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

We decided that the Plan does not have to pre-approve receiver (monitor), dedicated, for use with therapeutic 
glucose continuous monitor system (CPT Code K0554). 
 
You asked the Plan to pre-approve the items. You say that the monitor is necessary. The Plan denied your 
request. The Plan says you are not being treated with multiple daily injections of insulin. 
 
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 items. Our physician reviewer 
found in order to meet criteria for the CGM, you must be taking multiple shots of insulin daily; although 
insulin may be clinically indicated at this time, you are not using insulin and hence, do not meet criteria for 
CGM use. 
 
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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve receiver (monitor), dedicated, for use with therapeutic glucose continuous monitor system (CPT 
Code K0554).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network outpatient mental health care provided to the 
enrollee on January 17, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The provider 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. The Plan 
did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for 
these items/services. Therefore, we decided that the Plan does not have to pay for out of network outpatient 
mental health care provided to the enrollee on January 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on April 25, 
2019. 
 
You asked the Plan to pay for this claim. You say that this claim should be paid. The Plan denied your request. 
The Plan says this claim was filed on June 22, 2020, which is after the filing date. 
 
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 this 
service was not filed until June 22, 2020. 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 physician 
services provided to the enrollee on April 25, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy (PT) services (97164). 
 
You asked the Plan to pre-approve the additional physical therapy services. You say that the services are 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional physical therapy services. 
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer found the specialized skill, knowledge and 
judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the 
patient's current condition or to prevent or slow further deterioration. 
 
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 additional physical therapy services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve additional physical therapy (PT) services (97164).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) device. 
 
You asked the Plan to pre-approve a CGM device. You say that the item is 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. Medicare rules say that CGM devices covered when specific criteria are 
met.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a CGM device have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor (CGM) device.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve the Privigen rendered on January 28, 2020. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the services were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IVIG is covered when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services were medically necessary. Our physician reviewer found the enrollee has a history of a head and 
neck cancer has chronic refractory oral lichen planus treated with multiple prior lines of therapy without 
response. Although Privigen is not FDA-approved for this use; however, due to the rarity of this disorder 
mostly case reports but some patients do have a dramatic response and other treatment options are limited. The 
Privigen was reasonable and medically necessary for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-
approve the Privigen rendered on January 28, 2020.  
 
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on November 18, 2019 
and billed under codes 80307 and G0480. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the documentation submitted did not include a physician order/lab requisition or medical 
records stating exactly what tests are to be performed. The submitted documentation does not itemize what 
tests are included in this panel; therefore, the billed code cannot be verified.  It is noted multiple attempts were 
made to obtain additional information from the provider. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes and when necessary provide specific information 
regarding the services billed. In this case the records provided do not support the services billed. Therefore, we 
decided that the Plan does not have to pay for lab services provided to the enrollee on November 18, 2019 and 
billed under codes 80307 and G0480.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4 home health visits. 
 
You asked the Plan to pre-approve 4 home health visits. 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 HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 4 home health visits. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the enrollee does not have 
documented skilled therapy needs. Skilled therapy services are not required to establish a maintenance program 
or to prevent deterioration of the enrollee's condition. The enrollee's care needs, as a practical matter, can be 
provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 4 home health visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 4 home health visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a reclining chair. 
 
You asked the Plan to pre-approve a reclining chair. You say that you are requesting a mechanical seat lift to 
help stand up without falling. The Plan denied your request. The Plan says the reclining chair is not covered 
because it is a convenience item so this request has been denied. 
 
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 reclining chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve the power scooter. You say that you would like reconsideration because you 
are not able to stand or walk properly. The Plan denied your request. The Plan says the clinical information 
does not support that the criteria for coverage have been met. 
 
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 power scooter. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record does not indicate that your mobility deficit impairs participation in 
mobility related activities of daily living in the home. Your mobility deficit is currently helped by a walker. 
The documentation is not clear that you can safely maneuver the scooter in the home. 
 
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 power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve these OON services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services can be provided by 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 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 
the office visit to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing for all four 
quadrants (D4341). 
 
You asked the Plan to pre-approve periodontal scaling and root planing for all four quadrants. You say that the 
services are necessary. The Plan denied your request. The Plan says the requested services are not a covered 
benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 
periodontal scaling and root planing for all four quadrants (D4341).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF admission. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications. 
The enrollee had stable vital signs. There are no therapy notes to substantiate the need for skilled rehabilitation. 
The documentation does not support that the enrollee requires the specialized skills, knowledge, or judgment of 
a skilled professional nurse or qualified therapist to safely and effectively provide medically necessary and 
reasonable treatment. The documentation does not support that skilled nursing or skilled therapy services are 
required on a daily basis. As a practical matter, the enrollee does not require the necessary services on an 
inpatient basis, at a SNF level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the orthopedic surgeon is recommending you go 
through intense therapy for two more weeks. You say that you really need therapy with a trained professional 
to adjust to the new hip. The Plan denied your request. The Plan says your needs can be met at a lower level of 
care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 that there are no identified problems that need inpatient medical management and 
there are no complex nursing or rehabilitation needs. Our reviewer says that the medical records do not support 
a need for an intensive rehabilitation therapy program. 
 
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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve receiver (monitor), dedicated, for use with therapeutic 
glucose continuous monitor system (CPT Code K0554). 
 
You asked the Plan to pre-approve the items. You say that you are requesting review of denial of services. The 
Plan denied your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the items have not been met. You do not take insulin and test three 
(3) times a day. The Medicare rules state that insulin is required. Therefore, we decided that the Plan does not 
have to pre-approve receiver (monitor), dedicated, for use with therapeutic glucose continuous monitor system 
(CPT Code K0554).
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 the enrollee is clinically stable enough to 
be transferred to an LTACH level of care. You that her doctors will do rounds on a daily basis and physical, 
occupational, and speech therapy will assist to maintain the enrollee's strength and abilities. You say that the 
enrollee will be seen by a certified wound care nurse weekly in order to assess for any wounds. You say that an 
LTACH will be able to provide daily physician visits, daily labs, and a dietician to monitor her nutrition status. 
You say that LTACH care is medically reasonable and necessary. The Plan denied your request. The Plan says 
the records show that the enrollee has not completed the hospital stay. The Plan says that the requested LTACH 
care is not medically necessary. 
 
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 does not require services at the LTACH that are not already available at 
the current facility. Our reviewer says that LTACH services are not medically necessary and a transfer to a 
lower level of care may be considered when their treatment is completed. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee. 
 
You asked the Plan to pay for out of network services. You say that this claim should be paid. The Plan denied 
your request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The provider 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. The Plan 
did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for 
these items/services. Therefore, we decided that the Plan does not have to pay for physician services provided 
to the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) 
provided to the enrollee on June 12, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in ei ther a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a knee orthosis with 
suspension sleeve (L1833, L2397) provided to the enrollee on June 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you have constant pain in your hips and feet. 
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 foot orthotics.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the general health panel rendered on May 27, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a GHP (code 80050) is not covered or paid for by 
Medicare.  
 
The services at issue are a general health panel billed with code 80050. These services are not covered by 
Medicare. Therefore, we decided that the Plan does not have to pay for the general health panel rendered on 
May 27, 2020.