Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic manipulation of one or more of the extra-spinal 
regions (head region; lower extremities; upper extremities; rib cage; abdomen) provided from July 18, 2022, to 
July 25, 2022. 
 
You asked the Plan to pay for t chiropractic manipulation of one or more of the extra-spinal regions  
(head region; lower extremities; upper extremities; rib cage; abdomen). You say that the services were 
medically necessary. The Plan denied your request. The Plan says Medicare does not cover chiropractic 
treatments to extraspinal regions. The Plan covers only manual manipulation of the spine to correct 
subluxation. 
 
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 chiropractic manipulation of one or more of the extra-spinal regions (head 
region; lower extremities; upper extremities; rib cage; abdomen) provided from July 18, 2022, to July 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultraviolet therapy cabinet (E0694). 
 
You asked the Plan to pre-approve an ultraviolet therapy cabinet. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for the requested 
item have not been met. 
 
The Plan covers all items that Medicare covers. Medicare rules state that ultraviolet cabinets are covered for 
selected patients with generalized intractable psoriasis. 
 
In this case, the case record does not support that the enrollee has a diagnosis of generalized intractable 
psoriasis. Therefore, we decided that the Plan does not have to pre-approve an ultraviolet therapy cabinet 
(E0694).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 27, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's 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 February 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a home ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that you are appealing this denial. The Plan denied your 
request. The Plan says a ventilator is not covered by Medicare for the requested purpose. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide positive 
airway pressure (PAP) therapy, regardless of the underlying medical condition, are not covered.  
 
We looked at the file and Medicare rules. A ventilator is not covered by Medicare for the requested purpose. 
Based on this information, we decided that Medicare rules for coverage of ventilator have not been met. 
Therefore, we decided that the Plan does not have to pre-approve use of a home ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 2, 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 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with power options and 
accessories. 
 
You asked the Plan to pre-approve Group 3 power wheelchair. You say that the enrollee requires this 
wheelchair. The Plan denied your request. The Plan says the requested power option is not needed and the 
enrollee's needs can be met by a Group 3 power wheelchair with no power options instead. 
 
The Plan follows Medicare rules. Medicare rules state that a Group 3 power wheelchair with single power 
option is only covered if certain criteria are met, as described in the previous 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 Group 3 power wheelchair. Our 
reviewer says that the enrollee does not meet the Medicare criteria for the requested Group 3 power wheelchair. 
Our physician reviewer found the records do not support that the enrollee is high risk for skin breakdown, has a 
history of pressure ulcers, has had skin flap surgery, performs bladder self-catheterization, or has increased 
muscle tone or spasticity to meet criteria for the single power option, power tile. Thus, a Group 3 power 
wheelchair with single power option is not 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 Group 3 power wheelchair have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Group 3 power wheelchair with power options and accessories.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve out-of-network SNF care. You say that the enrollee has been denied by nine 
other facilities. The Plan denied your request. The Plan says in-network providers are available. 
 
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 
SNF care to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic continuous glucose monitor (CGM) 
receiver/monitor (K0554) and supply allowance used with a therapeutic device (K0553) provided May 12, 
2022. 
 
You asked the Plan to pay for the CGM device and supplies. You say that please find attached EOB, 
authorization, DWO and medical records for the enrollee. The Plan denied your request. The Plan says the 
services are not documented in the enrollees medical records. 
 The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 pay for the CGM device and supplies. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Plan requires that the enrollee take insulin 3 times a day d and adjusts doses 
according to blood glucose levels. This enrollee does not take insulin at all from the records provided. The Plan 
criteria for coverage are not met. This does not mean that the enrollee would not benefit from a CGM, but it 
does mean the criteria for coverage of the Plan are not met at this time. 
 
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 CGM device and supplies have not been met. Therefore, we decided that the 
Plan does not have to pay for the therapeutic continuous glucose monitor (CGM) receiver/monitor (K0554) and 
supply allowance used with a therapeutic device (K0553) provided May 12, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the home health services provided from April 5, 
2022, to May 3, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to reimburse you for the home health services. You say that you did not feel it was 
beneficial to have the enrollee moved to another new facility. You also say that the enrollee's plan would only 
authorize 3 days of care per week when they really needed 7 days per week. The Plan denied your request. The 
Plan says prior authorization was not obtained. The Plan also says services provided out-of-network are not 
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 reimburse you 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 did not pre-approve the item/service 
at issue. We found no exception that would require the Plan to reimburse you for these items/services. 
Additionally, the record indicates that the services were private pay. Therefore, we decided that the Plan does not have to reimburse you for the home health services provided from April 5, 2022, to May 3, 2022, by an out-
of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for dialysis and dialysis-related drugs from 
January 2, 2022, to May 3, 2022. 
 
You asked the Plan to waive the coinsurance for dialysis and dialysis-related drugs. You say that you believe 
you should not be responsible for the coinsurance. 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 20% 
coinsurance for in-network services to treat kidney disease and 20% coinsurance for in-network Medicare part 
B prescription drugs.  
 
You have been asked to pay a 20% coinsurance for dialysis and dialysis-related drugs. The total allowed 
amount for the services is $4,938.96 ($4,938.96 x 20% = $987.79). 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 dialysis and dialysis-related drugs from January 2, 2022, to May 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair (E0240) and a transfer bench (E0247). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says these items are not a covered benefit under your 
contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair and a transfer bench may be appropriate for you in this case, neither the Plan nor 
Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve a 
shower chair (E0240) and a transfer bench (E0247).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair. 
 
You asked the Plan to pre-approve a manual wheelchair. You say that this equipment is medically necessary as 
you can only walk short distances. The Plan denied your request. The Plan says the criteria for coverage have 
not been met. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a manual wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the functional electrical stimulator, transcutaneous 
stimulation of nerve and/or muscle groups, any type, complete system, not otherwise specified (E0770) and 
miscellaneous durable medical equipment (E1399). 
 
You asked the Plan to pre-approve the neuromuscular electrical stimulation device. You say that the doctor has 
prescribed the enrollee the L300 Go System for use at home. The Plan denied your request. The Plan says 
medical necessity cannot be established. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 neuromuscular electrical 
stimulation device have been met. Multiple attempts were made to obtain medical records from the provider without success. Therefore, we decided that the Plan does not have to pre-approve the functional electrical 
stimulator, transcutaneous stimulation of nerve and/or muscle groups, any type, complete system, not otherwise 
specified (E0770) and miscellaneous durable medical equipment (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair (E0240). 
 
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this item is not a covered benefit under the enrollee's 
contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate for the enrollee in this case, neither the Plan nor Medicare offers 
coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair 
(E0240).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6545. 
 You asked the Plan to pre-approve the compression stockings. You say that the requested compression wraps 
are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6545 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that the enrollee has open venous stasis ulcers or a qualifying wound. This means 
that the enrollee does not have a medical condition for which compression stockings can be covered or paid for 
by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings 
identified with code A6545.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 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 Prolia. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy. Our physician reviewer found the 
enrollee has age-related osteoporosis without current pathological fracture. The documentation does not 
support that the enrollee has a history of an osteoporotic fracture or trial and failure to zoledronic acid. The 
documentation does not support that zoledronic acid would likely be less effective and/or likely have adverse 
effects 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 3, 2022. 
 
You asked the Plan to pay for 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. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, we find that the testing described by the billed code 
is considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on May 3, 2022.
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 you are not an insulin user. You also 
say that you have used the glucose monitor and supplies for years. The Plan denied your request. The Plan says 
you do 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 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a home ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that the enrollee needs this for treatment of chronic 
obstructive pulmonary disorder (COPD). The Plan denied your request. The Plan says a ventilator is not 
covered by Medicare for this purpose and the enrollee's needs could be met by a bilevel positive airway 
pressure (BiPAP) device instead. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide positive 
airway pressure (PAP) therapy, regardless of the underlying medical condition, are not covered.  
 
We looked at the file and Medicare rules. A ventilator is not covered for the requested purpose. Based on this 
information, we decided that Medicare rules for coverage of ventilator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve use of a home ventilator.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit. 
 
You asked the Plan to pre-approve Retacrit. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Retacrit is only covered for certain indications. 
 
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 Retacrit. Our reviewer says that the 
documentation does not support that Retacrit is medically reasonable or necessary. Our physician reviewer 
found the enrollee has a diagnosis/medical history of rectal cancer, lung cancer, anemia, iron deficiency, 
vitamin B-12 deficiency and treatment with chemotherapy for non-myeloid, non-erythroid malignancy.  
The medical records do not document that the enrollee is not currently iron deficient or vitamin B-12 deficient 
and the enrollee has adequate iron or B-12 levels for use of the Retacrit as required by the NCD and the 
Medicare-approved major drug compendia. Therefore, the enrollee does not meet criteria for the requested 
drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Retacrit.