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

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested device. You say that the enrollee's blood glucose readings are 
fluctuating. The Plan denied your request. The Plan says the enrollee is not on insulin. 
 
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 use insulin 
with at least three daily injections or 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 requested 
device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires a multidisciplinary team 
approach with a coordinated plan of care at the intense level of therapy services that will provide therapy daily 
to reach their goal of getting home independently. The Plan denied your request. The Plan says the enrollee can 
safely receive the services needed in another setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and related 
accessories (E0673) provided on July 12, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and related accessories. You say that the items 
at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for 
payment for durable medical equipment have not been met. 
 
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.  
 
 
  The case record indicates that the items at issue in this appeal were provided for use outside of the home. 
Although these items may be helpful, neither Medicare nor the Plan covers equipment for use outside the 
home. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675) 
and related accessories (E0673) provided on July 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary for the enrollee to improve 
strength, endurance, mobility through daily medical oversight. The Plan denied your request. The Plan says the 
enrollee can receive the care needed in a lower level. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says the 
enrollee is not insulin treated. 
 
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 does not indicate that the enrollee uses insulin 
with at least three daily injections or requires 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 requested 
device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care office visit on October 7, 
2022. 
 
You asked the Plan to waive the copayment for an urgent care office visit. You say that in the past you have 
only had to pay $15. The Plan denied your request. The Plan says this cost sharing was charged 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 Medicare-covered urgent care facility visit.  
 
You have been asked to pay a $30 copayment for an urgent care office visit. This item/service falls within the urgently needed 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 an urgent 
care office visit on October 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for blood collection from an implant device 
provided on May 13, 2022. 
 
You asked the Plan to waive the copayment for the blood collection procedure. You say that on this date of 
service you only received blood work and should have no copayment. The Plan denied your request. The Plan 
says this cost sharing was charged 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 $350 
copayment for surgical services provided in an outpatient hospital facility.  
 
According to Medicare, code 36591 is considered a surgical procedure. You have been asked to pay $118.63, 
which is less than the standard $350 copayment for the blood collection procedure. This item/service falls 
within the outpatient surgery 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 blood 
collection from an implant device provided on May 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an adjunctive pre-diagnostic test for mucosal abnormalities 
(D0431) provided on December 7, 2022. 
 
You asked the Plan to pay for an adjunctive pre-diagnostic test. You say that you would like the Plan to pay for 
this. The Plan denied your request. The Plan says the rendered dental service is not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 an 
adjunctive pre-diagnostic test for mucosal abnormalities (D0431) provided on December 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Posturepedic mattress. 
 
You asked the Plan to pre-approve a Posturepedic mattress. You say that you would like the enrollee to be 
approved for a left chair mechanism and Posturepedic bed. The Plan denied your request. The Plan says a 
Posturepedic bed mattress does not serve a medical purpose and is not meant for repeated use by multiple 
patients. 
 
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. There is also no 
evidence provided that the enrollee has a hospital bed. Therefore, we decided that the Plan does not have to 
pre-approve a Posturepedic mattress.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 01, 2022. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and should be covered. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on November 01, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on 
October 27, 2022, to October 28, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that this copayment should 
be waived because you were admitted as an inpatient. The Plan denied your request. The Plan says this cost 
sharing was charged 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 $115 
copayment for Medicare-covered emergency room visits.  
 
The Plan confirmed you were under observation and not admitted as an inpatient. You have been asked to pay 
a $115 copayment for an emergency room visit. This item/service falls within the emergency care benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for an emergency room visit provided on October 
27, 2022, to October 28, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Imfinzi. 
 
You asked the Plan to pre-approve Imfinzi. The Plan denied your request. The Plan says that the drug is 
covered under Part D. 
 
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. 
 
We looked at the file and the rules. The documentation shows that the drug will be provider supplied (i.e., buy 
and bill). Thee requested medication will be an expense to the physician and will be included in the physician's 
bill. This means that the drug is eligible for Part B coverage. Based on this information, we decided that 
Medicare rules for coverage of Imfinzi have been met. Therefore, we decided that the Plan has to pre-approve 
Imfinzi.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit (99213) and an eye refraction (92015) 
provided on October 7, 2022. 
 You asked the Plan to pay for a specialist office visit (99213) and an eye refraction (92015). You say that you 
have gone to this location for 40 years. The Plan denied your request. The Plan says a refraction is only 
covered when billed as part of the routine eye exam. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers refractions when they are billed as part of the routine eye examination. 
 
We looked at the file and the Plan's rules. The Plan rules say that Original Medicare does not cover routine eye 
examinations (eye refractions) for eyeglasses/contacts. The Plan rules also say that they only cover refractions 
when they are billed as part of the routine eye examination. The record shows that this was not a routine 
examination and refraction, but a medical eye examination and refraction. Based on this information, we 
decided that the Plan's rules for coverage of a specialist office visit (99213) and an eye refraction (92015) have 
not been met. Therefore, we decided that the Plan does not have to pay for a specialist office visit (99213) and 
an eye refraction (92015) provided on October 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on October 
07, 2022. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you were never seen at the 
urgent care. The Plan denied your request. The Plan says this cost sharing was charged 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 $40 
copayment for urgently needed services. 
 
You have been asked to pay a $40 copayment for an urgent care visit. This item/service falls within the 
urgently needed 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 an urgent 
care visit provided on October 07, 2022.
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 the services are necessary for the 
enrollee to advance to functional status and return to baseline. The Plan denied your request. The Plan says the 
enrollee does not meet the requirements for approval. 
 
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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the 
current acute care 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 receiver. 
 
You asked the Plan to pre-approve a Dexcom G6 receiver. You say that the requested Dexcom is medically 
necessary. The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
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 use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
Dexcom G6 receiver have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Dexcom G6 receiver.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), prophylaxis (D1110), 
and intraoral imaging (D0220), provided by an out-of-network provider, on August 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services have been covered before. The 
Plan denied your request. The Plan says the dental services were received from an out-of-network provider and 
are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a periodic oral evaluation (D0120), prophylaxis (D1110), and intraoral imaging (D0220), provided 
by an out-of-network provider, on August 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a specialist office visit provided on October 
10, 2022. 
 
You asked the Plan to waive the cost share for a specialist office visit. You say that you disagree with the cost 
share. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $250 deductible and a $40 copayment which applies to 
physician/practitioner services/specialist.  
 
The item or service you asked the Plan to waive the cost share for falls within the physician/practitioner 
services/specialist benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract 
that there is a $250 deductible and a $40 copayment which applies to physician/practitioner services/specialist. 
You are being asked to pay $76.27 towards your $250 deductible. The total amount you are being asked to pay 
$116.27 ($76.27 + $40 = $116.27). This cost sharing is a contractual obligation that had not been met at the 
time a specialist office visit was received on October 10, 2022. Therefore, we decided that the Plan does not 
have to waive the cost share for a specialist office visit provided on October 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction (92015) on November 18, 2022. 
 
You asked the Plan to pay for an eye refraction (92015). You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says eye refractions are only covered by your plan if 
performed by a participating Plan vendor provider and performed as a routine screening. 
 Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when refractions are performed during a routine examination. 
 
We looked at the file and the Plan's rules. The Plan rules say that they cover eye refractions during a routine 
examination. Based on this information, we decided that the Plan's rules for coverage of an eye refraction 
(92015) have not been met. Therefore, we decided that the Plan does not have to pay for an eye refraction 
(92015) on November 18, 2022.