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

 
We decided that the Plan does not have to pre-approve scooter repairs. 
 
You asked the Plan to pre-approve the scooter repairs. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says you did not receive this scooter through the 
Plan and you do not meet criteria for the scooter. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 scooter repairs. Our reviewer says 
that the documentation does not reveal that you require an assistive device when you wear your prosthetic leg 
or that your mobility limitation is unable to be helped by a cane, walker, or manual wheelchair. The 
documentation does not reveal that you have safe storage for the scooter. Our physician reviewer found the 
documentation does not reveal that you meet the criteria per Local Coverage Determination (LCD): Power 
Mobility Devices (L33789) for the scooter and therefore the scooter repairs are not 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 the scooter repairs have not been met. Therefore, we decided that the Plan does 
not have to pre-approve scooter repairs.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve specialist services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve specialist services. You say that you do not feel like there is an in-network 
provider who can help with this specific issue. 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-approve 
specialist services to be provided by an out of network (OON) provider.  
 
Please contact the Plan for a list of in-network providers who can provide these services.
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 CGM. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria. 
 
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 tests 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 does not show that the enrollee tests their blood glucose levels at least four or more times 
a day and injects insulin at least three or more times per day. Medical records were not provided for review 
after multiple attempts by the Plan. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial mandibular and maxillary denture. 
 
You asked the Plan to pre-approve the denture. You say that you are asking for an exception, as you need this 
to eat and speak properly. The Plan denied your request. The Plan says this request exceeds the maximum 
count allowed per period. 
 
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 partial 
dentures once every five years.  
 
You have received other partial dentures within the past five years. Based on this information, we decided that 
the Plan's rules for coverage of the denture have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a partial mandibular and maxillary denture.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Invokana 100mg tablets.
You asked the Plan to pre-approve Invokana. You say that Invokana is medically necessary. The Plan denied your request. The Plan says Invokana is not eligible for coverage under the Part B medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Invokana 100mg tablets.
Benefits for Invokana may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint injection. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says there is 
lack of supportive documentation of a positive response of a diagnostic block. 
 
The Plan follows Medicare rules. Medicare rules say that sacroiliac joint injections are only covered under 
certain medical indications.  
 
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 requested services. Our physician 
reviewer found that the enrollee has chronic low back pain s/status post 2-level spine surgery, as well as SI 
joint pain. He has tried physical therapy and chiropractic therapy without sustained benefit. On June 15, 2020, 
the enrollee had bilateral SI joint injection with local anesthetic and steroid. The description of the pain relief is 
limited to "better". There is no documentation of the degree or duration of the pain relief obtained. Further, the 
progress notes indicate that a series of SI joint injections is proposed. There is a lack of documentation of the 
degree and duration of the pain relief from the SI joint injections. There is no role for a series of SI joint 
injections. Each injection should be evaluated for effectiveness and duration before deciding on another 
injection. Therefore, the requested procedure is not medically reasonable or 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a sacroiliac joint injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor and 
supplies. 
 
You asked the Plan to pre-approve continuous glucose monitor. You say that the enrollee is having trouble 
using other glucose monitors due to her vision. The Plan denied your request. The Plan says the denial of 
authorization for these items is correct, because the enrollee is not insulin treated and is not testing 4 or more 
times per day. 
 
The Plan follows Medicare rules. Medicare rules state that a continuous glucose monitor and supplies are only 
covered when all of the above listed criteria have been 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 continuous glucose monitor. Our 
reviewer says that the enrollee does not meet the Medicare criteria for this continuous glucose monitor. Our 
physician reviewer found the enrollee does not meet all of the coverage criteria because she does not use 
insulin and is not performing testing 4 or more times per day. 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continuous glucose monitor have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor and supplies.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Procrit. 
 
You asked the Plan to pre-approve Procrit (J0885). You say that you want the enrollee treated with this drug. 
The Plan denied your request. The Plan says the enrollee has not first tried and had a contraindication or 
intolerance to Retacrit. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Procrit (J0885). Our reviewer says that 
the drug is not reasonable or medically necessary. Our physician reviewer found the enrollee has not tried and 
failed the required drug and there is no indication that the plan's required drug would likely be less effective 
and/or likely have adverse effects for the enrollee. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Procrit (J0885) have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Procrit.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for radiology services provided by a 
participating provider on March 20, 2020. 
 
You asked the Plan to waive the copayment for radiology services. You say that you do not agree with this $10 
copayment. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
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 $10 
copayment for outpatient diagnostic tests/basic radiological services/specialist's.  
 
You have been asked to pay a $10 copayment for radiology services. The correct copayment has been applied 
to the service that was proided. Radiology services falls within the outpatient diagnostic tests/basic radiological 
services/specialist's 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 radiology services 
provided by a participating provider on March 20, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care provided on December 30, 2019 
and December 31, 2019. 
 
You asked the Plan to pay for subsequent hospital care. You say that the enrollee was under hospice care until 
December 23, 2019. You say that the claim should be reprocessed and paid accordingly. The Plan denied your 
request. The Plan says Original Medicare is responsible for payment. 
 
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 December 23, 2019. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for subsequent hospital 
care provided on December 30, 2019 and December 31, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on March 6, 2020 to March 9, 2020 by an out of network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that these services were provided in a facility. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained by the facility.
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 skilled nursing services provided on March 6, 2020 to March 9, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a 
non-participating provider on February 14, 2020 to February 16, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that this was an emergency 
situation. You say that since this was an unexpected incident it was difficult for you to go in-network. The Plan 
denied your request. The Plan says the correct copayment has been applied. 
 
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 $235 
copayment per day for days 1-7. There is not charge for additional days for inpatient hospital care.  
 
You have been asked to pay a $235 copayment per day for days 1-2. The total amount you are being asked to 
pay is $470 ($235 x 2 days = $470). The correct copayments have been applied to the length of stay that was 
provided at an inpatient hospital. An inpatient hospital stay falls within the inpatient hospital care 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 an inpatient hospital stay provided by a non-
participating provider on February 14, 2020 to February 16, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 5, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by an out-of-network provider without prior authorization. 
 
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 referring provider 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 laboratory services provided on May 5, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chiropractic office visit (99203), spinal manipulation 
(98940), and therapeutic services (97014, 97010, 97140) provided from January 29, 2019 to May 1, 2019. 
 
You asked the Plan to pay for a chiropractic office visit, spinal manipulation, and therapeutic services. You say 
that you have chiropractic coverage. The Plan denied your request. The Plan says these services are not 
covered. 
 
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 looked at the file and Medicare rules. The submitted medical records do not demonstrate that you had a 
subluxation. Based on this information, we decided that Medicare rules for coverage of spinal manipulation 
have not been met. A chiropractic office visit  and therapeutic services are not manual manipulation of the 
spine and therefore are not covered when provided by a chiropractor. Therefore, we decided that the Plan does 
not have to pay for a chiropractic office visit (99203), spinal manipulation (98940), and therapeutic services 
(97014, 97010, 97140) provided from January 29, 2019 to May 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on March 19, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the OON care. You say that you cannot refuse to see a patient in this facility and 
have been denied when you attempt to obtain authorization or contract with the Plan. The Plan denied your 
request. The Plan says there are network providers able to render these services and no authorization was 
obtained to provide this care out of network. 
 
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 medical services provided on March 19, 2020 
by an out of network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services received from January 22, 2020 to January 28, 
2020. 
 
You asked the Plan to pay for the services. You say that everything is slower and harder during COVID-19, 
and it is not acceptable that the claims are denied. The Plan denied your request. The Plan says that the claim 
was not filed timely. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
These services were rendered by a contract provider. The file does not show that the Plan provided notice that 
the services would not be covered. Under Medicare rules, this means the services is considered approved by the 
Plan. Therefore, we decided that the Plan has to pay for laboratory services received from January 22, 2020 to 
January 28, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on January 7, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization.  
 
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 
services at issue. 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 physician's services provided on January 7, 2020.