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

 
We decided that the Plan does not have to pre-approve additional transportation. 
 
You asked the Plan to pre-approve additional transportation. You say that you have used all your rides for 
regular follow up appointments. You also say that you see an endocrinologist regularly, and have needed 
several appointments recently due to trouble regulating your blood sugar. The Plan denied your request. The 
Plan says you have used the allowed 20 rides offered by the Plan. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 20 one-way trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on June 1, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that the service was provided to the enrollee at 
the request of their primary care physician. The Plan denied your request. The Plan says authorization was not 
obtained before the service was rendered to the enrollee. 
 
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 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 subsequent nursing facility care provided on June 1, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture service (97810) provided on March 26, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the acupuncture service. You say that this should be covered. The Plan denied 
your request. The Plan says the service you received out-of-network was not authorized. 
 
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 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 acupuncture service (97810) provided on March 26, 2022, by 
an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the esophagogastroduodenoscopy (EGD) provided on 
February 17, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the EGD. You say that the service was medically necessary. The Plan denied 
your request. The Plan says no prior authorization was obtained. 
 
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 
EGD. We found no exception that would require the Plan to pay for the EGD. The records provided for review 
do not show that the EGD was urgent or emergent. Therefore, we decided that the Plan does not have to pay for 
the esophagogastroduodenoscopy (EGD) provided on February 17, 2022, by an out-of-network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve specialist office visit. You say that you need to be evaluated by the provider 
due illness side effects. The Plan denied your request. The Plan says the service can be provided by an in-
network 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 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 
specialist office visit to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for GeneSight testing provided to the enrollee on March 13, 
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 pharmacogenetic testing is not considered reasonable and necessary merely on the basis of a 
patient having a particular diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that the current evidence does not support the use of 
GeneSight testing. 
 
Medicare does not currently consider the denied testing to be reasonable or necessary. 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 GeneSight testing provided to the enrollee on March 13, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a custom fabricated knee orthosis. 
 
You asked the Plan to pre-approve a knee orthosis. The Plan denied your request. The Plan says that the 
enrollee does not have recent injury, surgery, or evidence of instability. 
 
The Plan must follow Medicare rules. Medicare rules say that knee orthoses are only covered under certain 
medical 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 a knee orthosis. Our physician reviewer 
found that the enrollee has a medical history of chronic knee pain. A clinical progress note indicated that the 
enrollee has had knee arthroscopy in the past and continues to have knee pain, which interferes with her 
activities of daily living and mobility. The physical examination showed full range of motion with tenderness 
to palpation and varus deformity. The enrollee had knee osteoarthritis on radiographic imaging. Treatment 
included physical therapy and bracing. There is no indication of recent trauma or instability. However, the 
enrollee has knee osteoarthritis and knee unloader braces have been shown to be economical and effective 
treatment for knee osteoarthritis in the medical literature. Therefore, the requested knee orthosis (unloader 
brace) is 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 a knee orthosis have been met. Therefore, we decided that the Plan has to pre-
approve a custom fabricated knee orthosis.  
 
 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 suction pump, home model, portable or stationary, 
electric, any type, for use with external urine management system (K1006). 
 
You asked the Plan to pre-approve a PUREWICK TM external female urine collection device. You say that the 
enrollee is incontinent. The enrollee is also blind with hemispheric blindness in both eyes at night. Once she is 
in bed, she cannot get out of bed and go to the toilet without assistance. The Plan denied your request. The Plan 
says Medicare and the Plan do not cover incontinence supplies because they are disposable, non-reusable 
hygiene items and fall outside the scope of coverage. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate 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 suction pump, home model, 
portable or stationary, electric, any type, for use with external urine management system (K1006).
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 IRF care is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for IRF care have not been met. 
 
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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. There is not a reasonable expectation that the enrollee will be able to 
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the admission to an IRF 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. 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 that there are no complex nursing or rehabilitation needs. Medical care can be 
provided in a different 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (0037U) provided on April 22, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 The Plan must follow Medicare rules. Medicare rules say that to report a Molecular Diagnostic Test service, the 
appropriate claim information must be submitted.  
 
We looked at the file and Medicare rules. In this case, the claim was submitted without an appropriate DEX Z-
Code as required by LCA A56853. 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 the laboratory 
services (0037U) provided on April 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) receiver (K0554). 
 
You asked the Plan to pre-approve a CGM receiver. You say that you disagree with the denial and have 
submitted medical records. The Plan denied your request. The Plan says the enrollee does not meet coverage 
criteria for the requested item. 
 
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 or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM 
receiver have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM) receiver (K0554).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient mental health visits 
 
 You asked the Plan to pre-approve outpatient mental health visits. You say that you have been seeing the 
doctor for over fourteen years for therapy and med management for parity disease. You say that to have to wait 
to try and get in and start to see a new doctor would be detrimental to your health. The Plan denied your 
request. The Plan says your care can be safely managed by an in-network provider. We have in-network 
providers who can help treat your bipolar disorder and post-traumatic stress disorder (PTSD). 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 outpatient mental health visits. Our 
reviewer says that your condition is not an urgent/emergent condition.  Our physician reviewer found based on 
review of the records provided you do not require treatment by an out-of-network provider as the medical plan 
is able to provide a psychotherapist for the treatment of your condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of outpatient mental health visits have not been met. Therefore, we decided that 
the Plan does not have to pre-approve outpatient mental health visits
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the physical therapy visits to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the physical therapy visits. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the provider is out-of-network. 
 
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 physical therapy visits. We found no exception that would require the Plan to 
pre-approve the physical therapy visits. Therefore, we decided that the Plan does not have to pre-approve the 
physical therapy visits to be provided by an out-of-network (OON) provider.
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 IRF care is necessary in order to improve the 
enrollee's level of independence and functional mobility. The Plan denied your request. The Plan says the IRF 
care is not medically necessary, and the enrollee's needs can be met at a lower level of care such as a skilled 
nursing facility (SNF). 
 
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 was admitted for bilateral knee replacement surgery and is stable. There 
are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record supports a need for physical and/or occupational therapy. 
 
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: DME/ Orthotics
Decision: Unfavorable

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

 
We decided that the Plan does not have to pay for the laboratory services provided on July 12, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the DOS of the test/service must be the date the 
specimen was collected. 
 
We find that code 0037U is not supported in the medical record. Specifically, there is no documentation 
describing genetic testing on a sample collected on the date of service at issue. Therefore, we decided that the 
Plan does not have to pay for the laboratory services provided on July 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the one-year protection plan warranty (V2797) or pay more 
for the glasses purchased on July 14, 2022. 
 
You asked the Plan to pay for the warranty and to pay more for the glasses. You say that you agreed to pay an 
additional $58.49 for your glasses, but are now being charged another $25.00. The Plan denied your request. 
The Plan says the one-year protection plan warranty is not covered, and your $200 eyewear allowance has been 
exhausted. The Plan also says you did not contact the Plan prior to the date of service to verify benefits and 
provider eligibility. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case.  
We looked at the file and the Plan's rules. The record shows that your $200 eyewear allowance was exhausted 
on the purchased of these glasses on July 14, 2022. The one-year protection plan warranty (V2797) is not listed 
as a covered supplemental benefit, and sales tax is not covered. Based on this information, we decided that the 
Plan's rules for coverage of the warranty or pay more for the glasses have not been met. Therefore, we decided 
that the Plan does not have to pay for the one-year protection plan warranty (V2797) or pay more for the 
glasses purchased on July 14, 2022.  
 
Please Note: You do not owe any amount beyond the $58.49 that you paid on the date of service July 14, 2022.