Persius/hicric huggingface dataset:
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 would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested item is not medically 
necessary. 
 
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. Portable oxygen is not covered for patients who qualify 
for oxygen solely based on blood gas studies obtained during sleep.   
 
 
 
 
To qualify for home oxygen, the patient must meet one of the following blood gas levels: 
 
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 
 
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during 
sleep for a patient who have hypoxia symptoms during sleep;  
 
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for 
patients who have hypoxia symptoms during exercise; 
 
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of 
dependent edema, pulmonary hypertension, or erythrocythemia. 
 
For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, 
there is a rebuttable presumption of non-coverage. 
 
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 portable oxygen concentrator. Our 
reviewer says that the documentation does not support that the requested portable oxygen concentrator is 
medically reasonable or necessary. Our physician reviewer found you require a respiratory therapy visit for 
testing to ensure the oxygen saturation of greater than or equal to 91% with exertion. Used in conjunction with 
a stationary oxygen concentrator. Not recommended for use while sleeping. Therefore, you do not meet criteria 
for the requested portable oxygen concentrator. 
 
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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for disposable contact lenses (S0500) purchased from an out of 
network provider on July 1, 2020. 
 
You asked the Plan to pay for disposable contact lenses. You say that the out of network provider was the only 
one who could order your contact lens. The Plan denied your request. The Plan says rules for payment have not 
been met. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when received from a participating provider. 
 
We looked at the file and the Plan's rules. You did not obtain disposable contact lenses from a participating 
provider. Based on this information, we decided that the Plan's rules for coverage of disposable contact lenses 
have not been met. Therefore, we decided that the Plan does not have to pay for disposable contact lenses 
(S0500) purchased from an out of network provider on July 1, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on June 11, 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 this claim should be submitted to Original Medicare. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on July 6, 
2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan 
does not have to pay for physician services provided to the enrollee on June 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the 
panoramic x-ray (D0330) provided on February 15, 2018. 
 
You asked the Plan to pay for the dental services. You say that you just received a bill for services from 2 years 
ago. You say that you never received the services. You say that you had waited 2 hours to receive these 
services but ended up leaving out of frustration instead. The Plan denied your request. The Plan says the claim 
was processed correctly. The Plan says there is a $10 copayment for the oral exam. The Plan also says there is a 
$20 copayment for the dental x-ray. 
 
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 services you received are subject to 
copayments. Copayments are a contractual obligation you agreed to when you enrolled in the Plan's dental 
coverage. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation 
(D0150) and the panoramic x-ray (D0330) provided on February 15, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the medical services. You say that you are requesting review of denial of 
services. The Plan denied your request. The Plan says you or your physician have not provided clinical 
information to indicate the services you are requesting cannot be provided by an in-network and in-service-area 
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 medical services 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 provide a continuous glucose monitor. 
 
You asked the Plan to provide a continuous glucose monitor. You say that you need this brand of CGM 
because the other brand won't stick to your arm. The Plan denied your request. The Plan says criteria for a 
CGM is not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a continuous 
glucose monitor have not been met. Therefore, we decided that the Plan does not have to provide a continuous 
glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wig provided on May 19, 2020. 
 
You asked the Plan to pay for wig. You say that you were told that this would be reimbursable. The Plan 
denied your request. The Plan says the denial of payment for this item is correct, because wigs are not covered 
by Medicare. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pay for a wig provided on 
May 19, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve an MRI scan of the lumbar spine (72148). 
 
You asked the Plan to pre-approve an MRI scan of the lumbar spine. You say that this service is medically 
necessary. The Plan denied your request. The Plan says that rules for pre-approval have not been met. 
 
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 an MRI scan of the lumbar spine. Our 
reviewer says that the MRI is medically necessary at this time. Our physician reviewer found that, given the 
radicular nature of pain and prior negative films (plain), the MRI is indicated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI scan of the lumbar spine have been met. Therefore, we decided that the 
Plan has to pre-approve an MRI scan of the lumbar spine (72148).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical each additional radiographic image 
(D0230) and unspecified preventative procedure (D1999) provided on July 8, 2020. 
 
You asked the Plan to pay for the intraoral additional radiographic image and unspecified preventative 
procedure. You say that the services provided were necessary and the bill appears incorrect. The Plan denied 
your request. The Plan says you have exhausted your benefit for intraoral radiographic images, and the 
unspecified preventative procedure is not 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. The Plan covers the intraoral 
additional radiographic image and unspecified preventative procedure when the services are medically 
necessary and reasonable.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of the intraoral additional radiographic image and unspecified preventative procedure have not been 
met. Specifically, these services are limited to once a year and you have already exhausted the X-ray benefit. 
Furthermore, unspecified preventative procedures are never covered under your Plan?s supplemental benefit. 
Therefore, we decided that the Plan does not have to pay for the intraoral - periapical each additional 
radiographic image (D0230) and unspecified preventative procedure (D1999) provided on July 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for visual field exam (92083), lens, polycarbonate or equal 
(V2784) and frames (V2020) provided on August 3, 2020. 
 
You asked the Plan to pay for visual field exam, lens and frames. You say that the services should be covered. 
The Plan denied your request. The Plan says you have exhausted your maximum benefits. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers one routine eye exam per year and up to $200 towards the purchase and fitting of 
eyeglasses and pair of lenses. 
 
 
 
 
 
We looked at the file and the Plan's rules. You received a routine eye exam on the same day of your field vision 
exam that the plan paid in full. This means you have exhausted your maximum benefit for eye exams for the 
2020 Plan year. The plan paid $200 towards the purchase of your lenses and frames, you are responsible for the 
difference. Based on this information, we decided that the Plan's rules for coverage of visual field exam, lens 
and frames have not been met. Therefore, we decided that the Plan does not have to pay for visual field exam 
(92083), lens, polycarbonate or equal (V2784) and frames (V2020) provided on August 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion services provided on July 13, 2020. 
 
You asked the Plan to pay for the home infusion services. You say that you would like reconsideration because 
this provider bills as a home health provider. The Plan denied your request. The Plan says the provider type 
submitted is not valid for the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 62370, J2274, A4220 and G0162 are not supported in the record. Specifically, this 
provider is not a durable medical equipment provider, the services were not billed on an institutional claim and 
there is no evidence that the physician directly supervised the services rendered. 
 
 
 
 
 
 
 
 
 
 
 
Based on this information, we decided that Medicare rules for coverage of the home infusion services have not 
been met. Therefore, we decided that the Plan does not have to pay for home infusion services provided on July 
13, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray (CPT 71045) provided on July 24, 2020. 
 
You asked the Plan to pay for the x-ray. The Plan denied your request. The Plan says this is a duplicate claim. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be exact duplicates of another claim or claim line are denied.  
 
We looked at the file and Medicare rules. The x-ray in question was billed as a duplicate to a claim processed 
and paid by the Plan for the same date of service. Based on this information, we decided that Medicare rules for 
coverage of the x-ray have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray 
(CPT 71045) provided on July 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of the Superion interspinous spacer. 
 
You asked the Plan to pre-approve the Superion procedure. You say that it is felt that this treatment is needed. 
The Plan denied your request. The Plan says this has not been proven medically reasonable and necessary over 
the standard spinal fusion. 
 
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 Superion procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the spacer is experimental, and more research is needed to show safety and efficacy. 
 
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 Superion procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of the Superion interspinous spacer.
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 stay is medically necessary. The Plan 
denied your request. The Plan says the stay 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 there is no documentation provided necessitating admission to a LTACH. The 
enrollee still requires acute hospital level of care services and is receiving appropriate care at the present acute 
care facility. The enrollee does not require services at the LTACH that are not available at the acute care 
hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee 
requires that are not available at the health care setting being offered by the health plan. There are not requested 
LTACH services medically necessary, reasonable, and appropriate for the diagnosis and condition of the 
enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device (CPT Code 
22870 and 22869). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says medical studies haven't proven that the device(s) is helpful for treatment of the member's 
health problem. 
 
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 items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the spacer is experimental. More research is needed to show safety and efficacy. 
 
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 the Vertiflex Superion Interspinous device (CPT Code 22870 and 22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shoe insert. 
 
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 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 a shoe insert.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. 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 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 was admitted to the current acute care hospital with COVID-19-related 
pneumonia and respiratory failure. The enrollee required oxygen, dexamethasone, and convalescent plasma. 
The enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving care. There are no services available at the LTACH that the enrollee requires that 
are not available at the health care setting being offered by the health plan. 
 
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 long-term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a continuous glucose monitor. 
 
You asked the Plan to provide a continuous glucose monitor. You say that you are unable to continue pricking 
fingers so many times a day. The Plan denied your request. The Plan says medical records were requested from 
you doctor but not received. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results. 
 
We looked at the file and Medicare rules. There are no medical records in the case file showing that you 
perform blood glucose testing at least four times per day, use insulin with at least three daily injections, or 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this 
information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met. 
Therefore, we decided that the Plan does not have to provide a continuous glucose monitor.