Persius/hicric huggingface dataset:
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bed rails. 
 
You asked the Plan to pre-approve bed rails. You say that you are having issues getting out of bed. The Plan 
denied your request. The Plan says these bed rails are not covered by Medicare unless they are an integral part 
of a hospital bed. 
 
The Plan must follow Medicare rules. Medicare rules say that side rails may be covered when they are an 
integral part of  or accessory to  a covered hospital bed.  
 
We looked at the file and Medicare rules. These side rails are not being requested as part of a covered hospital 
bed. Based on this information, we decided that Medicare rules for coverage of bed rails have not been met. 
Therefore, we decided that the Plan does not have to pre-approve bed rails.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are not stable when walking. The Plan denied 
your request. The Plan says the request is not medically necessary. 
 
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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 IRF admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided June 21, 2022. 
 
You asked the Plan to pay for the ambulance response. You say that you did not need to be transported to the 
hospital. The Plan denied your request. The Plan says this service is not covered when there is no transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 21, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport (A0998) provided June 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an eye prosthetic to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an eye prosthetic. You say that the requested item is a medical necessity for 
you. The Plan denied your request. The Plan says rules for coverage for OON care have not been met. 
 
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 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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an eye prosthetic 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 pay for prophylaxis (D1110) provided by an out-of-network provider 
on May 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. 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 prophylaxis (D1110) provided by an out-of-network provider on May 24, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH admission is the safest and most 
efficient level of care based on the enrollee's complexity and history. The Plan denied your request. The Plan 
says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee 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 LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total hip arthroplasty to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a total hip arthroplasty. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for OON care have not been met. 
 
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 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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a total hip arthroplasty to be provided by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 25, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on August 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the admission day doctor service provided on February 10, 
2022. 
 
You asked the Plan to pay for the admission day doctor service. The Plan denied your request. The Plan says 
you were enrolled in hospice through February 9, 2022, and traditional Medicare needs to be billed for this 
service. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on February 9, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the admission day 
doctor service provided on February 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), treatment of a root canal 
obstruction on tooth #3 (D3331), and a pulp vitality test on tooth #3 (D0460) provided on June 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says your annual dental maximum has been met. The Plan also says 
that treatment of a root canal obstruction (D3331) and a pulp vitality test (D0460) are not covered by your 
dental 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, treatment of a root canal obstruction 
(D3331) and a pulp vitality test (D0460) are not among those covered under this benefit.  
 
The record shows that your annual dental maximum has been met. You have been asked to pay $107 for a 
limited oral evaluation. 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 a limited oral evaluation (D0140), treatment of a 
root canal obstruction on tooth #3 (D3331), and a pulp vitality test on tooth #3 (D0460) provided on June 22, 
2022.
Appeal type: Hospice
Decision: Favorable

 
We decided that the Plan has to pay for subsequent hospital care provided on March 31, 2022. 
 
You asked the Plan to pay for the hospital care. The Plan denied your request. The Plan says that they are not 
responsible for payment because the member was enrolled in hospice at the time services were provided. 
 
The Plan must follow Medicare rules. Medicare rules say that the Plan in effect at the time of inpatient 
admission is responsible for payment of inpatient services until the date of the enrollees discharge.  
 
We looked at the file and Medicare rules. Although the record shows the enrollee elected hospice coverage as 
of March 31, 2022, the enrollee was still an inpatient on that date. Therefore, we decided that the Plan has to 
pay for subsequent hospital care provided on March 31, 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: Favorable

 
We decided that the Plan has to waive the copayment for laboratory services provided on May 16, 2022. 
 
You asked the Plan to waive the copayment for laboratory services. You say that you received a bill for the 
laboratory services provided. You say that all the tests you received were routine. The Plan denied your 
request. The Plan says that 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 enrollees must pay $0 copayment for monitoring or routine Medicare-covered 
lab services including, but not limited to A1C, cholesterol/lipid panel screenings and complete blood count.  
 
The Plan says you must pay a $25 copayment for laboratory services. Based on the Plan contract, however, you 
cannot be asked to pay more than $0 copayment for monitoring or routine Medicare-covered laboratory 
services. The enrollee and the Plan both acknowledge a history of laboratory services completed for Vitamin D 
testing, which can infer the test is performed for monitoring purposes. Therefore, we decided that the Plan has 
to waive the copayment for laboratory services provided on May 16, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an Elvie electronic breast pump (E1399). 
 
You asked the Plan to pay for the Elvie electronic breast pump. You say that this pump is medically necessary. 
The Plan denied your request. The Plan says the requested pump is a deluxe or upgraded version of the 
standard breast pump that is covered. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of an Elvie electronic breast pump 
(E1399). have been met. No clinical records were submitted to support the request. There are no medical 
records provided to support that the standard equipment offered by the plan would not meet the enrollee's 
needs. Therefore, we decided that the Plan does not have to pay for an Elvie electronic breast pump (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy. 
 
You asked the Plan to pre-approve massage therapy. You say that massage therapy is necessary to work out 
your muscles. The Plan denied your request. The Plan says massage therapy does not meet the Plan's Medical 
Policy and is not medically necessary or standard of care. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve massage therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high back feature for a power scooter (K0108) and 
repair costs (K0739). 
 
You asked the Plan to pre-approve the high back feature and associated repair costs. You say that this change is 
medically necessary. The Plan denied your request. The Plan says the requested modification is not for a 
medical purpose and is for comfort. This feature is non-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. 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 a high back feature for a power scooter (K0108) and repair 
costs (K0739).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
appliances (E0667x2) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a pneumatic compression device and appliances. You say that this requested 
device cannot be obtained through the Plan's in-network provider. The Plan denied your request. The Plan says 
the enrollee must use network providers to get her medical care and services. 
 
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 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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a pneumatic compression device (E0652) and segmental appliances (E0667x2) to be provided by an out-of-
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Boost 3 nutritional drinks. 
 
You asked the Plan to pre-approve the Boost 3 drinks. You say that you have needed this supplement for years 
due to your history of being low weight related to sickle cell anemia. You believe that this should be covered. 
The Plan denied your request. The Plan says Medicare only covers nutritional formulas given through a feeding 
tube. Orally administered nutritional products are noncovered. 
 
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 Boost 3 nutritional drinks.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a laminotomy (63030). 
 
You asked the Plan to pre-approve the laminotomy. You say that this procedure is medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the laminotomy. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documentation of second line treatment with injection therapy. More conservative 
measures such as injection therapy are needed before surgical treatment can be considered. 
 
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 laminotomy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a laminotomy (63030).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) receiver and 
monitor (K0554). 
 
You asked the Plan to pre-approve a CGM receiver and monitor. You say that the requested device is necessary 
for the enrollee's condition. The Plan denied your request. The Plan says the enrollee does not meet coverage 
criteria for approval of 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 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 a CGM 
receiver and monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor (CGM) receiver and monitor (K0554).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monoferric. 
 
You asked the Plan to pre-approve Monoferric. The Plan denied your request. The Plan says the enrollee has 
not tried and failed Infed and Venofer. 
 
 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 Monoferric. Our physician reviewer 
found that the enrollee has iron-deficiency anemia. The Plan requires a trial of Infed and Venofer before they 
will approve the requested drug. There is no indication that the enrollee has tried and failed the required drugs. 
There is no indication that the Plan's required drugs would likely be less effective or likely have adverse effects 
for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Monoferric have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Monoferric.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair glide. 
 
You asked the Plan to pre-approve a stair glide. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair glide.