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

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 kit. 
 
You asked the Plan to pre-approve a Freestyle Libre 2 kit. You say that the requested a Freestyle Libre 2 kit is 
medically necessary. The Plan denied your request. The Plan says that the coverage criteria has 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 2 kit have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre 2 kit.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for air ambulance services provided on June 6, 2022. 
 You asked the Plan to pay for the air ambulance services. You say that the medical records provided support 
the need for the air ambulance services. The Plan denied your request. The Plan says the air ambulance 
transport was not medically necessary. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if the 
patients medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air ambulance services. Our reviewer 
says that air ambulance services were not medically necessary. Our physician reviewer found the enrollee does 
not appear to have had a medical condition warranting the use of an air ambulance (atraumatic back 
pain).  Even if the enrollee had a condition warranting the use of an air ambulance, the enrollee did not go the 
closest available facility. 
 
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 air ambulance services have not been met. Therefore, we decided that the 
Plan does not have to pay for air ambulance services provided on June 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0861) and accessories 
(E0955, E1007, E1012, E1028, E2300, E2311, E2313, E2363, E2377, E2607, E2615, K0108). 
 You asked the Plan to pre-approve a power wheelchair and accessories. You say that the requested power 
wheelchair and accessories are medically necessary. The Plan denied your request. The Plan says that the 
coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 wheelchair and accessories. 
Our reviewer says that the coverage criteria has not been met. Our physician reviewer found that the enrollee is 
functionally non-ambulatory and cannot use a cane or walker for mobility given her lower extremity weakness 
and risk for falling. She cannot functionally propel a manual wheelchair due to lack of upper extremity 
endurance. The enrollee cannot operate a power scooter due to an impaired ability to transfer independently. 
The enrollee requires a power wheelchair for mobility and accomplishing her daily activities. However, the 
clinical documentation is insufficient why a lower-level power wheelchair would not suffice for her needs 
versus a Group 3 power wheelchair. The enrollee does have Parkinsons disease with a history of stroke, but 
she is noted to have 3/5 motor strength in the upper extremities and can perform some transfers independently. 
The enrollee also has no history of skin breakdown, and it is not clear why she requires power tilt and recline 
for pressure relief. Additionally, she has no lower extremity edema that would require a power articulating 
platform and it is not clear if the power seat elevator will allow her to transfer independently given her varied 
ability to perform transfers. As the base power wheelchair is not medically necessary, the requested accessories 
are not covered. 
 
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 wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Group 3 power wheelchair (K0861) and accessories (E0955, 
E1007, E1012, E1028, E2300, E2311, E2313, E2363, E2377, E2607, E2615, K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ankle foot orthosis (AFO), plastic or other material with 
ankle joint, prefabricated, includes fitting and adjustment provided on November 1, 2022. 
 You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documentation submitted did not sufficiently support the billed supply code. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the documentation doesnt support that the joint is unstable or that there is joint 
laxity. There is no indication that an AFO is required for stabilization for medical reasons or that there is a 
potential to benefit the enrollee functionally. There is no indication the member is having ankle/foot pain or an 
unstable joint on exam. The requested AFO orthosis is not 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for ankle foot orthosis (AFO), plastic or other material with ankle joint, prefabricated, includes 
fitting and adjustment provided on November 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bath/shower chair (E0240). 
 
You asked the Plan to pre-approve a bath/shower chair. You say that you need a chair because you are 
concerned you may fall in the bath. The Plan denied your request. The Plan says this item is not covered 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 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 bath/shower chair (E0240).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services to be provided by the requested  
out-of-network provider. 
 
You asked the Plan to pre-approve dental services to be provided by the requested out-of-network provider. 
You say that there are no clinics in the enrollee's area to allow the enrollee to see their own dentist for the oral 
appliance to treat the diagnoses sleep apnea. The Plan denied your request. The Plan says there are seven 
in-network providers in the enrollee's area. The enrollee has out-of-network benefits that could be utilized to 
see an out-of-network provider. Furthermore, the Plans Care Management Department will be contacting the 
enrollee to offer their assistance in locating a participating provider. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve dental 
services to be provided by the requested out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for diabetic supplies provided on September 9, 2022. 
 
You asked the Plan to pay for the diabetic supplies. You say that you have provided all required documentation 
to support payment. The Plan denied your request. The Plan did not provide us with much information in its 
submission, but it appears that the Plans denial rationale was that records were requested from the provider 
but have not been received. 
 
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. diabetic supplies provided on September 9, 2022. Specifically, the minimal 
information in the file indicates that the Plans sole rationale for denial was based on a lack of records.  
However, it appears that you have submitted full medical records as well as shipping proof with your appeal 
submission.  The Plan has not made any assertions that the documents you submitted were insufficient or 
invalid.  The burden is on the Plan to show why its denial was correct.  By failing to even comment on your 
submitted documentation, we find that the Plan has not met this burden. Therefore, we decided that the Plan 
has to pay for diabetic supplies provided on September 9, 2022.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne Liquid CDx (F1LCDx) comprehensive 
genomic profiling test (0239U) provided on October 6, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the genetic testing. You say that the treating physician ordered the F1LCDx test 
to assist in treatment decisions for the enrollee. The Plan denied your request. The Plan says enrollees must 
receive their medical services from an in-network provider with the exception being urgent or emergent 
services. Non-emergent services with non-contracted providers require prior authorization before services 
being rendered.  
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 the FoundationOne Liquid CDx (F1LCDx) 
comprehensive genomic profiling test (0239U) provided on October 6, 2022, by an out-of-network (OON) 
provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 test at home tests (87426) provided on 
October 3, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the at home COVID_19 tests. You say that you do not agree with this denial, and 
you are appealing for payment. The Plan denied your request. The Plan says enrollees must receive their 
medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered. 
 
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 the COVID-19 test at home tests (87426) provided 
on October 3, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 10, 2021, billed with 
codes 81162, 81317, 81319, 81435, 81436, 81203, 81300, 81323, 81351 and 81307. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
August 10, 2021, billed with codes 81162, 81317, 81319, 81435, 81436, 81203, 81300, 81323, 81351 and 
81307.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the medical eye exam (code 92014), the 
visual field exam (code 92083), and the scanning computerized ophthalmic diagnostic imaging (code 92134) 
you received on August 24, 2022. 
 
You asked the Plan to waive the cost sharing for the medical eye exam (code 92014), the visual field testing 
(code 92083), and the scanning computerized ophthalmic diagnostic imaging (code 92134). You say that had 
you known that you would have been charged for these services, you would have purchased more than a year's 
worth of contacts prior to joining the plan. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for Medicare-covered eye exams. In addition, your contract says that you pay 20% coinsurance for 
outpatient diagnostic testing. 
 
You have been asked to pay a $30 copayment for the medical eye exam (code 92014), and 20% coinsurance for 
the visual field testing (code 92083, and the scanning computerized ophthalmic diagnostic imaging (code 
92134). Both of these services are considered outpatient diagnostic tests. 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 cost sharing for the medical eye exam (code 92014), the visual field exam (code 92083), and the scanning 
computerized ophthalmic diagnostic imaging (code 92134) you received on August 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667).  
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show at least four weeks of usage of E0650 or E0651. 
 
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 the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the patient has lower extremity lymphedema. He is using compression garments and attending 
lymphedema treatment, which has improved his lower extremity lymphedema. The therapy documentation 
indicates that the patient has been using a standard pneumatic compression pump and achieving a reduction in 
his lymphedema, which is noted with decreased measurements in his ankle, calf, knee, and thigh. It is therefore 
unclear why he would need an advanced lymphatic pump. Therefore, the requested segmental compression 
pump with calibrated gradient pressure (E0652) and appliance/accessory (E0667) is not 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 the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device (E0652, E0667).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 35 hours per week of home health aide services to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve 35 hours per week of home health aide services to be provided by an OON 
provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-
network providers that are able to provide these services. Therefore, coverage criteria have not been met. 
 
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 
35 hours per week of home health aide services to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from September 
25, 2022 to October 24, 2022. 
 You asked the Plan to pay for SNF care. You say that the enrollee required and received care coverable under 
the Medicare Act. The Plan denied your request. The Plan says the enrollee had no daily skilled nursing or 
therapy needs on the dates of service at issue. 
 
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 the enrollee did not have daily skilled nursing needs that required the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did 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 pay for skilled nursing facility (SNF) care provided from September 25, 2022 to October 24, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on 
September 26, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient care was medically 
necessary. The Plan denied your request. The Plan says the inpatient level of care was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the record did not show that at the time of inpatient admission the admitting 
physician reasonably expected that the enrollees necessary hospital care (including earlier emergency 
department and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided on September 26, 2022.