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

 
We decided that the Plan does not have to pre-approve a heavy-duty hospital bed E0303. 
 
You asked the Plan to pre-approve a heavy-duty hospital bed. You say that the requested hospital bed is 
medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. 
 
The Plan must follow Medicare rules. Medicare rules say a heavy-duty hospital bed has a weight requirement. 
Based on the medical records provided you do not meet that weight requirement. Therefore, we decided that 
the Plan does not have to pre-approve a heavy-duty hospital bed E0303.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for PT provided from March 3, 2020 to March 
12, 2020. 
 
You asked the Plan to waive the copayments for PT. You say that you should only owe a $20 copayment per 
each visit. The Plan denied your request. The Plan says the claims were processed correctly and you are being 
charged the correct amount. 
 
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 $40 
copayment for outpatient rehabilitation services provided in an outpatient hospital facility.  
 
You received PT at an outpatient hospital facility from March 3, 2020 to March 12, 2020 for a total of 4 visits. 
Therefore, you are responsible to pay a $40 copayment per each visit. The total amount you owe is: $40 
(copayment) x 4 (PT visits) = $160.  
 
You have been asked to pay the total copayment amount of $160 for PT. PT falls within the outpatient 
rehabilitation services 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 copayments for PT 
provided from March 3, 2020 to March 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for post-stabilization inpatient care provided November 23, 
2019. 
 
You asked the Plan to pay for the post-stabilization inpatient care. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the enrollee was stable for transfer to a plan facility. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 pay for the post-stabilization inpatient care. Our 
reviewer says that the post-stabilization inpatient care was not medically necessary. Our physician reviewer 
found the review indicates that the enrollee was hemodynamically and neurologically stable and appropriate for 
ambulance transport with monitoring to a Plan facility for observation level of care services after the 
emergency room evaluation. 
 
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 post-stabilization inpatient care have not been met. Therefore, we decided 
that the Plan does not have to pay for post-stabilization inpatient care provided November 23, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve computed tomography (CT) scan.
You asked the Plan to pre-approve the CT scan. You say that the records provided supports the need for a CT scan. The Plan denied your request. The Plan says that the records show that the enrollee has problems related to his pelvis. The Plan says that the records provided do not show the results of an exam that includes the pelvis and part of the body that make and store urine.
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 medically necessary. Our physician reviewer found the enrollee had a previous abnormal CT scan of abdomen and pelvis demonstrating a polypoid bladder mass. It has been longer than a year since this exam was performed. While a urologic examination is needed for evaluation of this abnormality, repeat imaging is also necessary and should not be delayed while pursuing further clinical examination. 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 been met. Therefore, we decided that the Plan has to pre-approve computed tomography (CT) scan.
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a disposable sensor for a continuous glucose monitor 
(CGM). 
 
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 the item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a sensor described by code A9276 is for use with 
a non-therapeutic CGM. 
 
We looked at the file and Medicare rules. The services at issue are a disposable sensor described by A9276. 
This item is for a non-therapeutic CGM and is not covered by Medicare. Based on this information, we decided 
that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a disposable sensor for a continuous glucose monitor (CGM).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve the continuation of SNF care. You say that the requested continuation of 
SNF care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for continued SNF care. 
 
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 the continuation of SNF care. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was 
originally admitted to acute care on 7/14/20 with a diagnosis of atrial fibrillation, urinary tract infection, 
bradycardia and aortic stenosis. The enrollee was transferred to SNF care on 7/17/20 with a last covered day of 
8/26/20. From a nursing perspective, the enrollee received oral medications.  The enrollee had stable vital 
signs. She was treated for pain with effect. She had uncomplicated wound care to her right heel. Regarding 
rehabilitation services, the enrollee received physical therapy and occupational therapy in the SNF.  By the 
dates in question, the enrollee was an independent to supervision level with functional mobility including gait 
to 65 feet with a rolling walker.  The enrollee required varying assist with activities of daily living. She could 
negotiate stairs with moderate assist. 
 
There are no identifiable skilled nursing service needs.  There are no identifiable skilled therapy service needs. 
The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee 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 the continuation of SNF care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PET scan of the brain for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says imaging may be supported if the doctor noted that the enrollee's thinking and reasoning 
processes have declined for at least six months. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found the enrollee does not 
have an indication for which a PET Scan can be covered at this time. In this case the requested PET scan has 
been ordered for non-oncological purposes. The treating provider's correspondence suggests that the member 
has Lewy Body Dementia. Medicare (via NCD) indicates that a PET/CT scan of the brain may only be covered 
for use in patients who meet the diagnostic criteria for both Fronto-Temporal Dementia and Alzheimer's 
Dementia (when additional requirements for coverage are met). In this case the member is not suspected of 
having either AD or FTD. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve PET scan of the brain for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transthoracic echocardiogram (TTE) with Doppler. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has mildly-reduced left 
ventricular ejection fraction to 45 percent in 2016 but no documented cardiac symptoms or cardiovascular 
physical exam. He is now scheduled for low-risk, non-cardiac knee surgery. In this circumstance, the requested 
TTE with Doppler is not medically necessary, as there is no documented clinical cardiac change. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve a transthoracic echocardiogram (TTE) with Doppler.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental bone graft.
You asked the Plan to pre-approve the dental service. You say that the service is needed for dental implants. The Plan denied your request. The Plan says the service is non-covered.
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. Although the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a dental bone graft.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine transportation to a clinical study out of network.
You asked the Plan to pre-approve this request. You say that the requested transportation is medically necessary. The Plan denied your request. The Plan says you are request coverage for transportation out of network to participate in a clinical trial. The Plan says that your primary care physician (PCP) advised there is no information on file indicating that you are currently registered or participating in a clinical research study. Your PCP does not support your request for transportation needs out of network.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation when to in network destinations. The Plan does not cover routine transportation out of network for participation in a clinical trial. Therefore, we decided that the Plan does not have to pre-approve routine transportation to a clinical study out of network.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the positron emission tomography (PET) scan rendered on 
February 3, 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 diagnosis is not appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee has non-Hodgkin's 
lymphoma (NHL) of unspecified type with no other submitted clinical information. The appropriate use of PET 
scans in NHL varies widely by histologic type, treatment received or planned, and whether the patient has signs 
or symptoms of the disease. There is insufficient information to determine that the scan done was appropriate. 
The services were therefore not supported or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the positron emission tomography (PET) scan rendered on February 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for determination of refractive state (92015), deluxe frame 
(V2025) and progressive lens per lens (V2781) from January 31, 2020 through February 25, 2020 provided by 
a non-participating provider. 
 
You asked the Plan to pay for the services. You say that you know the services are covered. The Plan denied 
your request. The Plan says you do not have out-of-network benefits. 
 
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. 
 
You are eligible for a refraction 1 per calendar year and pay $0 from an in-network supplemental vision 
provider. For frames and lenses you are eligible for up to $100 from an in-network supplemental vision 
provider. The provider you use is not a participating provider with the supplemental vision plan which is why 
your vision claims were denied and why you did not receive any reimbursement. 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. 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 determination of refractive state (92015), deluxe frame (V2025) and progressive lens per 
lens (V2781) from January 31, 2020 through February 25, 2020 provided by a non-participating provider.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a Dexcom continuous glucose monitor (CGM) and supplies
You asked the Plan to pre-approve the Dexcom CGM and supplies. You say that the enrollee is experiencing
severe hypoglycemia related to complications of bariatric surgery. The appellant says that the requested device
and supplies would ensure the enrollee's safety related to uncontrolled severe hypoglycemia. The Plan denied
your request. The Plan says that the enrollee does not have a diagnosis of diabetes. The Plan says that the
enrollee is not on multiple doses of insulin. The Plan says that the enrollee does not meet the criteria for
coverage and that Medicare does not cover the requested items for her clinical situation.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is 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 Dexcom CGM and supplies. Our
reviewer says that the requested items are considered medically reasonable and necessary in this case. Our
physician reviewer found that, although the enrollee does not have diabetes, there is a strong medical indication
for a CGM. The enrollee has low blood glucose following gastric bypass and cannot tolerate a standard
treatment with Acarbose for this problem. Although the enrollee does not meet the criteria listed in the LCD, as
she does not use insulin or have diabetes, deeds a CGM to help manage and prevent the low blood glucose
levels she is having.
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 Dexcom CGM and supplies have been met. Therefore, we decided that the
Plan has to pre-approve a Dexcom continuous glucose monitor (CGM) and supplies
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 facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint injections are covered when the above 
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 facet joint injections. Our reviewer says 
that the requested facet joint injections are not medically reasonable and necessary. Our physician reviewer 
found that the enrollee is a 77-year-old female with cervical spondylosis and chronic neck pain.  This request is 
for left C2-C5 facet joint nerve block. On July 14, 2020, the enrollee underwent left C2-C5 facet joint nerve 
block.  The office note dated August 6, 2020, states ?She underwent left C2-5 FJNB #1 with no improvement.?  
The provided medical records do not document that the enrollee has satisfied the coverage criteria.  Therefore, 
the requested injections are not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from February 28, 2020 
through March 22, 2020 and from March 25, 2020 through March 28, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's 
condition no longer required daily skilled services at an inpatient SNF level of care. 
 
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 pay for the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 the skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from February 28, 2020 through March 22, 
2020 and from March 25, 2020 through March 28, 2020.
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 the CGM. You say that this is necessary. The Plan denied your request. The 
Plan says the criteria are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that CGMs may be covered when the above criteria 
are met.  
 
In this case, the enrollee does not require multiple insulin injections per day and does not adjust the dose 
frequently based on the glucose monitor readings. As such, the coverage criteria for the CGM have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).