Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0100) and 
ground mileage (A0425). 
 
You asked the Plan to pre-approve additional routine transportation trips and ground mileage. You say that the 
requested additional transportation is necessary. The Plan denied your request. The Plan says the requested 
additional transportation trips exceed the benefit limit. Therefore, coverage criteria has not been met. 
 
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 a maximum of 36 one-way transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips (A0100) and ground 
mileage (A0425).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health visits. 
 
You asked the Plan to pay for the home health visits. You say that you would like reconsideration because you 
have a wound that needs to be taken care of and require physical therapy to walk. The Plan denied your 
request. The Plan says the notes do not show you  has a skilled need or meet coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health visits have not been met. Specifically, the documentation submitted does not 
include any medical records to confirm that Medicare coverage criteria have been met. Additionally, the record 
indicates that your provider has not verified that these services are medically necessary. Therefore, we decided 
that the Plan does not have to pay for home health visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a thighplasty. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 surgery. Our reviewer says that the 
requested surgery is not medically reasonable or necessary. Our reviewer found there is no rashing, itching, 
changes in mole, color or texture of skin, or easy bruising. The documentation does not support that the 
requested thighplasty is medically reasonable and necessary for the enrollee in this case. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a thighplasty.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup, including any pins when required (D2950).

You asked the Plan to pre-approve the core buildup. You say that tooth #19 has fractured lingual cusps, and existing composite. You also say that you recommend a core buildup and crown. The Plan denied your request. The Plan says this service is 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 a core buildup, including any pins when required (D2950).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approvehyperbaric oxygen therapy (99183, G0277).You asked the Plan to pre-approvehyperbaric oxygen therapy. You say that the enrollee needs this service.The Plan denied your request. The Plan says that this is not medically necessary.The Plan follows Medicare rules. Medicare rules say that program reimbursement for hyperbaric oxygen (HBO) therapy will be limited to that which is administered in a chamber (including the one man unit) and is limited to the conditions listed above, which include diabetic wounds of the lower extremities classified as Wagner grade III or higher in patientswho failed an adequate course of standard woundtherapy.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 hyperbaric oxygen therapy. Our reviewer says that the requested hyperbaric oxygen is medically necessary. Our physician reviewer found the enrollee has type II diabetes and a lower extremity wound due to diabetes that is classified as Wagner grade III.The enrollee's physician documents that IV antibiotics have been administered, and that the enrollee has not responded to conventional therapy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of hyperbaric oxygen therapy have been met.Therefore, we decided that the Plan has to pre-approvehyperbaric oxygen therapy (99183, G0277).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/orsend us the new information. This does not happen often. If we decide toopen the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested physician consultation. 
 
You asked the Plan to pre-approve the physician consultation. You say that you saw an in-network pain 
management provider and you do not want to continue with that provider. You say the referral to a new in-
network provider is too far away from your home. The Plan denied your request. The Plan says the exam can 
be done with an in-network provider and is not urgent or requires emergency attention. 
 
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 and accessible who can provide the services at issue in this appeal. We found no exception that would 
require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-
approve the requested physician consultation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvediabetic shoes to be provided by an out of network (OON) provider.You asked the Plan to pre-approvediabetic shoes. You say that you wouldlike to have these shoes so you do not walk with a limp.The Plan denied your request. The Plan says there are in-network providers available for these 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-approvediabetic shoes to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone density scan (77080) to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the bone density scan. You say that the network facilities are farther away 
and you would require transportation to them. The Plan denied your request. The Plan says there are network 
providers available. The services are not emergent or pre-authorized. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a bone 
density scan (77080) 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-approvean additional portable oxygen concentrator (POC) for the enrollee.You asked the Plan to pre-approvethe additional concentrator. You say that this is medically necessary.The Plan denied your request. The Plan says there are no records of the item being lost or damaged due to a specific accident or natural disaster.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 rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and 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 additional concentrator. Our reviewer says that the requested additional concentrator is not medically reasonable or necessary. Our physician reviewer found the plan indicates this enrollee was provided with a POC for supplemental oxygen while mobile within the home. Medicare does not cover duplicate durable medical equipment. The medical records do not explain why a second one is needed.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 concentrator have not been met.Therefore, we decided that the Plan does not have to pre-approvean additional portable oxygen concentrator (POC) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the fluoride gel carrier (D5986) and hospital or 
ambulatory surgical center call (D9420). 
 
You asked the Plan to pre-approve the fluoride gel carrier (D5986) and hospital or ambulatory surgical center 
call (D9420). You say that it is impossible for the enrollee to go to a dentist office for any services. You say 
that the enrollee cannot afford to pay out of pocket. The Plan denied your request. The Plan says the services 
are not covered benefits. 
 
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 the 
fluoride gel carrier (D5986) and hospital or ambulatory surgical center call (D9420).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of stabilizing or separating device into 
lower spine at single level (22689). 
 
You asked the Plan to pre-approve the insertion of stabilizing or separating device. You say that the insertion of 
the lumbar interspinous spacer would provide significant clinical and quality of life benefits. This treatment is 
medically necessary and appropriate for this stage of the disease. The Plan denied your request. The Plan says 
there is not enough evidence to support that interspinous spacer devices are safe and effective. 
 
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 insertion of stabilizing or separating device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the insertion of stabilizing or separating device into lower spine at single 
level (22689).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power wheelchair (K0822) and accessories (E2300, 
E0973, E1028, E2365, E2622) to be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that you were told this 
provider is the only one who can make custom wheelchairs. The Plan denied your request. The Plan says these 
items are available from in-network providers. 
 
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 power wheelchair (K0822) and accessories (E2300, E0973, E1028, E2365, E2622) 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 the requested brand specific wheeled walker/chair from 
an out of network provider. 
 
You asked the Plan to pre-approve a brand specific wheeled walker/chair. You say that this brand specific 
variable wheel resistance walker is not available in-network. The Plan denied your request. The Plan says 
Medicare does not cover DME for use outside the home and you must use a participating provider that accepts 
Medicare. 
 
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 a similar item to the item at issue in this appeal. We found no exception that would 
require the Plan to pre-approve this item.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Also payment cannot be made for items 
purchased from this provider because this provider is not a medical provider and is not enrolled in Medicare. 
Therefore, we decided that the Plan does not have to pre-approve the requested brand specific wheeled 
walker/chair from an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oxygen concentrator. 
 
You asked the Plan to pre-approve the concentrator. You say that this is medically necessary. The Plan denied 
your request. The Plan says this item may be covered for people with certain lung disorders. 
 
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 the concentrator. Our reviewer says that 
the requested concentrator is not medically reasonable or necessary. Our physician reviewer found the medical 
notes report that you have previously been shown to be hypoxemic at night during a sleep study. There is no 
mention of therapy with CPAP for the sleep apnea. For nocturnal hypoxemia in patients with sleep apnea, the 
appropriate treatment is CPAP. Oxygen is needed only if hypoxemia persists during treatment with appropriate 
CPAP pressures.  Oxygen without CPAP may actually worsen the apneic episodes. The records do not include 
documentation of nocturnal hypoxemia, or sleep study results documenting need for oxygen in addition to 
CPAP. 
 
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 concentrator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an oxygen concentrator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe nebulizer with compression (E0570) provided on January 23, 2020 by an out of network (OON) provider.You asked the Plan to pay fornebulizer with compression. You say that you received the purchase agreement from the orderingdoctor (an out-of-network provider) after the deadline for requesting an authorization.The Plan denied your request. The Plan says services should be received from network providers.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 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 forthe nebulizer with compression (E0570) provided on January 23, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5011, V5160, V5261) provided February 
25, 2020. 
 
You asked the Plan to pay for the hearing aids. You say that the hearing aids should be covered. The Plan 
denied your request. The Plan says hearing aids purchased out-of-network are not covered. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan?s coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from network providers.  
 
We looked at the file, and the Plan's rules. The hearing aids were not purchased from a contract provider. Based 
on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. 
Therefore, we decided that the Plan does not have to pay for the hearing aids (V5011, V5160, V5261) provided 
February 25, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy servicesprovided on March 24, 2020.You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the psychotherapy services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for psychotherapy services providedon March 24, 2020.