Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to reduce the coinsurance for the oxygen equipment. We decided that the Plan 
does not have to waive the coinsurance for the oxygen equipment.  
 
You asked the Plan to waive the coinsurance for the oxygen equipment. You say that you need the oxygen to 
live. You say you are requesting that the Plan reconsider payment. The Plan says that you have been charged 
the correct cost sharing amount. 
 
We decided that the Plan has to reduce the coinsurance for the oxygen equipment.  
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information 
(such as copayments, deductibles, and coinsurance). The records show that the Plan charged a 25% coinsurance 
for the oxygen equipment.  
 
  
The Plan says that you must pay $25.43 for the oxygen equipment on each date of service. ($25.43 x 3 dates of 
service = $6.29). Based on the plan contract, however, you cannot be asked to pay more than $20.35 for the 
oxygen equipment on each date of service. Therefore, we decided that the Plan has to reduce the coinsurance 
for the oxygen equipment from $25.43 per date of service to $20.35 per date of service.  
 
We also decided that the Plan does not have to waive the coinsurance for the oxygen equipment. 
 
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 the oxygen equipment. The allowed amount for the oxygen equipment is $101.74. ($101.74 x 
20% = $20.35) ($20.35 x 3 dates of service = $61.05). Therefore, we decided that the Plan does not have to 
waive the coinsurance for the oxygen equipment. 
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an intermittent limb compression device (E0651, 
E0669). 
 
You asked the Plan to pre-approve an intermittent limb compression device. You say that this is medically 
necessary. The Plan denied your request. The Plan says the submitted documentation is insufficient to show 
medical necessity. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not include medical records showing that the enrollee has lymphedema or chronic venous 
insufficiency with venous stasis ulcers. Therefore, we decided that the Plan does not have to pre-approve an 
intermittent limb compression device (E0651, E0669).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and 
management of an established patient provided on May 26, 2020 by an OON provider. 
 
You asked the Plan to pay for the domiciliary or rest home visit. You say that it is the responsibility of the 
facility to obtain proper pre-certification and pre-authorization. You also say that your doctors rely on the 
facility to obtain the proper permissions. The Plan denied your request. The Plan says the service was rendered 
by an OON provider. The Plan also says that prior authorization was not obtained. 
 
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 
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 domiciliary or rest home visit for the 
evaluation and management of an established patient provided on May 26, 2020 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-sterile gloves. 
 
You asked the Plan to pre-approve the gloves. You say that this is needed for your caretakers. The Plan denied 
your request. The Plan says this is not a 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 non-sterile gloves.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine foot care. 
 
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. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
Records do not show that any of these conditions are present. The services you are asking the Plan to pre-
approve are routine foot care services. 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 routine 
foot care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a receiver for a continuous glucose monitor. 
 
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your 
request. The Plan says this system is not required. 
 
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 monitor. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found you do not titrate insulin dosage off multi-dose daily insulin. You do not quality for a CGM. 
 
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 monitor have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a receiver for a continuous glucose monitor.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
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 medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the requested Intracept procedure is 
considered experimental for the treatment of low back pain. More research is needed to show safety and 
efficacy; therefore, the services are not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Intracept procedure.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Toujeo Solostar 300 unit/ML.
 
You asked the Plan to pre-approve Toujeo Solostar. You say that this service is medically necessary. The Plan 
denied your request. The Plan says this drug is not covered for your condition by your Medicare Part B plan. 
 
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 Toujeo Solostar 300 unit/ML.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says in-network 
providers are available. 
 
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 file shows that 16 OON visits were requested. The Plan has agreed to pre-approve 4 visits with the 
provider at issue. The requested provider is not a network provider with the Plan. The Plan has network 
providers available who can provide the services at issue in this appeal. We found no exception that would 
require the Plan to pre-approve additional OON services. Therefore, we decided that the Plan does not have to 
pre-approve medical services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown for tooth #12. 
 
You asked the Plan to pre-approve the crown. You say that this service is medically necessary. The Plan denied 
your request. The Plan says this service exceeds the maximum count allowed. 
 
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, you are limited to two crowns per year. 
The record shows that you received two crowns on June 30, 2020, and your crowns benefit has been exhausted. 
Therefore, we decided that the Plan does not have to pre-approve a crown for tooth #12.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual wellness visit you had. 
 
You asked the Plan to pay for the visit. The Plan denied your request. The Plan says this is only covered once 
per year. 
 
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 $0 
copayment for one annual wellness visit every 12 months.  
 
Review of the file shows that you had an annual wellness visit. The Plan only covers one 
annual wellness visit every 12 months. The records also show that you had a covered annual wellness visit.
The requested visit exceeds the benefit limit. 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 pay for the annual 
wellness visit you had.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group three power wheelchair (K0858) and 
accessories (E0956, E1002, E1028, E2310, K0108, E2620, E0955, E2623). 
 
You asked the Plan to pre-approve a group three power wheelchair and accessories. You say that you need this. 
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 a group 3 power wheelchair is covered if the 
beneficiary's mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity. 
 
We looked at the file and Medicare rules. The records do not show that your mobility limitation is due to a 
neurological condition, myopathy, or congenital skeletal deformity. Based on this information, we decided that 
Medicare rules for coverage of a group three power wheelchair and accessories have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a group three power wheelchair (K0858) and accessories 
(E0956, E1002, E1028, E2310, K0108, E2620, E0955, E2623).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a set of dentures (D5110, D5120). 
 
You asked the Plan to pre-approve the dentures. You say that you lost your current dentures in transit and need 
a replacement. The Plan denied your request. The Plan says the benefit for dentures has been exhausted. 
 
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 benefit for dentures is limited to 
one set every 5 years. A set was previously provided on May 8, 2018. Therefore, we decided that the Plan does 
not have to pre-approve a set of dentures (D5110, D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two additional intraoral periapical x-rays provided on 
June 2, 2020. 
 
You asked the Plan to pay for the additional intraoral periapical x-rays. You say that prior to rendering the 
services, you contacted the Plan and were incorrectly informed that you would receive payment. The Plan 
denied your request. The Plan says the enrollee's Plan only covers one intraoral periapical x-ray per calendar 
year. The Plan also say that payment has already been approved for one intraoral x-ray. 
 
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, intraoral x-rays are limited to one 
procedure per calendar year. The record shows that the enrollee received 3 intraoral x-rays on June 2, 2020, one 
of which was covered by the Plan, and the enrollee's intraoral x-rays benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pay for the two additional intraoral periapical x-rays provided on June 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar/sacral facet injection for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says the provided office notes clearly document bilateral lumbar radiculopathy. 
 
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 provided office notes clearly document bilateral lumbar radiculopathy. Lumbar facet loading 
maneuvers were negative and did not reproduce the enrollee's back pain. There is very significant non-facet 
pathology demonstrated on MRI imaging, including severe multilevel neural foraminal stenosis, 
circumferential disc bulge with anterior osteophyte at L1-2, diffuse degenerative disc disease, advanced 
interspace collapse with diffuse disc osteophyte complex at L4-5, left convex scoliosis, 4 mm anterolisthesis at 
L5-S1, and disc bulge with subluxation at L5-S1. Neither the physical exam nor imaging indicate the facet 
joints as the likely source of the enrollee's chronic pain. 
 
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 a lumbar/sacral facet injection for the enrollee.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for mental health services (90438) provided on July 23, 2020. 
 
You asked the Plan to pay for the mental health services. You say that you would like reconsideration because 
this claim was not paid in accordance to your contract with the Plan. The Plan denied your request. The Plan 
says that this claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has failed to substantiate their denial. The rules cited apply to Indian 
Health Services for outpatient hospitals. This appeal does not involve Indian Health services or outpatient 
hospital services. It is the burden of the Medicare Health Plan to substantiate the denial with evidence. The 
denial is not substantiated and we must find in your favor. Therefore, we decided that the Plan has to pay for 
mental health services (90438) provided on July 23, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee. 
 
You asked the Plan to pre-approve the monitor. You say that this is needed as you cannot see at all. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
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 monitor. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found you are noted to have type 2 diabetes, for which you take no medications. How often you test your blood 
glucose is not documented. There is no evidence that you use the results of blood glucose testing to self-adjust 
insulin doses multiple times per day. As such, the requested CGM is not shown to be medically necessary or 
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 monitor have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continuous glucose monitor for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Sandostatin LAR depot 20mg injection. 
 
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 no documentation of an FDA-approved indication for this injection. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the injection. Our reviewer says that the 
requested injection is not medically reasonable or necessary. Our physician reviewer found the Medicare-
approved drug compendia do not support the use of Sandostatin LAR depot 20mg injection for malabsorption, 
unspecified diarrhea and indeterminate colitis. The requested drug is not considered medically reasonable, 
necessary, safe, or effective for you. 
 
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 Sandostatin LAR depot 20mg injection.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on July 28, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
member?s terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on July 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical extraction of an erupted tooth, tooth 2 (D7210). 
 
You asked the Plan to pre-approve the dental services. You say that the plan was paying all of the dental bills 
except the oral surgery. The Plan denied your request. The Plan says this service is not covered under the plan 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
surgical extraction of an erupted tooth, tooth 2 (D7210).