Persius/hicric huggingface dataset:
Appeal type: Drugs
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 finger pricking is causing the enrollee significant pain. 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: 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require at least 3 hours a day / 5 days a week, or 15 hours over 7 
consecutive days, of therapy services. The enrollee will not be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. Therapy services may be provided at a lower level 
of 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment without transport
(A0998) provided on September 23, 2021.
You asked the Plan to pay for the ambulance response and treatment without transport. You say that you would
like reconsideration because you needed emergency services to determine if you were having a heart attack.
The Plan denied your request. The Plan says the Medicare ambulance benefit is a transport benefit, if no
transport of a Medicare beneficiary occurs; then there is no Medicare covered service.
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 September 23, 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 without
transport (A0998) provided on September 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CMG. You say that this device is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic CMG have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
therapeutic continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shoulder therapy kit (A9300), provided on August 31, 
2021. 
 
You asked the Plan to pay for the shoulder therapy kit. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this is not a covered item. 
 
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 pay for the shoulder therapy kit (A9300), provided on August 31, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Granix. 
 
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 step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has immunusuppression-
induced neutropenia following kidney transplant. He has not tried and failed the Plan's required drugs, 
Nivestym and Zarxio. The records do not show that the required drugs would be contraindicated or less 
effective; therefore, Granix is not reasonable or medically necessary. 
 
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 Granix.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee requires at least 3 hours a day / 5 days a week, or 15 hours over 7 consecutive days, of therapy services. The enrollee has cognitive deficits, and it is not clear that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. The services may be provided at a lower level of 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 pay for an office visit provided on September 23, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the services provided to the enrollee were medically 
necessary and the claim should be paid. The Plan denied your request. The Plan says the rendering provider is 
an out-of-network provider with no in-network provider referral or approved authorization. Also, the services 
rendered were not urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on September 23, 2021, by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that this is medically necessary. 
The Plan denied your request. The Plan says there is no documentation for a 4-week trial of a basic pneumatic 
compression device. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a bone growth stimulator (E0747). 
 
You asked the Plan to waive the copayment for a bone growth stimulator. You say that the item should be 
covered. The Plan denied your request. The Plan says the cost share was applied 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 20% 
coinsurance for durable medical equipment (DME) and related supplies.  
 
You have been asked to pay a 20% coinsurance for a bone growth stimulator. this item falls within the durable 
medical equipment (DME) and related 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 a bone growth stimulator (E0747).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided on 
August 15, 2021, through August 17, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that the cost share is wrong. 
The Plan denied your request. The Plan says the cost share was applied 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 $403 
copay per day one through five for inpatient hospital care.  
 
You have been asked to pay a $403 copay per day one through five for the inpatient hospital care. the inpatient 
hospital care falls within the inpatient hospital 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 copayment for the inpatient hospital care provided on August 
15, 2021, through August 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services rendered by the out-of-network (OON) 
provider on August 26, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the medical services rendered by the out-of-network (OON) provider on  
August 26, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve Carpal and Cubital Tunnel Surgery in an outpatient hospital 
setting. 
 
You asked the Plan to pre-approve these services. You say that the enrollee requires surgery for treatment. The 
Plan denied your request. The Plan says that that the requested service is not covered by Medicare or the health 
plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has denied these services based on internal Plan rules but has not 
provided any Medicare rules/rationale for their denial of these services. Therefore, we decided that the Plan has 
to pre-approve Carpal and Cubital Tunnel Surgery in an outpatient hospital setting.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power hospital bed. 
 
You asked the Plan to pre-approve a power hospital bed. You say that the requested item is a medical necessity 
for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested item 
have not been met. 
 
The Plan follows Medicare rules. The rules say that a hospital bed is covered if one or more of the criteria 
listed in the Medicare 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 power hospital bed. Our reviewer says 
that the requested item is not medically reasonable and necessary in this case. Our physician reviewer found 
that the provided records do not document that the enrollee has a medical condition which requires positioning 
of the body in ways not feasible with an ordinary bed; or requires positioning of the body in ways not feasible 
with an ordinary bed in order to alleviate pain; or requires the head of the bed to be elevated more than 30 
degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with 
aspiration; or requires traction equipment which can only be attached to a hospital bed and requires frequent 
changes in body position and/or has an immediate need for a change in body position. 
 
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 power hospital bed have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a power hospital bed.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the cervical spine 
without contrast. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no record of contact with the doctor after a recent six week trial of treatment that 
failed to improve symptoms. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 the MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found there is no record of 
contact with the physician after the dose of Depo medrol to determine if this scan is still needed. In addition, 
there are no red flags to mandate immediate MRI imaging without a six week trial of physical therapy, such as 
absent reflex or upper extremity weakness. 
 
 
 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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the cervical spine without contrast.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to still be unstable and requires additional short-term acute care 
hospital services that can safely completed at the current facility. There are no services at the LTACH that the 
enrollee requires that are not already available and covered at the current facility. Transfer to a LTACH is not 
medically necessary as it would not be clinically advantageous as the enrollee is not yet stable enough for 
transfer. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for nail debridement services provided on 
October 5, 2021. 
 
You asked the Plan to waive the copayment for the nail debridement. You say that you do not know why you 
received a bill for the visit. 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 $35 
copayment per visit for podiatry services.  
 
You have been asked to pay a $35 copayment for the nail debridement. The nail debridement falls within the 
Podiatry Services 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 nail debridement 
services provided on October 5, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit (99335) provided on 
September 16, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the domiciliary or rest home visit. You say that you would like this claim to be 
reprocessed towards payment. The Plan denied your request. The Plan says the services were rendered by a 
non-contracted provider without prior authorization from the Plan. 
 
  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 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 domiciliary or rest home visit (99335) 
provided on September 16, 2021 by an out-of-network (OON) provider.