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

 
We decided that the Plan does not have to pre-approve a group 4 standard power wheelchair (PWC) (K0877) 
and accessories. 
 
You asked the Plan to pre-approve a group 4 PWC and accessories. You say that the requested items 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. Medicare rules say that group 4 PWCs have added capabilities that are 
not needed for use in the home. Therefore, if these wheelchairs are provided they will be denied as not 
reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a group 4 PWC and accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 4 standard power wheelchair (PWC) (K0877) and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the notes are not clear about a subluxation of the spine. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found the only treatment 
allowed by Medicare for chiropractors is to treat a subluxation of the spine. The subluxation may be 
demonstrated by x-ray or by physical examination. There are no submitted imaging studies to reveal evidence 
of a subluxation. The submitted chart note/office visit note, dated August 6, 2020, reveals findings of motion 
palpation findings that revealed joint fixations/restrictions and static palpation revealing misalignment, 
tenderness and muscle spasms at vertebral levels of C1, C2, T1, T2, T8, L1, L5 and the right pelvis, along with 
a short leg and one positive orthopedic test, does not reveal evidence of subluxation per Medicare guidelines. 
Thus, chiropractic treatment is neither supported nor allowed per Medicare guidelines. 
 
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 chiropractic services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency room visit (99283, 96372, 73610, J1885, 
A9150) provided on February 29, 2020. 
 
You asked the Plan to pay for an emergency room visit. You say that this claim should be paid because you are 
not recognized by any government payers, including Medicare. The Plan denied your request. The Plan says 
payment cannot be made to providers that are not enrolled in Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program. 
 
We looked at the file and Medicare rules. The file shows that the provider of the services at issue is not 
enrolled in the Medicare program. Based on this information, we decided that Medicare rules for coverage of 
an emergency room visit have not been met. Therefore, we decided that the Plan does not have to pay for an 
emergency room visit (99283, 96372, 73610, J1885, A9150) provided on February 29, 2020.
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 based on the 
documentation provided, the enrollee does not have documented skilled nursing needs.  The enrollee does not 
have documented skilled therapy needs.  Daily skilled services are not required to establish a maintenance 
program or to prevent deterioration of the enrollee's condition.  The enrollee's care needs at this point are 
custodial and, 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 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on June 9, 
2020. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the charges 
because you did not travel far enough to warrant a copayment. 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 $50 
copayment for ambulance services.  
 
You have been asked to pay a $50 copayment for ambulance services. Ambulance services fall within the 
ambulance 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 copayment for ambulance services 
provided on June 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM). 

You asked the Plan to pre-approve a Freestyle Libre. You say that you need this because you are unable to use 
a lancing device. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CGM devices are covered only if the  beneficiary 
is insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-covered continuous 
subcutaneous insulin infusion (CSII) pump. 
 
We looked at the file and Medicare rules. The record shows that you are not currently insulin-treated. Based on 
this information, we decided that Medicare rules for coverage of a Freestyle Libre CGM have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor 
(CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Superion interspinous spacer for the enrollee. 
 
You asked the Plan to pre-approve the spacer. You say that this is medically necessary. The Plan denied your 
request. The Plan says a review of the current medical literature indicates that this service is considered 
experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the spacer. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the spacer is experimental. More research 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 spacer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Superion interspinous spacer for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that inpatient skilled nursing facility care is medically 
necessary. The Plan denied your request. The Plan says that you do not meet criteria for coverage of inpatient 
skilled nursing facility 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 SNF care. Our reviewer says that 
inpatient skilled nursing facility care is not medically necessary. Our physician reviewer found that you do not 
require skilled nursing or skilled therapy services on a daily basis. Additionally, as a practical matter, you do 
not require the necessary services on 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continued inpatient skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they 
are medically reasonable and necessary and replace a blood glucose monitor.  
 
We looked at the file and Medicare rules. Medicare rules also say that therapeutic CGMs are covered only 
when a patient has been performing four or more blood glucose testings every day and is insulin-treated with 
at least three or more daily injections of insulin or a Medicare-covered continuous subcutaneous insulin 
infusion (CSII) pump. The file shows that you are neither insulin-treated nor have a CSII pump. Therefore, we 
decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the optometry services (92014, 92250) provided on July 26, 
2019. 
 
You asked the Plan to pay for the optometry services. You say that this provider is in-network and the services 
should be covered. The Plan denied your request. The Plan says this provider is out-of-network and the enrollee 
has no 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. 
 
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 the optometry services (92014, 92250) provided 
on July 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit (99203) provided on 
February 12, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $25 
copayment for each visit for urgently needed services.  
 
You have been asked to pay a $25 copayment for the urgent care visit provided. According to the Families First 
Coronavirus response act, cost sharing is waived for medical visits only when the visit results in a test for 
COVID-19. The file does not show that you received a COVID-19 test, which means the cost sharing cannot be 
waived. 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 copayment for the office visit (99203) provided on  
February 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint nerve ablation. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is not enough medical evidence about this procedure. 
 
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 injection. Our reviewer says that the 
requested injection is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the use of radiofrequency ablation for pain management related to sacroiliitis has not been shown to 
provide clear long-term benefit than standard treatment for chronic sacroiliac joint pain. The provided medical 
records do not document that the enrollee has satisfied the above requirements. Therefore, this procedure is not 
medically necessary and reasonable. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacroiliac joint nerve ablation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a phone alert alarm. 
 
You asked the Plan to pre-approve the phone alert alarm. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says this is not a Medicare covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a phone alert alarm.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the X-ray of chest and related services (Q0092, R0070, 
71045) provided on January 5, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the X-ray of chest and related services. You say that based on the medical 
records you would like this claim reprocessed and reviewed for payment. The Plan denied your request. The 
Plan says prior authorization was not obtained by the facility or the provider; therefore, payment has been 
correctly denied. 
 
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 for the X-ray of chest and related services (Q0092, 
R0070, 71045) provided on January 5, 2020, by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia injections (J0897). 
 
You asked the Plan to pre-approve Prolia injections. You say that Prolia is the best course of treatment for the 
enrollee. The Plan denied your request. The Plan says rules for coverage for Prolia have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Prolia injections. Our reviewer says that the 
service is not medically accepted as prescribed. Our physician reviewer found that the enrollee underwent a 
Dual-Energy X-ray Absorptiometry (DEXA) scan on August 6, 2020. The results of this study support the 
diagnosis of osteopenia. Review of Medicare guidelines and approved compendia does not support the use of 
Prolia for the treatment of osteopenia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia injections have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Prolia injections (J0897).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve jaw surgery and dental services. 
 
You asked the Plan to pre-approve jaw surgery and dental services. You say that the requested jaw surgery is 
medically necessary. The Plan denied your request. The Plan says the requested jaw surgery is not medically 
necessary. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
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 jaw surgery and dental services. Our 
reviewer says that the requested jaw surgery and dental services are not medically necessary. Our physician 
reviewer found an appeal is being made for the denial of coverage for alveolar ridge augmentation to support 
the placement of dental implants. The reason for the denial was that the service is not a covered expense since 
the treatment involves the care and treatment involving the supporting structure of the teeth. A review of the 
documentation indicates that the treatment (bilateral maxillary alveolar ridge augmentation) is to provide 
support for dental implants. This involves the treatment of the supporting structures of the teeth which is not a 
covered expense. Bilateral maxillary alveolar ridge augmentation is treatment involving the supporting 
structure of the teeth which is not a covered expense according to the 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 jaw surgery and dental services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve jaw surgery and dental services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections for the enrollee. 
 
You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied 
your request. The Plan says the requested procedure is supported if the pain is localized to either the neck or 
back. 
 
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 injections. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case, the medial branch block provided 100% relief and the facet injection provided 40% 
relief. This does not meet the criteria. 

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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint injections for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an annual wellness visit on January 28, 
2020. 
 
You asked the Plan to waive the coinsurance for an annual wellness visit. You say that you disagree with the 
out-of-network charges. 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 50% 
coinsurance for out-of-network annual wellness visits.  
 
The record shows that you received an annual wellness visit on January 28, 2020 from an out-of-network 
provider. Therefore, you are responsible to pay your share of the out-of-network cost-sharing charges. The 
allowed amount is $209.33 and 50% of that is $104.67. 
 
You have been asked to pay the total coinsurance amount of $104.67 for an annual wellness visit. An annual 
wellness visit falls within the annual wellness visits 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 
coinsurance for an annual wellness visit on January 28, 2020.