Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services provided on April 4, 2022. 
 
You asked the Plan to pay for the lab services. You say that this testing was performed as ordered by the 
treating provider. You submitted the results to support the testing was completed. The Plan denied your 
request. The Plan says that laboratory testing is not a Medicare benefit when done without documentation of 
medical indication from the treating provider. Requests to obtain this documentation were not successful. 
 
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. 
 
The enrollee was referred for the lab services by a contract provider. The file does not show that the plan 
provided notice that the lab services would not be covered. Though the Plan notes that attempts were made to 
obtain documentation, such requests were only made to the referring provider. The lab provider was not given 
the opportunity to provide the documentation being sought. Additionally, such records of a network provider 
are deemed under the Plan's control, and failure to obtain them cannot be held against the appealing provider. 
Under Medicare rules, this means the lab services is considered approved by the plan. Therefore, we decided 
that the Plan has to pay for the lab services provided on April 4, 2022.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 25, 2022, billed with 
code 0037U. 
 
You asked the Plan to pay for the genetic testing. You say that this is a Medicare-covered test which was 
medically necessary. The Plan denied your request. The Plan says the required Z-code was not reported on the 
claim. As such, this was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the coverage status is listed in the DEXTM Diagnostics Exchange. The unique identifier must be reported on the 
claim. 
 
We looked at the file and Medicare rules. Review of the claim does not support that the unique identifier was 
reported. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on April 25, 
2022, billed with code 0037U.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cryoneurolysis using the Iovera system for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says Medicare does not cover procedures that are experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this is considered an experimental/investigational procedure. Therefore, the request is deemed 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve cryoneurolysis using the Iovera system for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Libre receiver and sensors (CGM). 
 
You asked the Plan to pre-approve the Freestyle Libre CGM. You say that the enrollee is able to control 
diabetes with the Freestyle Libre sensor. When off of it the enrollee does not do well and their health drops. 
The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for the requested 
device. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 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, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the Freestyle Libre CGM have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the Freestyle Libre receiver and sensors 
(CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve new simply thick easy gel mix. 
 
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your 
request. The Plan says oral supplements are not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve new simply thick easy gel mix.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
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 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 patients 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 these services. Our reviewer says that 
the criteria for coverage are not met. Our physician reviewer found the records show that the enrollee has a 
personal mobility deficit that impairs participating in mobility-related activities of daily living (MRADLs) in 
the home; however, there is no documentation that the mobility deficit cannot be helped by the use of an 
upright walker. The mobility evaluation on July 21, 2022 states that the upright walker meets her mobility 
needs in the home. The criteria for coverage are not met; therefore, the power scooter is 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 a power scooter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667) for the 
enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says no swelling has been reported in the area of the chest, trunk, or abdomen. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no documentation of lymphedema of the chest, trunk, or abdomen. The provided records do 
not document lymphedema of the chest, trunk, or abdomen on any of the examinations in the medical notes 
provided. As records do not document trial and failure of a standard pneumatic compression pump, then it 
cannot be said that the enrollee has unique characteristics that would indicate a segmented pump over a 
standard pump. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device (E0652, E0667) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair ramp/lift. 
 
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 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. Therefore, we 
decided that the Plan does not have to pre-approve a wheelchair ramp/lift.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve computed tomography (CT) colonography. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says that Medicare does not cover this study for the purpose of screening for disease of the 
colon or rectum. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 the scan. Our reviewer says that the 
requested scan is medically reasonable and necessary. Our physician reviewer found that you are 94 with 
chronic obstructive pulmonary disease (COPD) and are on long-term anticoagulants. Your history is such that 
the entire colon needs to be screened. You have right lower quadrant pain. Due to your advanced age and 
comorbidities, this CT colonography would provide the most information with the lowest risk and should be 
approved. 
 
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 scan have been met. Therefore, we decided that the Plan has to pre-approve 
computed tomography (CT) colonography.  
 
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 the physician services provided on April 22, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the physician services provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network 
care. 
 
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 had network providers available who could have provided 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 physician services provided on April 22, 2022, 
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional trips. You say that you need additional rides for medical 
appointments. The Plan denied your request. The Plan says additional trips beyond the allowed amount per 
year are not covered. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 20 one-way trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are still weak and unable to do the things you 
will need to do at home without injuring yourself further. The Plan denied your request. The Plan says you 
have improved with therapy and has no further ongoing skilled nursing care needs. You have met PT goals. 
Restorative rehab completed; also, medically stable with no daily skilled needs. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found You do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Januvia. 
 
You asked the Plan to pre-approve Januvia. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not a covered 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 Januvia.  
 
Benefits for Januvia 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a skilled nursing facility stay provided from 
February 1, 2022, to February 17, 2022. 
 
You asked the Plan to waive the copayment for a skilled nursing facility stay. You say that you feel you were 
misled by both the providers and the plan. The Plan denied your request. The Plan says the copayment applied 
was correct. 
 
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 $172 
copayment per day, for days 21-60 for skilled nursing facility admission for skilled nursing facility (SNF) care.  
 
You have been asked to pay a $1376 copayment for an 8 day stay for a skilled nursing facility stay. A skilled 
nursing facility stay falls within the Skilled Nursing Facility (SNF) 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 a skilled nursing facility stay 
provided from February 1, 2022, to February 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve supply allowance used with a therapeutic CGM device 
(K0553). 
 
You asked the Plan to pre-approve the CGM supply allowance. You say that by using the Libre, you have been 
able to get your hemoglobin A1C down. You are a brittle diabetic. Your glucose level goes up to 250-300 with 
one slice of bread. The Plan denied your request. The Plan says based on the clinical information provided, this 
request is not reasonable or necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan.  
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, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the CGM supply allowance have not been met. 
Therefore, we decided that the Plan does not have to pre-approve supply allowance used with a therapeutic 
CGM device (K0553).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance service on May 12, 2022. 
 
You asked the Plan to waive the copayment for ambulance. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing you are being charged is correct. 
 
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 $350 
copayment per one-way trip for Medicare-covered ambulance services. Covered ambulance services include 
fixed wing, rotary wing, and ground ambulance services, to the nearest appropriate facility that can provide 
care if they are furnished to a member whose medical condition is such that other means of transportation could 
endanger the persons health or if authorized by the plan. 
 
 
 
 You have been asked to pay a $350 copayment for ambulance. Ambulance fall within the Ambulance services 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for ambulance service on May 12, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a prescription infusion provided on May 
28, 2022. 
 
You asked the Plan to waive the coinsurance for a prescription infusion. You say that you were unaware that 
there was such a large coinsurance for this item. The Plan denied your request. The Plan says the coinsurance 
that was applied was correct. 
 
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 20% 
coinsurance for Medicare Part B prescription drugs. The allowed amount of this item was $4,973.06 x 20% = 
$945.15, which is slightly less than the 20% minimum. 
 
You have been asked to pay a $945.15 coinsurance for a prescription infusion. A prescription infusion 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 a prescription infusion provided on May 28, 2022.