are requesting payment. The Plan denied your request. The Plan says Original Medicare is responsible 
for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for an office visit provided on April 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep sedation/general anesthesia (D9222, D9223), 
therapeutic parenteral drugs (D9612) and an unspecified procedure (D9999). 
 
You asked the Plan to pre-approve the dental services. You say that you are requesting reconsideration for the 
denial of the services. The Plan denied your request. The Plan says these services are not covered under your 
benefit plan. 
 
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 deep 
sedation/general anesthesia (D9222, D9223), therapeutic parenteral drugs (D9612) and an unspecified 
procedure (D9999).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup services for teeth # 23,24,26,27, retainer 
crowns for teeth #:23,24,26,27, and pontic for tooth #25 (D6750, D6245, D2950). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as you do 
not meet the clinical requirements to be approved. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the dental 
services when the services are medically necessary and reasonable.  
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the dental services. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found that the bone support of the abutment 
teeth appears to be less than 50%. The requested services cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve core buildup services for teeth # 23,24,26,27, retainer crowns for teeth #:23,24,26,27, 
and pontic for tooth #25 (D6750, D6245, D2950).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. 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 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 pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the procedure is not on the CMS inpatient only list. There is no medical 
indication for inpatient level of care services for the procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine month continued use of a noninvasive ventilator 
(NIV) (E0466). 
 
You asked the Plan to pre-approve continued use of a NIV. You say that the enrollee has used this device since 
2016. You are requesting reconsideration. The Plan denied your request. The Plan says the request for 
continued use of a NIV is not medically reasonable and necessary. 
 
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. 

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 continued use of a NIV. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the enrollee has severe obesity, 
COPD and obstructive sleep apnea (OSA). The enrollee has had a home ventilator since 2016. There are no 
pulmonary function tests to confirm the diagnosis of COPD and assess severity. There is no documentation of 
chronic carbon dioxide (CO2) retention with an arterial blood gas (ABG) done while stable. There is no 
documentation that bilevel positive airway pressure (BiPAP) with average volume-assured pressure support 
(AVAPS) has been tried and failed as an outpatient. Medicare does not cover a home ventilator when used at 
settings that can be provided with BiPAP. In addition, the enrollee is using the device at least 4 hours/day for 
only 50% of days. The current device has been approved for 3 months which allows time to transition to 
BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued use of a NIV have not been met. Therefore, we decided that the Plan 
does not have to pre-approve nine month continued use of a noninvasive ventilator (NIV) (E0466).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95861, 95865, and 95868 billed for date of 
service June 3, 2022.  
 
You asked the Plan to pay for procedure codes 95861, 95865, and 95868. You say that you would like the Plan 
to reconsider their denial of payment. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
We asked our coder 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 procedure codes 95861, 95865, and 95868. Our reviewer 
says that the medical records do not support the second unit of codes 95861, 95868, and 95865. Our reviewer 
found that, in this case Electromyography (EMG) was only run in the bilateral upper extremities (BUE). 
Therefore, only one unit of 95861 should have been billed as that reflects the monitoring in both arms. 
Likewise for 95868-while this service was done, it was also recorded bilaterally. It is inclusive of all cranial 
nerve supplied muscles. Therefore only 1 unit was necessary. Similarly for 95865 this is an "all inclusive" code 
for monitoring of the Recurrent laryngeal nerve (RLN). Therefore, it is not proper coding to bill for multiple 
units. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the second unit of codes 95861, 95868, and 95865 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 95861, 95865, and 95868 billed 
for date of service June 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the military green Q-Logic 3 joystick armor (K0108). 
 
You asked the Plan to pre-approve the military green Q-Logic 3 joystick armor. You say that the denial of this 
particular item does not make the base or any other accessories unusable. You also say that this item is not an 
integral part of the base, thus a split decision should be possible. The Plan denied your request. The Plan says 
this is an accessory that is not medically necessary. The Plan also says that this is a color preference (military 
green) and is not required for a wheelchair to operate or for a medical need of the enrollee. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
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 pre-approve the military green Q-Logic 3 joystick armor (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continued use of non-invasive ventilator (NIV) for 
October 7, 2023, through April 26, 2024. 
 
You asked the Plan to pre-approve the ventilator. You say that the ventilator is medically necessary. The Plan 
denied your request. The Plan says the ventilator is not medically necessary. 
 
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.  

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 ventilator. Our physician reviewer 
found the record indicates that the enrollee has chronic respiratory failure from chronic obstructive pulmonary 
disease. The record indicates that the enrollee was successfully treated with a device in bilevel positive airway 
pressure (BiPAP)-IVAPS mode. The provided primary source documentation does not contain sufficient 
detailed information in the medical record to justify the treatment selected. The enrollee could be treated with a 
BiPAP machine with average volume-assured pressure support (AVAPS) capability, as ordered, and failure of 
such a device has not been documented. The Plan has indicated coverage for such a device is available upon 
request. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the continued use of non-invasive ventilator (NIV) for October 7, 2023, through April 26, 
2024.