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

 
We decided that the Plan does not have to pre-approve a power wheelchair and accessories. 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested device is not a covered 
benefit when provided not in the home setting. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a power wheelchair and accessories is being requested for use in a SNF or hospital. 
Therefore, we decided that the Plan does not have to pre-approve a power wheelchair and accessories.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is not at her current level of function. 
The Plan denied your request. The Plan says the enrollee does not need an intensive program with a team of 
professionals. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found 
that the enrollee was admitted to the acute care hospital for a urinary tract infection and was discharged to a 
private home. There is ongoing weakness. Her medical problems are stable. The complexity of her nursing, 
medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
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 the enrollee is an established patient and that it 
would be beneficial for them to receive care from this out-of-network facility. The Plan denied your request. 
The Plan says the services have been requested out-of-network and there are in-network providers available to 
the enrollee for these services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit 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 Nuvail. 
 
You asked the Plan to pre-approve Nuvail. The Plan denied your request. The Plan says this drug is not eligible 
for coverage under the Part B 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 Nuvail.  
 
Benefits for Nuvail 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on October 14, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that it is the facilities responsibility to obtain 
authorization and you would like the claim reprocessed for payment for the services that were rendered. The 
Plan denied your request. The Plan says the rendering provider is an OON provider and there was no referral 
from an in-network provider or an approved authorization. Also, the service rendered was 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 home health visit provided on October 14, 2021, 
by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64629, 64628). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is experimental. 
 
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 an Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental. More research is needed to show it is safe 
and effective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64629, 64628).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on 
September 20, 2021. 
 
You asked the Plan to pay for the nursing facility care. You say that you did not receive proper notice of the 
enrollee's benefits. You also say that the medically necessary services were rendered to the enrollee in good 
faith. The Plan denied your request. The Plan says the enrollees claim would be covered under Original 
Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of 
the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the 
enrollees coverage before rendering services and to know proper billing procedures for a Medicare Advantage 
member on hospice.  
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 subsequent nursing facility care (99309) provided on 
September 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve a portable ventilator. You say that the requested device is medically 
necessary. The Plan denied your request. The Plan says the requested device does not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 portable ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has severe COPD. There 
is no ABG done as outpatient while stable to confirm chronic CO2 retention. AVAPs can be provided via 
bipap; this has not been tried at home. Medicare does not cover a home ventilator when used as bipap. 
 
 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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of inpatient mental health care from June 
24, 2022, forward. 
 
You asked the Plan to pre-approve inpatient mental health care. You say that the stay is medically necessary. 
The Plan denied your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient mental health care. Our 
physician reviewer found it did appear that the records were supervised and evaluated by a physician. Based 
upon review the records provided for the admission of this patient does not meet the criteria for June 24, 2022, forward as this patient was not shown to be a danger to themselves or others, delusions, auditory or visual 
hallucinations noted. The patient was cooperative/compliant with treatment while not showing any threats the 
safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continuation of inpatient mental health care from June 24, 2022, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lenses (V2784) and frames (V2020) provided on October 
10, 2020. 
 
You asked the Plan to pay for the lenses and frames. The Plan denied your request. The Plan says you 
purchased this eyewear on October 10, 2020 and did not submit your reimbursement forms until December 30, 
2021, which is past the allowed 12-month timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the lenses and frames was not filed until December 30, 2021. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the lenses (V2784) and frames (V2020) provided on October 10, 
2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Paragard intrauterine device (IUD). 
 
You asked the Plan to pay for an IUD. You say that a pregnancy will cost the Plan much more money than an 
IUD. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that items/services for the purposes of preventing 
conception (contraception) are not considered medically reasonable and necessary.  
 
Records show that the requested service is primarily for the purpose of contraception. The documentation does 
not show that this service is being requested to treat a specific illness/injury. As such, the Medicare rules for 
coverage of this item/service have not been met. Therefore, we decided that the Plan does not have to pay for a 
Paragard intrauterine device (IUD).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) of the head or brain (70450), 
CT of the maxillofacial area (70486), x-ray exam of the knee (73564), and x-ray exam of the lower leg (73590) 
provided on January 10, 2022. 
 
You asked the Plan to pay for the CT scans and x-rays. You say that your doctor did not get pre-authorization 
for these services, and you feel this should not fall on you. The Plan denied your request. The Plan says 
medical records were requested but not received. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the computed tomography (CT) of the 
head or brain (70450), CT of the maxillofacial area (70486), x-ray exam of the knee (73564), and x-ray exam 
of the lower leg (73590) provided on January 10, 2022. have been met. Specifically, no medical records were 
submitted with this case. Therefore, we decided that the Plan does not have to pay for the computed 
tomography (CT) of the head or brain (70450), CT of the maxillofacial area (70486), x-ray exam of the knee 
(73564), and x-ray exam of the lower leg (73590) provided on January 10, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vraylar. 
 
You asked the Plan to pre-approve Vraylar. The Plan denied your request. The Plan says your plan does not 
cover outpatient prescription drugs. 
 
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 Vraylar.  
 
 
 Benefits for Vraylar 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a FreeStyle Libre CGM. You say that the enrollee is legally blind and is not 
able to get a drip of blood on the small strip into the reader. The Plan denied your request. The Plan says the 
enrollee does not meet criteria for the requested device. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and 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 assesses 
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 CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
FreeStyle Libre continuous glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve TAVR/TAVI with prosthetic valve; percutaneous 
femoral artery approach (CPT code 33361) and inpatient hospital care. 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary due to the 
enrollee's symptoms. The Plan denied your request. The Plan says the enrollee's request is not medically 
necessary because their records show the enrollee does not have aortic stenosis, and the enrollee's records show 
they are requesting this procedure instead for aortic insufficiency. The Plan states the enrollee's records do not 
show that they are enrolled in a clinical study evaluating TAVR for this problem of aortic insufficiency. 
 
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 services. Our physician reviewer 
found guidelines would not support aortic valve replacement based on the submitted medical records. As a 
result, at this time the requested TAVR would not be considered medically necessary in this enrollee's clinical 
management based on the submitted documentation. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve TAVR/TAVI with prosthetic valve; percutaneous femoral artery approach (CPT code 
33361) and inpatient hospital care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that you are appealing the denial of the 
compression stockings. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan.  
 
 Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code 
A6549.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic radiological services 
provided on July 27, 2021. 
 
You asked the Plan to waive the copayment for the diagnostic radiological services. You say that you feel the 
cost-sharing was improperly assessed on the claim and you feel there should be no copayment. The Plan denied 
your request. The Plan says the proper copayment was applied for the service that was rendered. 
 
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 $275 
copayment for Diagnostic Radiological services performed in an Outpatient Hospital. The total amount allowed 
was $218.93 which is less than the copayment amount of $275; therefore, only $218.93 was charged as the 
copayment. 
 
  You have been asked to pay a $218.93 copayment for the diagnostic radiological services. The diagnostic 
radiological services 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 copayment for the diagnostic radiological services provided on 
July 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve breast cancer gene testing (BRCA 1, BRCA 2) (CPT 
code 81162). 
 
You asked the Plan to pre-approve the breast cancer gene testing. You say that your oncologist ordered the 
gene testing so you can be properly treated for cancer. You state that you are getting weaker by the day and 
require the testing to move forward with treatment. The Plan denied your request. The Plan says the Medicare 
rules have not been met. The Plan must follow Medicare rules. We looked at the file and Medicare rules. 
Review of records do not show that you have a known BRCA mutation in your family. Review of medical 
records do not show you have breast, ovarian, pancreatic, or prostate cancer. Based on this information, we 
decided that Medicare rules for coverage of the breast cancer gene testing have not been met. Therefore, we 
decided that the Plan does not have to pre-approve breast cancer gene testing (BRCA 1, BRCA 2) (CPT code 
81162).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cushioned floor mat. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 
 
 
 
 
 
 
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a cushioned floor mat.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuous glucose monitor (CGM) supplies. 
 
You asked the Plan to pre-approve CGM supplies. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested items. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and 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 assesses 
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 require 
frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this 
information, we decided that Medicare rules for coverage of CGM supplies have not been met. Therefore, we 
decided that the Plan does not have to pre-approve continuous glucose monitor (CGM) supplies.