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

 
We decided that the Plan does not have to pay for the diabetic supplies provided from February 19, 2020, to 
May 18, 2020. 
 
You asked the Plan to pay for the test strips (A4253), calibrator solution (A4256)and lancets (A4258). You say 
that the Plan should pay this claim. The Plan denied your request. The Plan says the documentation did not 
include a valid physician order or proof of delivery. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order and proof of delivery for the supplies provided in this case. 
The physician order was written after the date of service and there is no proof of delivery documentation. The 
record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the diabetic supplies provided from February 19, 
2020, to May 18, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not covered when dispensed from a pharmacy. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve push handles for a manual wheelchair. 
 
You asked the Plan to pre-approve push handles. You say that you are appealing. The Plan denied your request. 
The Plan says the denial of authorization for this feature is correct, because the approved wheelchair already 
includes push handles and therefore this requested feature is duplicative. 
 
The Plan must follow Medicare rules. 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. 
 
The file shows that the Plan approved a wheelchair which already includes push handles. Therefore, these 
separately requested push handles are duplicative. Therefore, we decided that the Plan does not have to pre-
approve push handles for a manual wheelchair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ondansetron ODT 4mg tablets. 
 
You asked the Plan to pre-approve Ondansetron. You say that Ondansetron is medically necessary. The Plan 
denied your request. The Plan says Ondansetron is not being prescribed in a situation that would make it 
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 Ondansetron ODT 4mg 
tablets.  
 
Benefits for Ondansetron 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve night gradient compression stockings. 
 
You asked the Plan to pre-approve the compression stockings. You say that the night garment is intended to 
reduce the swelling. The Plan denied your request. The Plan says the item is not covered by Medicare or your 
plan. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
non-covered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve night gradient 
compression stockings.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services provided on March 8, 2020. 
 
You asked the Plan to pay for the critical care services. You say that these services were medically necessary 
and should be covered. The Plan denied your request. The Plan says the records do not support the billed 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that critical care progress notes must document the 
time spent providing care.  
 
In this case, the progress note does not document time spent. As such, the billed critical care services are not 
supported. Therefore, we decided that the Plan does not have to pay for the critical care services provided on 
March 8, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost shares for the Medicare Part B drugs provided from 
May 20, 2020, to June 26, 2020. 
 
You asked the Plan to waive the cost shares for the services provided. You say that the services should be 
covered under Part D. The Plan denied your request. The Plan says the cost share was applied correctly. 
 
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 20% for 
Medicare Part B prescription drugs.  
 
The file shows that you received Aminolevulinic Acid HCL by a physician in an outpatient setting. You have 
been asked to pay 20% for each Part B drug. The services fall within the Medicare Part B prescription drugs 
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 cost shares for the Medicare Part B drugs 
provided from May 20, 2020, to June 26, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) sessions. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the requested additional PT is not generally accepted as specific and 
effective for your condition. You have had extensive previous therapy and it doesn't appear that your functional 
level requires the unique skills of a professional therapist to safely and effectively provide treatment, that the 
services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. 
You are able to complete a home exercise program. You do not require PT to establish a program or maintain 
your current condition. 
 
 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve physical therapy (PT) sessions.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abutment supported porcelain fused to metal crown 
(D6059) and custom fabricated abutment (D6057) provided on August 10, 2020. 
 
You asked the Plan to pay for the abutment supported porcelain fused to metal crown and custom fabricated 
abutment. You say that you would like some reimbursement for the services you received. The Plan denied 
your request. The Plan says the services provided are 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. 
 
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 pay for the 
abutment supported porcelain fused to metal crown (D6059) and custom fabricated abutment (D6057) provided 
on August 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Image Guided Radiation Therapy (IGRT). 
 
You asked the Plan to pre-approve Image Guided Radiation Therapy. You say that IGRT is medically 
necessary. The Plan denied your request. The Plan says rules for coverage have not been met. 
 
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 Image Guided Radiation Therapy. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found IGRT for whole breast radiation is an accepted standard only for exceptional 
circumstances such as difficult patient set-up, prior radiation necessitating more accurate localization, or 
abutment of the field against a critical organ (such as heart in left sided breast cancers). Per NCCN and ASTRO 
guidelines, routine use of IGRT is not within the standard practice for this type of cancer. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Image Guided Radiation Therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Image Guided Radiation Therapy (IGRT).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on August 5, 2020. 
 
You asked the Plan to waive the copayment for the office visit. You say that you already paid a $60 copayment 
for the procedure. You say that you shouldn't have to pay an office visit copayment. The Plan denied your 
request. The Plan says the copayment applied correctly. 
 
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 $30 
copayment for each specialist visit for Medicare-covered services.  
 
You have been asked to pay a $30 copayment for the office visit. The office visit falls within the "Outpatient 
hospital services" benefit category. The records show you had an office visit for an infected abscess. 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 provided on August 5, 2020.
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. The Plan denied your request. The Plan says based on 
Medicare guidelines and the information the Plan received about the enrollee's condition, that the requirements 
for a LTACH admission have not been met. 
 
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 that the enrollee was admitted to the current acute care hospital with cardiac arrest 
and subarachnoid hemorrhage requiring intubation and later tracheostomy and a NG feeding tube. She was 
recently able to tolerate CPAP for 7 hours. A PEG tube has not yet been placed due to hypokalemia. She 
remains non-verbal and not able to follow commands. She has a poor prognosis according to recent records. 
The enrollee appears to be stabilizing but requires additional short term acute care services which can be safely 
completed at the current facility. She requires PEG placement. The enrollee does not require services at the 
LTACH that are not already available at the current facility. There are no services at the LTACH that the 
enrollee requires that are not already available and covered at the current facility. Therefore, this request for 
LTACH services will be considered not medically necessary at this time. Transfer to a lower level of care may 
be considered when appropriate. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Continuous Glucose Monitoring (CGM) System. 
 
You asked the Plan to pay for the CGM. You say that you would like the CGM to be authorized. The Plan 
denied your request. The Plan says you are not on insulin so you do not meet coverage criteria. 
 
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 the enrollee does not 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. Based on this information, we 
decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan 
does not have to pay for Continuous Glucose Monitoring (CGM) System.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a positron emission tomography (PET) with concurrently acquired 
computed tomography (CT) scan from the skill to mid-thigh (78815). 
 
You asked the Plan to pre-approve a PET CT scan from the skill to mid-thigh. You say that the services are 
necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage 
criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a PET CT scan from the skill to mid-
thigh. Our reviewer says that the services are medically necessary. Our physician reviewer found the PET/CT 
scan from skull to mid-thigh is requested to guide subsequent management of cancer treatment after completion 
of initial anti-cancer therapy. The case file does not contain documentation of three prior FDG PET scans used 
to guide subsequent management of cancer treatment after completion of initial anti-cancer 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 a PET CT scan from the skill to mid-thigh have been met. Therefore, we 
decided that the Plan has to pre-approve a positron emission tomography (PET) with concurrently acquired 
computed tomography (CT) scan from the skill to mid-thigh (78815).  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services (99291) provided. 
 
You asked the Plan to pay for the critical care services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the documentation does not support 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. 
 
In this case, the CPT Code Manual definition of code 99291 is Critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the record does now 
describe how much time was spent on this service. Based on this information, we decided that Medicare rules 
for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have 
to pay for critical care services (99291) provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the clinical crown lengthening (D4249) provided 
on July 15, 2020. 
 
You asked the Plan to reimburse you for the dental service. You say that when you signed up for this plan you 
thought that some dental would be covered. You say that the booklet says that you can have 1 periodontal 
treatment every 6 to 36 months. You say that you had a periodontal treatment done so it should be covered. 
You also say there needs to be more detail on what is and what is not covered in the handbook. The Plan denied 
your request. The Plan says clinical crown lengthening is not listed as a covered service. 
 
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. The Evidence of Coverage says the periodontal services that are 
covered include deep cleaning, deep cleaning maintenance, and full mouth debridement. While clinical crown 
lengthening is a periodontal service, it is not listed as a covered periodontal service. Therefore, we decided that 
the Plan does not have to reimburse you for the clinical crown lengthening (D4249) provided on July 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on August 22, 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 type of testing is not covered as a screening. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. The test at issue in this appeal was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for lab services provided to the enrollee on August 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator for the enrollee. 
 
You asked the Plan to pre-approve a portable ventilator. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says that there is no evidence that the requested mechanical 
ventilator is indicated. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says 
that a portable ventilator is not medically reasonable and necessary for the enrollee in this case. Documentation 
as submitted does not support the need for a home ventilator. Our physician reviewer found that the enrollee's 
condition does not meet Medicare criteria for a portable ventilator. 
 
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 ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator for the enrollee.