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

 
We decided that the Plan does not have to pre-approve custom foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary. The Plan denied 
your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve custom foot orthotics.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve interspinous and/or interlaminar device (a device used 
to support and stabilize the spine) CPT- 22869 and 22870. 
 
You asked the Plan to pre-approve the interspinous and/or interlaminar device. You say that you believe this is 
the most appropriate treatment for this enrollee and that this choice meets the requirements as being reasonable 
and medically necessary. The Plan denied your request. The Plan says this service is not covered by Medicare 
or the plan. Medical studies haven't proven that this device is helpful for treatment of your health problem. 
 
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 experimental and investigational devices are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the interspinous and/or interlaminar device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve interspinous and/or interlaminar device (a device used to support and stabilize the 
spine) CPT- 22869 and 22870.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill. 
 
You asked the Plan to pre-approve the supplemental benefits. You say that you would like reconsideration 
because it is not reasonable to deny you this benefit due to all of your medical conditions. The Plan denied your 
request. The Plan says you do not require intensive care coordination and are not at high risk of hospitalizations 
or adverse health outcomes. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. The Plan offers a supplemental benefit that states that in 
order to be eligible, you must have a high risk of hospitalization or other adverse health outcomes and must 
require intensive care coordination. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the supplemental benefits have not been met. Specifically, the documentation submitted by your 
primary care provider indicates that you do not require intensive care coordination and are not at high risk of 
hospitalizations or adverse health outcomes. Therefore, we decided that the Plan does not have to pre-approve 
special supplemental benefits for the chronically ill.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuous glucose monitor supplies. 
 
You asked the Plan to pre-approve continuous glucose monitor supplies. You say that  The Plan denied your 
request. The Plan says that you do not meet criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs and supplies are covered 
when the above criteria have been met. 
 
We looked at the file and Medicare rules. The file indicates you are not treated by insulin injections three or 
more times a day or testing your blood glucose four or more times a day. Based on this information, we 
decided that Medicare rules for coverage of continuous glucose monitor supplies have not been met. Therefore, 
we decided that the Plan does not have to pre-approve continuous glucose monitor supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve FreeStyle Libre continuous glucose monitor (CGM) 
supplies (K0553). 
 
You asked the Plan to pre-approve FreeStyle Libre CGM supplies. You say that you need this due to a fear of 
needles. The Plan denied your request. The Plan says this is not covered for patients who are not insulin-
treated. 
 
The Plan must follow Medicare rules. Medicare rules say that a CGM and related supplies are covered only 
when the beneficiary is insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-
covered continuous subcutaneous insulin infusion (CSII) pump/ 
 
 
 
 
 
We looked at the file and Medicare rules. The record shows that you are not currently insulin-treated. Based on 
this information, we decided that Medicare rules for coverage of FreeStyle Libre CGM supplies have not been 
met. Therefore, we decided that the Plan does not have to pre-approve FreeStyle Libre continuous glucose 
monitor (CGM) supplies (K0553).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that your mother-in law really needs this. 
The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Life Alert device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
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 a Life Alert device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a basket for a walker (E1399). 
 
You asked the Plan to pre-approve the basket. You say that the basket is medically necessary. The Plan denied 
your request. The Plan says the requested basket is a convenience item and is not covered. 
 
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 a basket for a walker (E1399).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is considered investigational. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this is considered an experimental/ investigational procedure because the peer reviewed literature shows 
a wide variation in efficacy. Therefore, the request is considered 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacroiliac joint radiofrequency ablation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hernia surgery to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve an outpatient surgery. You say that you started care with this provider and 
you would like the surgery done here. The Plan denied your request. The Plan says there are multiple in-
network providers available for this service. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a hernia surgery to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ensure. 
 
You asked the Plan to pre-approve Ensure. You say that you are losing weight fast and have no appetite. The 
Plan denied your request. The Plan says that this is not covered by Medicare. 
 
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 nutritional supplements. Therefore, we decided that the Plan 
does not have to pre-approve Ensure.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Magnetic Resonance Imaging (MRI) of the right knee. 
 
You asked the Plan to pre-approve a Magnetic Resonance (e.g. proton) imaging, any joint of lower extremity; 
without contrast material (73721). You say that the MRI is necessary prior to surgery for measurements. The 
Plan denied your request. The Plan says an MRI is not necessary to plan for knee replacement surgery. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
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 Magnetic Resonance (eg, proton) 
imaging, any joint of lower extremity; without contrast material (73721). Our reviewer says that the MRI is not 
medically necessary. Our physician reviewer found an MRI is not needed. It is not clinically needed and not 
needed for total knee surgery preparation. 
 
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 Magnetic resonance (eg, proton) imaging, any joint of lower extremity; 
without contrast material (73721) have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Magnetic Resonance Imaging (MRI) of the right knee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an over-the-bed table. 
 
You asked the Plan to pre-approve an over-the-bed table. The Plan denied your request. The Plan says that this 
is not a covered benefit. 
 
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 an over-the-bed table.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you cannot get around with the 
portable oxygen tanks because they are too heavy. The Plan denied your request. The Plan says you were 
provided with a home oxygen system including portable oxygen tanks for your oxygen needs within your 
home. 
 
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet 
the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would 
benefit from the use of portable oxygen in the home.  
 
We looked at the file and Medicare rules.  The record shows that you have a stationary oxygen system with 
refillable portable tanks. This portable oxygen system serves the same purpose as a portable oxygen 
concentrator. The medical record does not show that the portable oxygen system is not meeting your in-home 
needs. Based on this information, we decided that Medicare rules for coverage of the portable oxygen 
concentrator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable 
oxygen concentrator.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services. 
 
You asked the Plan to pre-approve home health aide services. You say that you are not able to bathe on your 
own. The Plan denied your request. The Plan says the criteria for home health services have not been met. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy. The rules also say that custodial care is not 
covered. 
 
We looked at the file and Medicare rules. The record shows that the requested services are personal care 
services and are custodial in nature. The record does not show that you have any skilled nursing or therapy 
needs. Based on this information, we decided that Medicare rules for coverage of home health aide services 
have not been met. Therefore, we decided that the Plan does not have to pre-approve home health aide services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a SI joint radiofrequency ablation. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is considered experimental and investigational. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this is considered an experimental/ investigational procedure because of the wide variation in efficacy in 
published literature. Therefore, the request is considered 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a SI joint radiofrequency ablation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implants. 
 
You asked the Plan to pre-approve the implants. You say that this is medically necessary. The Plan denied your 
request. The Plan says dental services are not covered. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve dental implants.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system and a cup holder for a 
power wheelchair. 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says these items are statutorily not covered. 
 
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 a power seat elevation system and a cup holder for a power 
wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two resin-based composites (codes D2331 and D2392). 
 
You asked the Plan to pre-approve the resin-based composites. You say that you need these fillings because 
you are in a lot of discomfort. The Plan denied your request. The Plan says these services are not covered under 
your plan. 
 
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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve two 
resin-based composites (codes D2331 and D2392).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Rezum procedure (water vapor thermal therapy) for 
the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says the records must show prostate cancer. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the criteria has not been met. Specifically, the enrollee has known prostate cancer, has urinary 
retention requiring frequent catheterization, and is not a poor candidate for other surgical interventions for 
benign prostatic hypertrophy (BPH). 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Rezum procedure (water vapor thermal therapy) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network rehab facility for the 
enrollee. 
 
You asked the Plan to pre-approve the referral. You say that this provider can help ease the enrollee's severe 
anxiety. The Plan denied your request. The Plan says there are contracted facilities that can provide similar 
services. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a referral to an out-of-network rehab facility for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the abdomen/pelvis. 
 
You asked the Plan to pre-approve the CT scan. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 the CT scan. Our reviewer says that the 
requested CT scan is not medically reasonable and necessary. Our physician reviewer found that the NCCN 
Guidelines for Non-small cell lung cancer has the recommended surveillance after completion of definitive 
treatment for stages I and II. The guidelines do not include scans of the abdomen and pelvis. 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a CT scan of the abdomen/pelvis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed for the enrollee. 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says that total electric hospital beds are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the incontinence supplies, adult diapers. 
 
You asked the Plan to pre-approve the adult diapers. You say that the enrollee is not able to afford the costs of 
the adult diapers and would like the health insurance to pay for them. The Plan denied your request. The Plan 
says this item is not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve the incontinence supplies, adult 
diapers.