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

We decided that the Plan does not have to pre-approve allograft services. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee is not a candidate for 
physical therapy. The Plan denied your request. The Plan says the clinical value has not been demonstrated. 
 
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 requested services. Our physician 
reviewer found that the requested allograft remains experimental in cases of posterior lumbar spinal fusion 
surgery. More research is needed to show safety and efficacy. 
 
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 services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve allograft services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.
You asked the Plan to pre-approve a PET scan. You say that a PET scan is medically necessary. The Plan
denied your request. The Plan says Medicare coverage criteria are not met due to the diagnosis for which it was
ordered. We overturned the Plans denial. The Plan requested a reopen and stated that we did not
apply the correct criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare does not cover a PET scan for
the initial treatment of prostate cancer. Therefore, we decided that the Plan does not have to pre-approve a
positron emission tomography (PET) scan.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network services provided from January 10, 2020, to
August 14, 2020.
You asked the Plan to pay for out of network services. You say that these services should be covered by the
Plan. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.
We overturned the Plans denial. The Plan requested a reopen and provided additional information to
show the provider is out of network. In addition, the Plan confirmed that there were no call history records on
the recorded line to show a customer service representative referred you for these services.
The Plan is correct in this case. 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 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 out of network services provided from January 10,
2020, to August 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) machine 
you purchased on November 22, 2021. 
 
You asked the Plan to pay for the CPAP machine. You say that payment was denied for this item but this 
device is necessary for your quality of life. The Plan denied your request. The Plan says the CPAP machine is 
not eligible for purchase and is therefore not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items designated by Medicare as capped rental 
items can only be rented, not purchased.  The CPAP machine you purchased is considered a capped rental item, 
so it must be rented. We looked at the file and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the CPAP machine have not been met. Therefore, we decided that the Plan does 
not have to pay for the continuous positive airway pressure (CPAP) machine you purchased on November 22, 
2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for transfer from an IRF to a SNF.
You asked the Plan to provide coverage for this transfer. You say that at the time of the appeal, SNF services
were medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not
met. We overturned the Plans denial. The Plan requested a reopen and provided additional information.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for SNF services.
Our Physician Reviewer determined SNF services would be beneficial. The Plan requested a reopen
and stated there was no medical reason to transfer from an IRF to a SNF. The medical records show you were
admitted to the IRF on September 19, 2021. You were provided with physical and occupational therapy 15
hours over a 7-day period. The length of stay was estimated to be 7 to 10 days, with an expected disposition to
the community. The Plan is correct in this case. It has been demonstrated that the services you required were
already being provided in the IRF. Medicare criteria for transfer were not met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of skilled nursing facility (SNF) services have not been met. Therefore, we
decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor. 
 
You asked the Plan to pre-approve a Freestyle Libre continuous glucose monitor. You say that this is necessary 
because the enrollee struggles to check his blood sugar. The Plan denied your request. The Plan says the 
requirements 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 
Freestyle Libre continuous glucose monitor have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Freestyle Libre continuous glucose monitor.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp (J0881). 
 
You asked the Plan to pre-approve Aranesp. You say that Retacrit is unavailable due to a national shortage. 
The Plan denied your request. The Plan says this request does not meet the Plan's Part B step therapy criteria 
for the requested drug. 
 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 Aranesp. Our reviewer says that 
Aranesp (J0881) is not medically reasonable and necessary for the enrollee. Our physician reviewer found the 
enrollee has not tried and failed the required drugs, Retacrit or Procrit. Our reviewer also found that the 
documentation does not support that Retacrit or Procrit (Epoetin Alfa) would likely be less effective, and/or 
would likely have adverse effects for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp (J0881).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for surgical services provided by
You asked the Plan to provide coverage for opt out providers. You say that there are no other providers
available to do this surgery. The Plan denied your request. The Plan says the provider requested is not in
network and is not a Medicare eligible provider. We overturned the Plans denial. The Plan requested a
reopen and confirmed that this provider is not a Medicare eligible provider.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program. The
provider in this case opted out of the Medicare program in 2013. Therefore, we decided that the Plan does not
have to provide coverage for surgical services to be provided by a provider who is not eligible to treat Medicare
enrollees.
Appeal type: Imaging
Decision: Unfavorable

We decided the Plan does not have to provide coverage for a PET scan for the enrollee.
You asked the Plan to provide coverage for a PET scan. You say that a PET scan is medically necessary. The
Plan denied your request. The Plan says PET scans are not covered for initial treatment strategy for prostate
cancer. We overturned the Plans denial. The Plan requested a reopen and stated that we did not
apply the correct criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare does not cover PET scans for
the initial treatment strategy for prostate cancer. Based on the diagnosis and the request the PET scan was
requested to determine initial treatment strategy and not reoccurrence. Medicare rules for coverage of a PET
scan have not been met. Therefore, we decided that the Plan does not have to provide coverage for a positron
emission tomography (PET) scan for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided the Plan does not have to pay for dental services provided on July 5, 2021, for code D0150.
You asked the Plan to pay for these services. You say that these dental services should be covered. The Plan
denied your request. The Plan says this benefit was applied on October 7, 2020, less than a year from the
service in question and that this service is only covered every three years. We overturned the Plans denial
because proof of payment for the services on October 7, 2020, was not included in the case file. The Plan
requested a reopen and provided proof of payment for those services.
The Plan is correct in this case. Medicare does not cover dental services. The Plan offers a dental benefit that
exceeds Medicare coverage. Though the Plan offers a dental benefit in excess of Medicare coverage, this dental
exam was not available for coverage at the time of service. Therefore, we decided that the Plan does not have
to pay for dental services provided on July 5, 2021 and billed under code D0150.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assembly and operation of pump (99190 and 99191), 
autologous blood or component (86891) and red blood cells (P9022) provided on June 16, 2021. 
 
  You asked the Plan to pay for the assembly and operation of pump (99190 and 99191), autologous blood or 
component (86891) and red blood cells (P9022). You say that the patient did not have a choice of Perfusion 
providers because our service was arranged directly with the surgeon and facility. You say that the claim 
should be reprocessed according to the patients in- network level benefits since our services are considered 
medically necessary. The Plan denied your request. The Plan says non-physician services provided to inpatients 
which must be furnished directly by the hospital or billed through the hospital under arrangements. The Plan 
also says that CPT code 36600 was not billed with an appropriate modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare pays for inpatient hospital services 
under the Inpatient Prospective Payment System (PPS). All items and non-physician services furnished to 
inpatients must be furnished directly by the hospital or billed through the hospital under arrangements. 
 
We find that the services are not supported in the medical record. Based on this information, we decided that 
Medicare rules for coverage of the assembly and operation of pump (99190 and 99191), autologous blood or 
component (86891) and red blood cells (P9022) have not been met. Therefore, we decided that the Plan does 
not have to pay for the assembly and operation of pump (99190 and 99191), autologous blood or component 
(86891) and red blood cells (P9022) provided on June 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share charged to the enrollee for skilled nursing
facility (SNF) services provided from February 1, 2021, to February 4, 2021.
You asked the Plan to waive this cost share. You say that you do not believe this cost share is correct. The Plan
denied your request. The Plan says this cost share was applied based on the services provided and the Plan
contract agreement. We overturned the Plans denial. The Plan requested a reopen and stated that
we did not apply the correct contract criteria. The Plan demonstrated that this claim processed
correctly with a payment of $969.45 to the provider and a $552.00 cost share assessed to the enrollee. You were in
the SNF from January 1, 2021, to February 4, 2021. The first 20 days were no charge. As of day 21, there was a
$184 copayment per day for continue SNF stay up to 100 days.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information (such as copayments, deductibles and coinsurance).
The contract with the Plan clearly says that you must $184 per day for days 21 to 100 of a SNF stay. The
enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a
contractual obligation the enrollee agreed to pay when the enrolled in the Plan. Therefore, we decided that the
Plan does not have to waive the cost share charged to the enrollee for skilled nursing facility (SNF) services
provided from February 1, 2021, to February 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ophthalmology consultation services to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve ophthalmology consultation services. You say that this is medically 
necessary. The Plan denied your request. The Plan says there are in-network providers available to meet your 
medical needs. 
 
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 
ophthalmology consultation services to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hot or cold packs therapy (97010) provided from August 2, 
2021, to August 20, 2021. 
 
You asked the Plan to pay for hot or cold packs therapy. You say that these services were necessary and should 
be paid. The Plan denied your request. The Plan says this service has a status indicator of "B" which means that 
payment for this service is always bundled into payment for another service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this 
case, the CPT code 97010 has a status code of B  Bundled Code. Payment for covered services are always 
bundled into payment for other services not specified. If Relative Value Units (RVUs) are shown, they are not 
used for Medicare payment. If these services are covered, payment for them is subsumed by the payment for 
the services to which they are incident. 
 
We find that CPT code 97010 is not supported in the medical record. Specifically, payment for this service is 
always bundled into payment for another service. Based on this information, we decided that Medicare rules 
for coverage of hot or cold packs therapy have not been met. Therefore, we decided that the Plan does not have 
to pay for hot or cold packs therapy (97010) provided from August 2, 2021, to August 20, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a diagnostic colonoscopy.
You asked the Plan to provide coverage for a diagnostic colonoscopy. You say that this service was necessary
and should be covered by the Plan. The Plan denied We overturned the Plans denial based on Local
Coverage Determination (LCD): Colonoscopy and Sigmoidoscopy-Diagnostic (L34614). The Plan requested a
reopen and stated that the LCD applied by us is not within the jurisdiction of Wisconsin.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that items and
services that are not medically necessary are not covered. The Plans says a diagnostic test cannot be ordered for
the purpose of surveillance or for screening. Your physician did not order this colonoscopy for symptoms
present that need treatment. At the time of the appeal, medical necessity for this colonoscopy was not
established. Based on this information, we decided that Medicare rules for coverage of a diagnostic
colonoscopy have not been met. Therefore, we decided that the Plan does not have to provide coverage for a
diagnostic colonoscopy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve grab bars for a bed. 
 
You asked the Plan to pre-approve grab bars. You say that this is necessary for the enrollee's condition. The 
Plan denied your request. The Plan says this item is not covered by Medicare or the Plan. 
 
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 grab bars for a bed.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from October 12, 2021, 
to November 10, 2021. 
 You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee 
does not meet the Medicare guidelines for coverage. 
 
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 pay for the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a 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 the skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from October 12, 2021, to November 10, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for office visits provided from January 15, 2021, to May 30, 2021.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The
Plan denied your request. The Plan says these services must be reviewed by your primary carrier at the time of
service as this Plan was your secondary insurer. We overturned the Plans denial. The Plan requested a
reopen and stated that we did not apply the correct criteria. The Plan provided documentation to show
that at the time of service they were not your primary insurer.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers
when an enrollee has another type of insurance. The Plan has met its obligation with regards to coordination of
benefits.
Specifically, the Plan has identified the primary payer at the time of service. The Plan reached out to obtain the
explanation of benefits from the other insurance carrier, but the documentation has not been submitted. The
primary insurer states this process can take up to 30 days. Once the Plan receives this information, they will
reprocess your claims. As the secondary insurer, the Plan cannot be held responsible for these services until the
primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to
pay for office visits provided from January 15, 2021, to May 30, 2021.
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 on November 6, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that you fell in your bathroom. You say that 
you needed help getting up. You say that an ambulance was called. You also say that you feel this should be 
paid. The Plan denied your request. The Plan says since there was no transport provided, there is no payable 
service. The Plan also says that the previous ambulance service was paid because you had been transported. 
 
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 November 6, 2021. 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 on November 6, 2021.