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

 
We decided that the Plan does not have to pre-approve Freestyle Libre 14-day reader/flash monitoring system 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that the records provided will 
show proof of medical necessity. The Plan denied your request. The Plan says the enrollee does not meet the 
Medicare criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and 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 assesses 
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 continuous glucose monitor have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Freestyle Libre 14-day reader/flash 
monitoring system
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that you would be equally well served at an alternative level of care. 
 
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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for SNF services. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second facet joint injection. 
 
You asked the Plan to pre-approve repeat facet joint injection. You say that this procedure is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for the second 
facet joint injection service have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a second confirmatory diagnostic facet joint 
procedure is considered medically reasonable and necessary when after the first diagnostic facet joint 
procedure, there is a consistent positive response of at least 80% relief of primary (index) pain. 
 
We looked at the file and Medicare rules. In this case, the documentation does not support that there was at 
least 80% relief of primary pain after the first diagnostic facet joint injection. Based on this information, we 
decided that Medicare rules for coverage of repeat facet joint injection have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a second facet joint injection.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 23, 2021. 
 
You asked the Plan to pay for the services provided. You say that the lab work was requested by the enrollee's 
doctor. The Plan denied your request. The Plan says the billed codes cannot be verified. 
 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken.  
 
We looked at the file and Medicare rules. In this case, the claim was billed with an office place of service code. 
The records do not support that the sample was taken in an office setting. Based on this information, we 
decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided 
that the Plan does not have to pay for the lab services provided on August 23, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee has an ulcer. The Plan denied your 
request. The Plan says the enrollee does not require daily skilled nursing or therapy services 
 
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 services. Our physician reviewer 
found that the enrollee was admitted to the hospital with a urinary tract infection and a sacral pressure injury. A 
wound care consult recommended cleansing the wound with normal saline, patting dry, Santyl to wound bed 
daily, packing with gauze or Aquacel, and covering with Biatain multilayer silicone foam dressing. The 
enrollee does not require skilled therapy service needs. Although she does require skilled nursing services, the 
documentation does not support that it is medically necessary to provide skilled services on a daily basis, on an 
inpatient basis, in a skilled nursing facility 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses (V2020, V2100, V2750, V2745) and the 
warranty (V2797) provided on January 21, 2022. 
 
You asked the Plan to pay for the eyeglasses and warranty. You say that you had cataract surgery in December 
2021, and went to get a routine checkup with glasses a month later. You feel these services should be covered 
in full or that you are owed a free pair of eyeglasses. The Plan denied your request. The Plan says this claim 
was processed correctly. Your vision benefit covers up to $200 for routine eyewear. This amount was paid at 
the time of services, and you are responsible for the remaining cost. In addition, warranties are not covered by 
your vision benefit or by Medicare. 
 
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. The Plan covers eligible eyewear services up to $200 per year. 
 
We looked at the file and the Plan's rules. Though the Plan offers a supplemental benefit in excess of Medicare 
coverage, a warranty for eyewear is not among those services/items covered by this benefit. That means that 
you are responsible for the $15 charge for this service. Therefore, we decided that the Plan does not have to pay 
for the warranty (V2797) provided on January 21, 2022. 
 
In addition, the record shows that the total cost of the eyeglasses was $229.95. After the Plan applied your 
benefits, you were asked to pay $23.96 for these services. That means that the Plan has paid the correct amount 
for these eyeglasses. Please note that regarding your complaint that these services should be covered by your 
medical benefits: Medicare covers only the cost of base/standard lenses and base frames. Add-ons generally are 
not covered. If these eyeglasses were covered by Medicare, then based on the information billed, you would be 
responsible for the cost of the lens tint (V2745) and the anti-reflective coating (V2750). The billed cost of these 
two services was $65, so it is to your advantage that the Plan processed and paid for these services under your 
supplemental benefit, which does offer coverage of lens features. Therefore, we decided that the Plan does not 
have to pay an additional amount for the eyeglasses (V2020, V2100, V2750, V2745) provided on January 21, 
2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve laboratory services provided to the enrollee on October 25, 2021. 
 
You asked the Plan to pre-approve the services. You say that this should be paid for. The Plan denied your 
request. The Plan says that this testing is unlikely to impact therapeutic decision-making in the clinical 
management of the patient. 
 
The Plan must follow Medicare rules. Medicare rules say that laboratory services are covered when the test 
results provide the clinician with information that will improve patient outcomes and/or change physician care 
and treatment of the patient. 
 
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 services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the review has determined that this testing would provide the clinician with information that would 
improve patient outcomes and guide medical management. The test is considered clinically valid and useful. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve laboratory services provided to the enrollee on October 25, 2021.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve these services. You say that you live closer to this facility. The Plan denied 
your request. The Plan says that there are participating providers available for these services. 
 
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 
physical therapy to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation (A0100). 
 
You asked the Plan to pre-approve additional non-emergency transportation. You say that consideration and 
approval of the case is requested given that the patient requires transportation to arrive at his dialysis 
treatments. You also say that not having the transport service may cause the patient to be absent because they 
do not have alternatives to reach the unit and even become medically complicated and reach a hospitalization. 
The Plan denied your request. The Plan says the enrollee has exhausted the established benefit of 24 one-way 
trips. 
 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 twenty-four (24) (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 the enrollee has exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency transportation (A0100).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on March 29, 2021. 
 
You asked the Plan to pay for genetic tests. You say that the proper usage of Place of Service (POS) code 81 
was billed on this claim. The Plan denied your request. The Plan says the denial of payment for this testing is 
correct, because this testing was not billed with the appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 genetic tests 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 genetic testing provided on March 29, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency transportation; taxi (A0100) beyond the 
enrollees 24-trip limit. 
 
You asked the Plan to pre-approve the routine transportation. You say that the enrollee requires reliable 
transportation to dialysis. The Plan denied your request. The Plan says the enrollee has exhausted his routine 
transportation benefit. 
 
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 24 trips per year.  
 We looked at your request, the records in the case file, and the rules. The Plan provided documentation 
showing that 24 transports have been covered in 2022. 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 non-emergency transportation; taxi (A0100) beyond the enrollees 24-trip 
limit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-intravenous conscious sedation (D9248). 
 
You asked the Plan to pre-approve non-intravenous conscious sedation. You say that you have not been to a 
dentist in about 4 years and your tooth is cracked from front to the back. You also say that you do not want to 
have any pain during the procedure and would like to have the intravenous sedation during the procedure. The 
Plan denied your request. The Plan says this service is not covered under your plan. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve non-
intravenous conscious sedation (D9248).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second routine eye exam so you may get contact 
lenses. 
 You asked the Plan to pre-approve a second routine eye exam. You say that you had a routine exam earlier in 
the year, but you only received an eyeglass lens prescription and not a contact lens prescription. You need a 
prescription so you can get contact lenses. The Plan denied your request. The Plan says you had a previous 
routine eye exam provided on January 24, 2022. This service is covered once per year. 
 
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. The Plan covers one routine eye exam (eye refraction) per year. 
 
We looked at the file and the Plan's rules. The record shows that you have had a routine eye exam in 2022. 
Based on this information, we decided that the Plan's rules for coverage of a second routine eye exam have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a second routine eye exam so you 
may get contact lenses.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that you can safely receive the services you need in other settings. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care.  You were admitted for surgical repair of a hip fracture after a fall. Your medical problems are stable. There are 
no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a 
need for physical and/or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found 
that your condition does not meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

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

 
We decided that the Plan does not have to pre-approve massage therapy, 1 hour per month. 
 
You asked the Plan to pre-approve massage therapy. You say that your body does not circulate toxins out 
normally. You say that massages help with this. You say that since switching to this plan that does not cover 
massage therapy, all of your symptoms have returned, and your quality of life has been severely impacted. You 
also say that the 30-minute massages that are covered in conjunction with chiropractic care are not enough to 
cover your whole body. The Plan denied your request. The Plan says massage therapy can be covered when 
performed with a complimentary medicine service such as chiropractic care. The Plan says that the records do 
not show that this service would be performed with a complimentary medicine service. The Plan also says that 
massage therapy is not covered. 
 
 
 
 
 
 
 The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve massage therapy, 1 hour per month.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Accu-Chek FastClix lancets. 
 
You asked the Plan to pre-approve these services. You say that the supplies are needed for the enrollee's type II 
diabetes. The Plan denied your request. The Plan says the services are available from the preferred provider. 
 
The Plan must follow Medicare rules. Medicare rules say that Plans may limit enrollees to preferred providers 
for durable medical equipment and supplies.  
 
We looked at the file and Medicare rules. The requested items are from a non-preferred provider. The services 
are available from one of the Plans preferred providers. Based on this information, we decided that Medicare 
rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Accu-Chek FastClix lancets.