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

We decided that the Plan does not have to pre-approve a group 2 power wheelchair. 
 
You asked the Plan to pre-approve the group 2 power wheelchair. You say that you would like reconsideration 
because this wheelchair is medically necessary. The Plan denied your request. The Plan says you are not noted 
to lack the upper arm strength to propel a manual wheelchair or that unable to complete your MRADLs with 
current manual wheelchair. 
 
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 group 2 power wheelchair. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no documentation that you have a personal mobility deficit that 
impairs participation in mobility related activities of daily living (MRADLs). There is no documentation that 
your mobility deficit cannot be helped by the use of a manual wheelchair. There is no documentation that you 
can safely operate a power mobility device. 
 
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 group 2 power wheelchair have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a group 2 power wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that your medical needs are being met in the current acute setting. 
 
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. You appear 
to be improving but requires additional short term acute care services only for continued weaning which can 
safely be completed at the current facility. You do not require services at the LTACH that are not already 
available at the current facility. Our physician reviewer found that your condition does not meet Medicare 
criteria for LTACH services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Part B drugs provided on January 18, 
2019. 
 
You asked the Plan to waive the coinsurance for the Part B drugs. You say that you were informed the claim 
would be handled but you received a bill for $600. You say that insurance should pay the full amount. The Plan 
denied your request. The Plan says the coinsurance 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% 
coinsurance for non-preferred Medicare Part B covered drugs. 
 
You have been asked to pay $600.95, which is 20% of the allowed amount for the Part B drugs. The allowed 
amount is $3,004.73 (20% x $3,004.73 = $600.95). The Part B drugs falls 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 coinsurance for the Part B drugs 
provided on January 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the infusion therapy services and to waive 
the copayment for the debridement services received March 5, 2020 to April 28, 2020. 
 
You asked the Plan to waive the coinsurance for the infusion therapy services and to waive the copayment for 
the debridement services. You say that you would like the plan to reconsider their decision. The Plan denied 
your request. The Plan says the claims have been processed correctly per your plan benefits. 
 
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% 
coinsurance for outpatient hospital services.  
 
You have been asked to pay 20% coinsurance for the infusion therapy services to pay a $200 copayment for the 
debridement services. The infusion therapy services and the debridement services fall within the outpatient 
hospital 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 coinsurance for the infusion therapy 
services and to waive the copayment for the debridement services received March 5, 2020 to April 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial periapical x-ray (D0220) and the 3 additional 
periapical x-rays (D0230) provided on July 24, 2020. 
 
You asked the Plan to pay for the x-rays. You say that the provider advised that the extractions would be 
covered at 100%. The Plan denied your request. The Plan says periapical x-rays are 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. Therefore, we decided that the Plan does not have to pay for the initial 
periapical x-ray (D0220) and the 3 additional periapical x-rays (D0230) provided on July 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G orthotic device. 
 
You asked the Plan to pre-approve the MyoPro device. You say that the Plan's denial rationale is not valid, that 
this device is the only method that will help the enrollee have function of their dominant arm. Additional 
occupational therapy will not be able to restore any adequate level of function. You provide multiple rebuttals 
to the Plan's arguments. The Plan denied your request. The Plan says this is not a medically necessary item. 
This is a deluxe feature and cannot be covered. 
 
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 MyoPro device. Our reviewer says 
that the requested items are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a past history of stroke with right upper extremity weakness. A MyoPro 
Motion G Orthotic device has been requested. Based on the medical records provided there is no 
documentation that the MyoPro Motion G Orthotic device at issue in this case medically reasonable and 
necessary. Current guidelines consider robotic therapy of "uncertain utility compared with dose-matched 
conventional upper limb exercise therapies". 
 
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 MyoPro device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a MyoPro Motion G orthotic device.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Computed Tomography Angiography (CTA) scan 
(75574). 
 
You asked the Plan to pre-approve the CTA. You say that this test is medically necessary. The Plan denied 
your request. The Plan says rules for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Computed Tomography Angiography is never 
covered for screening, i.e., in the absence of signs, symptoms or disease. 
 
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 CTA. Our reviewer says that the 
requested imaging is not medically necessary. Our physician reviewer found the enrollee has no history of 
significant or symptomatic cardiovascular disease. At his most recent follow-up visit he had no symptoms or 
signs of cardiovascular disease, his EKG showed non-specific STT changes which were unchanged from a 
prior EKG and he was noted to be "stable from a cardiovascular standpoint". 
 
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 CTA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Computed Tomography Angiography (CTA) scan (75574).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ALS routine disposable supplies (A0398) provided June 13, 
2020. 
 
You asked the Plan to pay for ALS routine disposable supplies. You say that this claim needs to be 
reconsidered as it denied as requested information not received. Please review and process this claim for 
payment. The Plan denied your request. The Plan says payment for these items is included in the payment for 
the ambulance transport. Medicare does not allow for separate billing of these services and supplies. 
 
The Plan must follow Medicare rules. Medicare rules say oxygen and other items and services provided as part 
of the transport are included in the fee schedule base payment rate and are not separately payable. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ALS routine disposable supplies have not been met. Therefore, we decided that the Plan does not 
have to pay for ALS routine disposable supplies (A0398) provided June 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter occlusion or embolization (S2095). 
 
You asked the Plan to pre-approve transcatheter occlusion or embolization. You say that the services are 
necessary. The Plan denied your request. The Plan says based on Medicare billing criteria, procedure codes 
with a status code of "I" are not valid for Medicare purposes. 
 
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 S2095 is transcatheter occlusion or embolization. 
 
We find that CPT code S2095 is not supported. Specifically, procedure codes with a status code of "I" are not 
valid. Medicare uses a different code for reporting and payment of these services. Based on this information, 
we decided that Medicare rules for coverage of transcatheter occlusion or embolization have not been met. 
Therefore, we decided that the Plan does not have to pre-approve transcatheter occlusion or embolization 
(S2095).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pneumatic compressor (E0652). 
 
You asked the Plan to pre-approve the pneumatic compressor. You say that you would like reconsideration 
because this member has conditions which would preclude safe and effective use of a leg only sustained high 
pressure E0651. The Plan denied your request. The Plan says the member has not tried and failed a 4 week trial 
with a basic pneumatic compression device. 
 
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 pneumatic compressor. Our 
reviewer says that is not covered for the treatment of lymphedema of the extremities alone. Our physician 
reviewer found the documentation does not reveal objective evidence on a physical exam of lymphedema 
extending onto the chest, trunk and/or abdomen. 
 
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 pneumatic compressor have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the pneumatic compressor (E0652).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on June 12, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider 
on June 12, 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 the Prolia. You say that you would like reconsideration because this drug is 
medically necessary. The Plan denied your request. The Plan says the member does not meet step therapy 
exception criteria. 
 
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 the Prolia. Our reviewer says that step 
therapy criteria have not been met. Our physician reviewer found the documentation does not support a history 
if an osteoporotic fracture or previous treatment, contraindication, or intolerance to zoledronic acid. 
 
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 Prolia have not been met. 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 a non-therapeutic continuous glucose monitor (CGM) 
with sensor and receiver. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is covered when specific 
criteria are met and non-therapeutic supplies are not covered.  
 
We looked at the file and Medicare rules. The services at issue are a non-therapeutic CGM and non-therapeutic 
supplies. These items are not covered by Medicare. Therefore, we decided that the Plan does not have to pre-
approve a non-therapeutic continuous glucose monitor (CGM) with sensor and receiver.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lift chair kit for the car. 
 
You asked the Plan to pre-approve a lift chair kit. You say that you require the device. The Plan denied your 
request. The Plan says the record does not support medical necessity. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare can cover vehicle modifications if they meet the definition of 
Durable medical equipment. This item does not meet the definition of durable medical equipment.  
 
The item at issue in this appeal is for use outside of the home and is not DME. Although this item may be 
helpful, neither Medicare nor the Plan covers equipment for use outside the home that is also not DME. 
Therefore, we decided that the Plan does not have to pre-approve a lift chair kit for the car.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee remains hemodynamically unstable for transfer. 
 
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. There is no 
evidence that the enrollee requires services that are not currently available. As LTACHs and acute care 
hospitals (ACH) are licensed to provide the same level of care, there is no advantage in transferring the enrollee 
to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The 
enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. Our 
physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long-term acute care hospital (LTACH) services for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the ultrasound you had on February 25, 
2020. 
 
You asked the Plan to reduce the copayment for the ultrasound. You say that you already paid a $65 copayment 
for this service, so you shouldn't owe any more. The Plan denied your request. The Plan says the copayment for 
this service is $105, so you were appropriately charged an additional $40 after you made this payment. 
 
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 $105 
copayment for Medicare-covered diagnostic radiological diagnostic services.  
 
You have been asked to pay a $105 copayment for the ultrasound. The ultrasound falls within the Medicare-
covered diagnostic radiological diagnostic 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 reduce the 
copayment for the ultrasound you had on February 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inhalation of nitrous oxide/analgesia, anxiolysis 
(D9230), removal of torus mandibularis (D7473) and cone beam CT capture and interpretation with limited 
field of view - less than one whole jaw (D0364). 
 
You asked the Plan to pre-approve the dental services. You say that you cannot eat anything solid as it hurts 
you. The Plan denied your request. The Plan says the services do not meet the criteria for adult emergency care 
and is not 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 services are not listed in your EOC as a covered benefit; therefore, 
the services are not covered. Therefore, we decided that the Plan does not have to pre-approve inhalation of 
nitrous oxide/analgesia, anxiolysis (D9230), removal of torus mandibularis (D7473) and cone beam CT capture 
and interpretation with limited field of view - less than one whole jaw (D0364).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent observation care (99224, 99225) provided on 
November 8, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for the subsequent observation care. You say that resubmitting the claim with 
supporting documentation. Please review and reprocess for payment. The Plan denied your request. The Plan 
says enrollee's must receive their medical services from an in-network provider with the exception being 
urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization 
before services being rendered. 
 
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 subsequent observation care (99224, 99225) 
provided on November 8, 2019 by an out of network (OON) provider.