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

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation (A0170). 
 
You asked the Plan to pre-approve additional mileage for routine transportation. You say that you need 
transportation to get to a medical appointment. The Plan denied your request. The Plan says your benefit only 
allows 50 miles. 
 
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 routine transportation up to 36 one-way trips per year, with each one-way trip not to 
exceed 50 miles. 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, the provider is 
located 84 miles from your residence. The Plan only covers up to 50 miles for each one-way trip. Therefore, we 
decided that the Plan does not have to pre-approve additional mileage for routine transportation (A0170).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3000, L3030). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says these items are not a covered benefit for the enrollee's 
condition. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
The records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate, neither Medicare nor the Plan provides coverage of orthotics for his 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3000, L3030).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided from October 6, 2021, through 
October 13, 2021, at DRG 871. 
 
You asked the Plan to pay for inpatient services at DRG 871. You say that principal diagnosis code A41.9 is 
clinically validated and coded correctly. You say that you disagree with the DRG change and request reversal 
of the downgrade. The Plan denied your request. The Plan says principal diagnosis code A41.9 is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services with principal diagnosis code A41.9, defined as sepsis, 
unspecified. 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 pay for inpatient services at DRG 871. Our 
reviewer says that the documentation does not support principal diagnosis code A41.9. Our physician reviewer 
found that there was no documentation of sepsis in the medical records.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient services provided from October 6, 2021, through October 13, 2021, at DRG 871.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a commode chair. 
 
You asked the Plan to pre-approve a commode chair. You say that this is necessary for your condition. The 
Plan denied your request. The Plan says the criteria for coverage of this item have not been met. 
 
The Plan must follow Medicare rules. The rules say that a commode chair is covered only for enrollees who are 
confined to a bed or room. 
 
The file does not show that you are confined to a bed or room as defined by Medicare rules. Therefore, we 
decided that the Plan does not have to pre-approve a commode chair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital visit services provided on January 6, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for hospital visit services. You say that you would like to request reconsideration of 
the denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
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 hospital visit services provided on January 6, 
2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental inlay - porcelain/ceramic (D2630) provided on 
September 30, 2021. 
 
You asked the Plan to pay for the dental inlay. You say that this service code is covered. The Plan denied your 
request. The Plan says the dental inlays are not covered under your supplemental benefit. 
 
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 the dental 
inlay - porcelain/ceramic (D2630) provided on September 30, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 24 additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation. You say that this transportation is 
necessary for your condition. The Plan denied your request. The Plan says the benefit for routine transportation 
has been exhausted. 
 
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 24 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 24 additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the application of desensitizing medicaments (D9910 x 2) 
provided April 7, 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 the application of desensitizing medicaments (D9910) is 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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
application of desensitizing medicaments (D9910 x 2) provided April 7, 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 appellant says please find clinical 
documents to support the request for authorization of LTACH admission for 14 days. The Plan denied your 
request. The Plan says the enrollee is receiving appropriate in-patient acute care and is currently unstable for 
transfer to an LTACH. 
 
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 was admitted to the acute care hospital with sepsis, pneumonitis, 
NSTEMI (non-ST-elevation myocardial infarction) and acute respiratory failure requiring IV antibiotics, 
mechanical ventilation, and fluids. A tracheostomy tube and percutaneous endoscopic gastrostomy feeding tube 
was placed. Recent notes describe the enrollee as now tolerating trach collar during the day but still on pressure 
support ventilation at night, however, with worsening pneumonia and unresolved ileus requiring additional 
treatment and monitoring. The enrollee appears to be somewhat unstable and should only require short-term additional acute care services that can be safely administered at the current facility until more stable and 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current facility. There are no services at the LTACH that the enrollee requires that are not 
already available and covered at the current facility. Transfer to the LTACH is not medically necessary as the 
enrollee is not yet stable for transfer and as it would not be clinically advantageous at this time. Completion of 
treatment at the current facility is recommended. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 23, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on April 19, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a hospital outpatient clinic visit. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-
network, and it was determined these services were not urgent or emergent. 
 
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 a hospital outpatient clinic visit provided on April 
19, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oxygen equipment (E1392) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the oxygen equipment. You say that the network providers do not have the 
specific oxygen equipment desired. The Plan denied your request. The Plan says there are network providers 
than can provide comparable equipment. 
 
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 at issue in this appeal. We found no exception that would require the Plan 
to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve oxygen 
equipment (E1392) to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Sotalol. 
 
You asked the Plan to pre-approve Sotalol. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical 
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 Sotalol.  
 
Benefits for Sotalol 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal maintenance (D4910) and a comprehensive 
oral evaluation (D0150) provided by a periodontist. 
 
You asked the Plan to pre-approve periodontal maintenance and an evaluation. You say that your dentist will 
not see you until you consult with a periodontist. The Plan denied your request. The Plan says the requested 
services are not covered by a periodontist. 
 
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 when received by a periodontist. Therefore, we decided that the Plan 
does not have to pre-approve periodontal maintenance (D4910) and a comprehensive oral evaluation (D0150) 
provided by a periodontist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontic-porcelain/ceramic (D6245) and a retainer fixed 
partial denture retainer crown - porcelain/ceramic (D6740). 
 
You asked the Plan to pre-approve pontic-porcelain/ceramic (D6245) and a retainer fixed partial denture 
retainer crown - porcelain/ceramic (D6740). You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the services requested are not covered 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, 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 
pontic-porcelain/ceramic (D6245) and a retainer fixed partial denture retainer crown - porcelain/ceramic 
(D6740).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93880 billed for date of service March 12, 
2022. 
 
You asked the Plan to pay for procedure code 93880. You say that the decision should be reconsidered, and the 
claim processed for payment. The Plan denied your request. The Plan says procedure codes 93979 and 93931 
have been paid. The Plan also says payment for code 93880 is bundled into payment for code 76536. 
  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 93880 
is a column II code to column I code 76536. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 93880 billed for date of service March 12, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Letairis 10mg tablets. 
 
You asked the Plan to pre-approve Letairis. You say that Letairis is medically necessary. The Plan denied your 
request. The Plan says this drug is not eligible for coverage under the Part B medical 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 Letairis 10mg tablets.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction of tooth #3 and 19 (D7210) and additional 
periapical x-rays (D0230) provided on March 23, 2022. 
 
You asked the Plan to pay for extractions and x-rays. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says extractions are not covered by your dental benefits. The 
Plan also says that your benefit for periapical x-rays 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, extractions are not among those 
covered under this benefit. The record shows your benefit for periapical x-rays was exhausted on date of 
service March 23, 2022. Therefore, we decided that the Plan does not have to pay for an extraction of tooth #3 
and 19 (D7210) and additional periapical x-rays (D0230) provided on March 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided 
on December 17, 2021. 
 
You asked the Plan to pay for an evaluation. You say that you disagree with the denial of dental services. The 
Plan denied your request. The Plan says a comprehensive periodontal evaluation (D0180) is not covered by 
your routine 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, 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 a 
comprehensive periodontal evaluation (D0180) provided on December 17, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve protein-bound Paclitaxel. 
 
You asked the Plan to pre-approve the requested drug. You say that the enrollee needs to get started on 
treatment as soon as possible. The Plan denied your request. The Plan says the enrollee has not tried and failed 
Taxol (paclitaxel) or Taxotere (docetaxel). 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested drug. Our physician 
reviewer found that the enrollee has stage IV breast cancer. Abraxane (protein bound paclitaxel) has been 
requested. The Plan requires a trial of Taxol (paclitaxel) or Taxotere (docetaxel) before they will approve the 
requested drug. In this case, the enrollee has not tried and failed the required drugs. There is no documentation 
provided indicating that the Plans 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 the requested drug have not been met. Therefore, we decided that the Plan does 
not have to pre-approve protein-bound Paclitaxel.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that this device is medically necessary. 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 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 therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
therapeutic continuous glucose monitor (CGM).