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

 We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor. 
 
You asked the Plan to pre-approve a Dexcom G6 continuous glucose monitor. You say that this is medically 
necessary. The Plan denied your request. The Plan says this brand is not covered. 
 
The Plan follows Medicare rules. Medicare rules say that Medicare Advantage (MA) plans may specify brands 
and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the Durable 
Medical Equipment (DME) to only those preferred brands and manufacturers, as long as the conditions listed in 
the rules section are met. 
 
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 a Dexcom G6 continuous glucose 
monitor. Our reviewer says that the requested brand of continuous glucose monitor is not medically necessary. 
Our physician reviewer found the records do not contain sufficient information to show why the enrollee needs 
a Dexcom device instead of the Plan's preferred brand. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Dexcom G6 continuous glucose monitor have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics. 
 
You asked the Plan to pay for foot inserts. You say that you would like reconsideration because the requested 
foot inserts are medically necessary. The Plan denied your request. The Plan says the requested foot inserts are 
not a covered benefit. 
 
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.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intensity modulated radiation therapy (IMRT) services. 
 
You asked the Plan to pre-approve IMRT services. You say that the requested services are a medical necessity 
for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
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 IMRT services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the use of IMRT for palliation is not standard of care for routine palliation and not 
supported in the case file. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IMRT services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve IMRT services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on June 07, 
2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you were charged for a one-
day inpatient hospital copayment and you were never an inpatient. The Plan denied your request. The Plan says 
this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers. 
 
You have been asked to pay a $295 copayment for outpatient surgery. This item/service falls within the 
outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical 
centers benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.  Therefore, we decided that the Plan does not have to waive the copayment for outpatient surgery provided on 
June 07, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Disposable drug delivery system (A4306) provided on 
March 15, 2022. 
 
You asked the Plan to pay for procedure code A4306. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says a disposable drug delivery system coded as 
A4306 is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say disposable drug delivery systems coded as A4306 are 
non-covered devices because they do not meet the Medicare definition of durable medical equipment. 
Therefore, we decided that the Plan does not have to pay for the Disposable drug delivery system (A4306) 
provided on March 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upper extremity addition, additional disconnect 
insert for locking wrist unit, each (L6616). 
 
You asked the Plan to pre-approve the disconnect insert. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says a second disconnect insert 
exceeds your needs and cannot be covered. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have L6615 (disconnect locking wrist unit). L6615 serves the same purpose as the 
disconnect insert. Therefore, we decided that the Plan does not have to pre-approve the upper extremity 
addition, additional disconnect insert for locking wrist unit, each (L6616).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Coflex interlaminar stabilization device (22867). 
 
You asked the Plan to pre-approve the Coflex device. You say that this device is medically necessary due to the 
enrollee's diagnosis and failure to adequately respond to multiple non-surgical treatments. The Plan denied your 
request. The Plan says the 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 looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Coflex device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the Coflex interlaminar stabilization device (22867).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 14, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. 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 May 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve these services. You say that the bed is needed for your care. The Plan 
denied your request. The Plan says the item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visit to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve office visit. You say that you are scared to have surgery with another 
surgeon and that he has already done surgery on you twice. The Plan denied your request. The Plan says there 
are participating providers in your network. You do not have out of network benefits. 
 
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 
office visit to be provided by an out-of-network (OON) provider.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transcutaneous electrical nerve stimulation (tens) device, 
four or more leads, for multiple nerve stimulation (E0730) provided May 25, 2022. 
 
You asked the Plan to pay for the TENS device. You say that according to the enrollee's prescription, the 
prescribing physician recommends a(n) extended/ lifetime use of equipment as they are diagnosed with chronic 
pain and compromised mobility without the option for surgical correction. The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician, 
there was no claims submitted for an evaluation and management service and there is no evidence of a prior 
telehealth service with the ordering physician as required per CMS guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for transcutaneous electrical 
nerve stimulation (tens) device, four or more leads, for multiple nerve stimulation (E0730) provided May 25, 
2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve computed tomography (CT), of the thorax, diagnostic; with 
contrast material(s) (71260). 
 
You asked the Plan to pre-approve this service. You say that a CT scan of the chest is medically necessary for 
the enrollee. The Plan denied your request. The Plan says that a CT scan of the chest is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 this service. Our reviewer says that the 
requested service is medically necessary. Our physician reviewer found that the enrollee has recently been 
diagnosed with seronegative Rheumatoid arthritis for which she is treated with Prednisone and Methotrexate. 
Rheumatoid arthritis may affect the lungs with an interstitial disease pattern and in a patient on Prednisone the 
prevalence of compression insufficiency fractures is well known; this patient has back pain. Her thoracic spine 
will be visible on the CT scan of the chest which allows for analysis of a possible compression fracture in 
addition to analysis of the lungs and mediastinum. She also has a history of diverticulitis so the examination of 
the abdomen and pelvis is important. All of these factors provide ample indications for the requested CT scans 
of the chest, abdomen, and pelvis. The denied CT scan of the chest should be approved.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have been met. Therefore, we decided that the Plan has to pre-
approve computed tomography (CT), of the thorax, diagnostic; with contrast material(s) (71260). 
  
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve FreeStyle Libre 3 sensor. 
 
You asked the Plan to pre-approve FreeStyle Libre 3 sensor. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that CGM devices that do not meet the definition of a 
therapeutic CGM as defined in CMS Ruling 1682R will be denied as non-covered (no benefit).   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of FreeStyle Libre 3 sensor have not been met. Specifically, the requested CGM device does not meet 
the definition of a therapeutic CGM. Non-Therapeutic CGMs are not covered by Medicare or the Plan. 
Therefore, we decided that the Plan does not have to pre-approve FreeStyle Libre 3 sensor.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cardiomyopathy risk panel (81286, 81403, 81404, 81405, 
81406, 81407, 81408, 81439) provided on January 18, 2022. 
 
You asked the Plan to pay for a cardiomyopathy risk panel. You say that this is supported in the records. The 
Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular 
(CV) risk assessment panels, except the basic lipid panel, for symptomatic and asymptomatic patients. 
 
We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not 
covered. Based on this information, we decided that Medicare rules for coverage of a cardiomyopathy risk panel have not been met. Therefore, we decided that the Plan does not have to pay for a cardiomyopathy risk 
panel (81286, 81403, 81404, 81405, 81406, 81407, 81408, 81439) provided on January 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for podiatry office visit provided on February 
15, 2022. 
 
You asked the Plan to waive the copayment for podiatry office visit. You say that you disagree with the cost of 
the copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $25 copayment for Podiatry Services.  
 
The enrollee has been asked to pay a $25 copayment for podiatry office visit. This item/service falls within the 
Podiatry Services benefit category. This means that 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 
upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
podiatry office visit provided on February 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar facet joint radiofrequency ablation procedure.  
You asked the Plan to pre-approve a lumbar facet joint radiofrequency ablation procedure. You say that the 
services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 
coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a diagnostic facet joint procedure is covered when 
specific criteria are met. 
 
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 a lumbar facet joint radiofrequency 
ablation procedure. Our reviewer says that the services are not medically necessary. Our physician reviewer 
found the NCD and LCD require 2 sets of diagnostic medial branch blocks (MBBs) which produce 80% pain 
relief. The second set has not been done. Therefore, the request is deemed not medically reasonable and 
necessary at this point. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a lumbar facet joint radiofrequency ablation procedure have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a lumbar facet joint radiofrequency ablation 
procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit provided on August 24, 2022. 
 
You asked the Plan to pay for a specialist office visit. You say that this claim should be covered. You also say 
that you do not feel that you had an extensive evaluation at your first visit. The Plan denied your request. The 
Plan says if you get services that are excluded, you must pay for them yourself. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for a specialist office visit provided on August 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on February 04, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of our plans network) will not be covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The 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 office visit provided on February 04, 2022, by an 
out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an ultrasound (76641) provided on March 
29, 2022. 
 
You asked the Plan to waive the coinsurance for the ultrasound. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 30% 
coinsurance for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a 30% coinsurance for the ultrasound ($46.46). This item/service falls within the 
Outpatient diagnostic tests and therapeutic services and supplies 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 an ultrasound (76641) provided on March 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you do not want to go to the recommended 
provider the Plan approved. The Plan denied your request. The Plan says out-of-network services are not 
approved unless they are not available in-network or are emergent. The Plan also says that they have approved 
an in-network provider for this service. 
 
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 office visit to be provided by an out-of-network (OON) provider.