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

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with multiple 
power options including a power tilt/recline seating system. 
 
You asked the Plan to pre-approve the Group 3 PWC with multiple power options. You say that the requested 
PWC should be approved. The Plan denied your request. The Plan says the PWC base code cannot be approved 
as the multiple power option criteria are not met. 
 
The Plan follows Medicare rules. Medicare rules say that a PWC with multiple power options is only covered 
when the criteria for a power tilt and recline seating system are met, or the enrollee requires a mounted 
ventilator.  
 
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 Group 3 PWC with multiple power options. Our reviewer says that the requested PWC base is not considered reasonable and necessary based on 
LCD criteria. Our physician reviewer found the enrollee is a 68-year-old female with a past medical history of 
a stroke who requires a power wheelchair for mobility. Based on the medical records provided there is no 
documentation that the enrollee meets the criteria for the power tilt and recline seating system. Records do not 
document the enrollee requires self-catherization, has muscle spasticity, or is at high risk of skin 
breakdown. There is also no documentation that the enrollee requires a mounted ventilator. 
 
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 Group 3 PWC with multiple power options have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with multiple power 
options including a power tilt/recline seating system.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Coflex device. 
 
You asked the Plan to pre-approve these services. You say that your doctor has recommended this device. The 
Plan denied your request. The Plan says that the requested Coflex lumbar interspinous decompression device is 
unproven and not medically necessary due to insufficient evidence of efficacy. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The Coflex device is 
experimental. More research is needed, and high failures have been reported. Our physician reviewer found 
that your condition does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Coflex device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve the dental items. You say that all of your teeth have been extracted. You 
also say that you are not able to afford dentures on your own. The Plan denied your request. The Plan says 
complete or partial dentures are covered once every 5 years. The Plan also says that the frequency limit has 
been exceeded. 
 
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 and dentures are listed as covered, the 
frequency limit of once every 5 years has been exceeded. The record shows that the Plan paid for partial 
dentures that you received on September 24, 2020. Therefore, we decided that the Plan does not have to pre-
approve a complete upper denture (D5110) and a complete lower denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endosteal implant (D6010) for tooth # 30. 
 
You asked the Plan to pre-approve the dental service. You say that an implant is necessary to prevent the 
enrollee's teeth from shifting and other more serious issues. The Plan denied your request. The Plan says 
endosteal implant is not listed as a covered service. The Plan also says that you are not enrolled in the optional 
supplemental dental rider. 
 
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 endosteal implant is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
endosteal implant (D6010) for tooth # 30.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pulmonary rehabilitation (PR) services. 
 
You asked the Plan to pre-approve pulmonary rehabilitation services. You say that the requested services are 
medically necessary. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary PR programs 
for those with moderate to very severe COPD. There must be a referral from the doctor treating the disease.  
 The services must be provided in a doctors office or an outpatient hospital setting. The PR program must 
include specific components. Benefits are limited to a maximum of 36 visits, with an additional 36 visits if 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve pulmonary rehabilitation services. Our 
reviewer says that the requested pulmonary rehabilitation (PR) is not medically necessary. Our physician 
reviewer found that the enrollees condition is suspected to be related to previous coronavirus pneumonia. The 
reviewer found that there were no pulmonary function tests in the records. Therefore, the reviewer found that 
the requested pulmonary rehabilitation is considered not medically. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of pulmonary rehabilitation services have not been met. Specifically, the file does 
not indicate that the enrollee has COPD. Therefore, we decided that the Plan does not have to pre-approve 
pulmonary rehabilitation (PR) services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 77 miles for a total of 127 miles. 
 
You asked the Plan to pre-approve additional mileage. You say that you can no longer get transportation to 
your doctor because it is over a 50 mile trip one way. You also say that you do not have other transportation 
option. The Plan denied your request. The Plan says each one-way trip must not exceed 50 miles driving 
distance. 
 
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 when each one-way trip must not exceed 50 miles of driving 
distance.  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. Therefore, we decided that the 
Plan does not have to pre-approve an additional 77 miles for a total of 127 miles.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer (J1439). 
 
You asked the Plan to pre-approve Injectafer. 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 Injectafer. Our reviewer says that 
Injectafer (J1439) is not medically reasonable and necessary for the enrollee. Our physician reviewer found the 
provided records do not indicate that the enrollee has tried and failed the Plan's preferred step one alternative. 
Our reviewer found that the record does not indicate that the enrollee has a contraindication to, or would have 
an adverse effect from the Plan's preferred step one alternative. The elements of the coverage criteria are not 
satisfied. Our physician reviewer also found that the requested service cannot be 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 Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer (J1439).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on May 21, 2021. 
 
You asked the Plan to pay for genetic testing. You say that you were compliant with Medicare regulations for 
billing the date of service and the place of service. The Plan denied your request. The Plan says the denial of 
payment for this testing is correct, because the documentation submitted does not support the Place of Service 
(POS) code billed. 
 The Plan must follow Medicare rules. Medicare rules say that 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 genetic testing 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 genetic testing provided on May 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services you received from October 28, 2021, to 
November 9, 2021. 
 
You asked the Plan to pay for the acupuncture services. You say that you were told that these services would be 
covered. The Plan denied your request. The Plan says acupuncture is not covered for anything other than 
chronic low back pain. 
 
The Plan must follow Medicare rules. For services provided on or after January 21, 2020, Medicare offers 
limited coverage for acupuncture treatments for chronic low back pain meeting certain requirements, up to 12 
sessions per 90-day period, and no more than 20 sessions per year. Your Plan follows these same rules. 
 According to the records, you received these acupuncture services for the treatment of persistent headaches, not 
for chronic low back pain.  Neither Medicare nor your Plan covers acupuncture services for this condition. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Therefore, we decided that the Plan does not have to pay for 
acupuncture services you received from October 28, 2021, to November 9, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rental and dialysis/laboratory, drugs, medical/surgical 
supplies, and hemodialysis services provided from July 5, 2021, to July 14, 2021. 
 
You asked the Plan to pay for the rental and dialysis/laboratory, drugs, medical/surgical supplies, and 
hemodialysis services. The Plan denied your request. The Plan says the enrollee was elected Hospice effective 
June 26, 2021, and terminated July 31, 2021. The Plan also says that according to the enrollee's Hospice 
benefits, these charges are to be billed to Original Medicare for processing of payment. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the rental and dialysis/laboratory, drugs, medical/surgical 
supplies, and hemodialysis services provided from July 5, 2021, to July 14, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a skilled nursing facility (SNF) stay 
provided from August 1, 2021, to August 31, 2021. 
 
You asked the Plan to waive the copayments for a skilled nursing facility stay. You say that nobody explained 
your benefits to you. You also say you were kept two weeks longer than you should have been. The Plan 
denied your request. The Plan says you have been charged the correct cost sharing amount. 
 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 $0 
copayment for days 1-20 for a skilled nursing stay. The Plan contract also says there is a $160 copayment for 
days 21-100. 
 
You are not being charged for the first 20 days you were in the SNF, from July 21, 2021, to August 9, 2021. 
According to the Plan, your out-of-pocket maximum was met for the 2021 year on August 23, 2021. Therefore, 
you have been asked to pay a total of $1,000.03 for the rest of your stay, which is less than the full copayment 
amount of $1,600 for the 10 remaining days. A skilled nursing facility stay falls within the Skilled Nursing 
Facility (SNF) Care benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for a skilled nursing 
facility stay provided from August 1, 2021, to August 31, 2021.  
 
Your complaint about staying longer than expected and the services you received are not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport provided on September 2, 2021. 
 
You asked the Plan to pay for ambulance service, basic life support, non-emergency transport provided on 
September 2, 2021. The Plan denied your request. The Plan says the ambulance transport does not meet 
Medicare coverage criteria. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance service, basic life support, non-
emergency transport provided on September 2, 2021. Our reviewer says that the ambulance transport was not 
medically reasonable and necessary. Our physician reviewer found the enrollee is a 73 year old female with 
dementia and recent treatment in the hospital for gastrostomy malfunction, altered mental status. She was 
transported from the hospital to a nursing facility non-emergently by ambulance. She was hemodynamically stable and did not require any treatment during transportation. She did not require 
one on one monitoring. The documentation does not support that other means of transport (such as stretcher 
van, wheelchair van) were contraindicated for this enrollee. The documentation does not support that the 
enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped 
ambulance can provide for safe transport. The documentation does not support that the ambulance transport 
was medically reasonable and necessary 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 ambulance service, basic life support, non-emergency transport provided on 
September 2, 2021 have not been met. Therefore, we decided that the Plan does not have to pay for ambulance 
service, basic life support, non-emergency transport (A0428, A0425) provided on September 2, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray (72110) provided on September 3, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the x-ray. You say that this bill should be paid. The Plan denied your request. 
The Plan says the claim processed correctly. Medicare rules say that plans can require enrollees to get care 
from network providers.   
The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases 
involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the x-ray (72110) provided on September 3, 2021 
by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on October 22, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. 
 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 77002 
is a column II code to column I code 71260. 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 imaging services provided to the enrollee on October 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Janumet tablets. 
 
You asked the Plan to pre-approve Janumet. You say that if Janumet is stopped, it would be detrimental to the 
enrollee's glycemic management, which you expect will worsen. The Plan denied your request. The Plan says 
Janumet tablets are a self-administered drug and falls under Part D coverage. The Plan also says that drugs 
covered under Part D are not eligible for coverage under Part B. 
 
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 Janumet tablets.  
 
Benefits for Janumet 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 pay for the two dimensional (2D) oral/facial photographic image 
(D0350) provided on January 19, 2021. 
 
You asked the Plan to pay for the 2D oral/facial photographic image. You say that you should not have to pay 
this $60 bill. You also say that your insurance is in-network with this office and provider, and this service was 
a necessary procedure. The Plan denied your request. The Plan says this service is not covered under your plan. 
 
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 two 
dimensional (2D) oral/facial photographic image (D0350) provided on January 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for renal dialysis treatment provided from 
October 1, 2021, to October 29, 2021. 
 
You asked the Plan to waive the coinsurance for renal dialysis treatment. You say that you receive dialysis due 
to COVID-19 causing kidneys to shut down. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing amount. The Plan also says that effective September 30, 2021, COVID-19 
treatment coverage returned to the pre-pandemic standard benefits.  
 
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 20% 
coinsurance for in-network renal dialysis services.  
 
 The record shows effective September 30, 2021, COVID-19 treatment coverage returned to the pre-pandemic 
standard benefits. You have been asked to pay $62.22, which is 20% of the allowed amount for each renal 
dialysis treatment ($311.08 allowed amount x 20% coinsurance = $62.22). You have been asked to pay a total 
of $808.86, which is 20% coinsurance for 13 renal dialysis treatment. 
 
Renal dialysis falls within the Services to Treat Kidney Disease benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the coinsurance for renal dialysis treatment provided from October 1, 2021, to October 29, 2021.