Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), teeth cleaning (D1110), 
intraoral periapical radiographic images (D0220), pontic (D6240), and crowns (D6750 x2) provided on May 
17, 2022, by an out-of-network provider. 
 
You asked the Plan to pay for the dental services. You say that you want the Plan to pay for the services. The 
Plan denied your request. The Plan says the dental services were received from an out-of-network provider and 
are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a periodic oral evaluation (D0120), teeth cleaning (D1110), intraoral periapical radiographic images 
(D0220), pontic (D6240), and crowns (D6750 x2) provided on May 17, 2022, by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on May 6, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on May 6, 
2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve sacroiliac joint fusion (27279). 
 
You asked the Plan to pre-approve sacroiliac joint fusion. You say that the requested service is a medical 
necessity for you. The Plan denied your request. The Plan says that rules for coverage have not been met 
because the requested service is not medically necessary. 
 
The Plan follows Medicare rules. The rules say that MIS of the SIJ is considered medically necessary when the 
criteria listed in the Medicare rules section of this letter have been 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 sacroiliac joint fusion. Our reviewer 
says that the requested service is medically reasonable and necessary in this case. Our physician reviewer found 
that you have sacroiliitis as diagnosed by 3 provocative tests. You have had sacroiliac joint injections which 
have produced 80 percent pain relief but of shortening duration of relief. The request meets all of the coverage 
criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sacroiliac joint fusion have been met. Therefore, we decided that the Plan has to 
pre-approve sacroiliac joint fusion (27279).   
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 treatment with Breztri Aerosphere. 
 
You asked the Plan to pre-approve Breztri Aerosphere. You say that the requested drug is a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs 
have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Breztri 
Aerosphere.  
 Benefits for Breztri Aerosphere 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 pay for the receiver (monitor), dedicated, for use with therapeutic 
glucose continuous monitor system (K0554) supply allowance used with a therapeutic CGM device (K0553) 
provided March 2, 2022. 
 
You asked the Plan to pay for the CGM and supplies. You say that you are submitting medical records along 
with CMN, WOL form, delivery details in order to process the claim. The Plan denied your request. The Plan 
says this is not medically necessary as the enrollee is not currently insulin treated.  
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 perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the CGM and supplies have not been met. 
Therefore, we decided that the Plan does not have to pay for the receiver (monitor), dedicated, for use with 
therapeutic glucose continuous monitor system (K0554) supply allowance used with a therapeutic CGM device 
(K0553) provided March 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing billed with code 0117U provided on 
January 20, 2022. 
 
You asked the Plan to pay for the laboratory testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the claim did not include all of the required documentation to process. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must include the unique test identifier in 
order to be processed. 
 
We looked at the file and Medicare rules. Review of the file shows that the claim did not include the required 
unique test identifier. Based on this information, we decided that Medicare rules for coverage of the laboratory 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory testing 
billed with code 0117U provided on January 20, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from  
March 22, 2022, to April 20, 2022. 
 
You asked the Plan to pay for SNF care. The Plan denied your request. The Plan says SNF care is not 
medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that based on the medical records provided there is no documentation that the 
enrollee required skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled 
professional nurse were not required to safely and effectively provide medically necessary and reasonable 
treatment. The records did not document the need for intravenous medications, new tube feeding or ostomy 
care or daily complex wound care or respiratory care. This enrollee did not require skilled therapy services, i.e., 
the specialized skill, knowledge and judgment of a qualified therapist were not required to safely and 
effectively provide medically necessary and reasonable treatment. Although the records document the enrollee 
was very limited functionally, provided records do not document a significant decline in the enrollees 
functional status compared to her recent baseline to necessitate daily inpatient skilled therapy services. As a 
practical matter this enrollee did not require the services on an inpatient basis, only in a skilled nursing facility 
setting. Services in the nursing facility appear custodial in this case from March 22, 2022, to April 20, 2022.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for SNF care provided from March 22, 2022, to April 20, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency ambulance transportation (A0428). 
 
You asked the Plan to pre-approve non-emergency ambulance transportation. The Plan denied your request. 
The Plan says the medical records received do not support this service because there is no medical need for the 
enrollee to require an ambulance. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve non-emergency ambulance 
transportation. Our reviewer says that the record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service. Our physician reviewer found the 
record does not indicate that the enrollee's clinical condition is such that other methods of transport, such as 
stretcher van, are contraindicated or that the expertise, services and lifesaving and life-sustaining equipment 
that only a fully equipped ambulance can provide was required. Our reviewer found that the elements of the 
coverage criteria are not satisfied. Our physician reviewer also found that the requested service cannot be 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of non-emergency ambulance transportation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve non-emergency ambulance transportation (A0428).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a supply allowance for a therapeutic continuous glucose 
monitor (CGM) (K0553) provided on January 5, 2022. 
 
You asked the Plan to pay for a supply allowance for a CGM. You say that you disagree with the denial and 
have submitted medical records for review and approval. The Plan denied your request. The Plan says the 
documentation submitted did not include a valid physician order. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  The record does not contain a valid physician order for the supplies provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for a supply allowance for a therapeutic continuous glucose monitor 
(CGM) (K0553) provided on January 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oxygen concentrator (E1390) purchased on May 18, 2022. 
 
You asked the Plan to pay for an oxygen concentrator. You say that the enrollee's doctor directed you to 
purchase this. The Plan denied your request. The Plan says this is only covered as a rental. 
 
The Plan must follow Medicare rules. Medicare rules say that only rented oxygen equipment is eligible for 
coverage. Purchased oxygen equipment is statutorily non-covered. 
 
We looked at the file and Medicare rules. The oxygen equipment at issue was purchased, not rented. Based on 
this information, we decided that Medicare rules for coverage of an oxygen concentrator have not been met. 
Therefore, we decided that the Plan does not have to pay for an oxygen concentrator (E1390) purchased on 
May 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee remains in the acute hospital and needs 
to be slowly weaned off intravenous pain medication. The Plan denied your request. The Plan says the request 
for IRF services does not meet the requirements for approval. 
 
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 complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies at an intensive rehabilitation therapy program. The 
enrollee can receive medically necessary care at the current acute care hospital. 
 
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 IRF admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) 
provided on May 16, 2022. 
 
You asked the Plan to pay for ambulance response and treatment, no transport. You say that you were not 
aware that you would be charged if you didn't take the ambulance to the hospital. 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 May 16, 2022. 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 ambulance response and treatment, no transport 
(A0998) provided on May 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the device is medically necessary. The Plan 
denied your request. The Plan says the enrollee's respiratory disease process is less severe and a RAD (CPAP, 
BIPAP, BIPAP with back up) is more appropriate than a ventilator to meet her needs. Furthermore, coverage 
criteria indicates if the NIV is intended for use as a PAP device and not as a ventilator it is not covered by 
Medicare. 
 
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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
COPD, as well as obesity-hypoventilation syndrome, OSA, and end-stage renal disease. The enrollee was 
provided with a home ventilator upon discharge from the hospital in April 2022, with approval for 3 months. 
The enrollee is using the device. However, it appears her respiratory needs could be met with BiPAP, which 
can provide the AVAPS mode of support. 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a low dose computed tomography (LDCT) scan for lung 
cancer screening provided on May 25, 2022. 
 
You asked the Plan to pay for the requested LDCT scan. You say that you did not know the service would not 
be covered. The Plan denied your request. The Plan due to your age, you were not eligible for the service. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.   
We reviewed the file and the Medicare rules. We find that based on the medical records you do not meet the 
age criteria for the service to be covered. Therefore, we decided that the Plan does not have to pay for a low 
dose computed tomography (LDCT) scan for lung cancer screening provided on May 25, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are homeless and cannot take care of yourself. 
The Plan denied your request. The Plan says the request does not meet Medicare guidelines because you are 
receiving adequate and necessary intensive rehabilitation in the Inpatient Rehabilitation Facility. All the 
services you need are offered at the IRF. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found You do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
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 you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that 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 does not require services at the LTACH that are not available at the acute 
care hospital where the enrollee is currently receiving care. All medically necessary care is being provided in 
the current acute care setting. There are no services available at the LTACH that the enrollee requires that are 
not available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be 
furnished safely and effectively only on an inpatient basis. 
 
 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.