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

 
We decided that the Plan does not have to pre-approve the power operated vehicle (E1230) and other power 
wheelchair base (K0014). 
 
You asked the Plan to pre-approve the power scooter. You say that it is medically necessary for the enrollee to 
have a motorized scooter. This enrollee will be more independent with the use of a scooter. The Plan denied 
your request. The Plan says the medical records received do not support that the enrollee met the guidelines for 
this device. 
 
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.  
 
The file shows that you do not have a mobility deficit that impairs your participation in MRADLs, your 
condition can be improved by a walker, cane or manual wheelchair, you cannot safely operate the PMD being 
requested. Medicare requires specific documentation of the members medical condition, impairment and need 
for a power mobility device in addition to specific evaluations be done in order for this device to be covered. The enrollee has not completed the necessary specialty and home evaluations nor provided the appropriate 
documentation for approval of this device. Despite multiple requests, the required documentation for the 
requested power scooter was not received. This means that Medicare rules for coverage of a PMD have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the power operated vehicle 
(E1230) and other power wheelchair base (K0014).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Supartz FX injection. 
 You asked the Plan to pre-approve Supartz FX injection. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Supartz is only covered for certain indications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Supartz FX injection. Our reviewer 
says that the requested drug is not medically necessary. Our physician reviewer found the enrollee has a 
diagnosis of osteoarthritis of the right knee. Based on the medical records provided there is no documentation 
that the Supartz FX injection at issue in this case meets all Medicare criteria for medically reasonable and 
necessary and safe and effective for the enrollee. The only record provided in this case is a letter of medical 
necessity; no office visit notes, imaging studies or treatment records from physical therapy have been provided 
as required by Medicare rules. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Supartz FX injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Supartz FX injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement power seat lift chair. 
 
You asked the Plan to pre-approve these services. You say that you need the hair to maintain your daily 
activities and need a recliner lift chair. The Plan denied your request. The Plan says the services are not 
covered. 
 
The Plan must follow Medicare rules. The rules say that replacement cases suggesting malicious damage, 
culpable neglect, or wrongful disposition of equipment should be investigated and denied. 
 
We looked at the file and Medicare rules. The file shows that you have two recliner lift chairs that are not more 
than five years old or irreparably damaged. The file shows that the current chair was misused and not eligible 
for replacement. 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 a replacement power seat lift 
chair.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Faslodex. 
 
You asked the Plan to pre-approve Faslodex. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Faslodex. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has a diagnosis of high grade serous ovarian carcinoma. Faslodex is not Food and 
Drug Administration-approved for the treatment of high grade serous ovarian carcinoma. The use of Faslodex 
for the treatment of high grade serous ovarian carcinoma is not supported by one of the major drug compendia 
or by clinical research that appears in a CMS-approved medical journal or by the National Comprehensive 
Cancer Network (NCCN). The NCCN does have a recommendation for use of Faslodex for low grade serous 
carcinoma but not for high grade disease. Therefore, the enrollee does not meet criteria for the requested drug.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Faslodex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Faslodex.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc injections (J7325). 
 
You asked the Plan to pre-approve the Synvisc injections. You say that the injections are medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a repeat series of injections with Hyaluronan is 
considered medically necessary when symptoms have recurred and at least six months have elapsed since the 
prior series of injections. 
 
We looked at the file and Medicare rules. Records show the previous injection was given on October 19th, 
2022. This is less than six months ago. Based on this information, we decided that Medicare rules for coverage 
of the Synvisc injections have not been met. Therefore, we decided that the Plan does not have to pre-approve 
Synvisc injections (J7325).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that these items are medically necessary. 
The Plan denied your request. The Plan says this is not a covered item. 
 
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 incontinence supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the screening services provided on September 26, 
2022. 
 
You asked the Plan to reimburse you for the screening services. You say that you would like to be reimbursed 
for these services. The Plan denied your request. The Plan says the provider in this case is not enrolled in 
Medicare. The Plan also says that payment cannot be made for services performed by a provider that is not 
enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to reimburse you for the screening services 
provided on September 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hyperbaric oxygen therapy provided on September 1, 2022. 
 
You asked the Plan to pay for hyperbaric oxygen therapy. You say that the hyperbaric oxygen therapy was 
medically necessary. The Plan denied your request. The Plan says the requested hyperbaric oxygen therapy 
does not meet the Medicare NCD coverage criteria. 
 
The Plan follows Medicare 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 pay for hyperbaric oxygen therapy. Our reviewer 
says that the requested hyperbaric oxygen therapy was not medically necessary in this case. Our physician 
reviewer found that the enrollee has a diagnosis of non-pressure chronic ulcer of right ankle with necrosis of 
muscle. The enrollee has a history of diabetes and small vessel peripheral vascular disease not amenable to 
surgery. The enrollee has had a non-healing wound for 9 months despite wound care, debridement, and skin 
graft. The note from the enrollees provider says the wound currently extends to tendon/muscle. The notes do 
not show presence of abscess, bone infection, or gangrene (Wagner Grade 2). The review has determined that 
the requested hyperbaric oxygen therapy does not meet the Medicare NCD 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 hyperbaric oxygen therapy have not been met. Therefore, we decided that the 
Plan does not have to pay for hyperbaric oxygen therapy (CPT 99183) provided on September 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain/ceramic crown (D2740) and a core buildup, 
including any pins when required (D2950) for teeth# 30 and 31. 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested items are not medically necessary. 
 
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 Plan covers these items 
when the services are medically necessary and reasonable.  
 
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 these items. Our reviewer says that you 
do not meet criteria for coverage of the requested items. Our physician reviewer found that a review of the 
documentation indicates that tooth number 30 has a crown in place which appears adequate. The buccal 
abfraction can be restored using traditional filling materials. Tooth number 31 has a restoration in place which 
appears adequate and functional. There was no documentation provided indicating decay in either tooth. The 
requested dental items are not medically necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of these items have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a porcelain/ceramic crown (D2740) and a core buildup, including any pins when required 
(D2950) for teeth# 30 and 31.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 6, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service 
on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on September 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual wellness visit (AWV) (G0439) provided on 
October 18, 2022. 
 
You asked the Plan to pay for the AWV. You say that you do not feel that you received an annual wellness visit 
during your previous visit. The Plan denied your request. The Plan says the benefit limit for this service has 
been exceeded. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. 
Therefore, we decided that the Plan does not have to pay for the annual wellness visit (AWV) (G0439) 
provided on October 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visits provided on 
September 13, 2022 and September 26, 2022. 
 
You asked the Plan to waive the copayment for the office visits. You say that this physician is your primary 
care provider. The Plan denied your request. The Plan says this cost sharing was charged correctly. The 
physician became the member's primary care provider after this date of service. 
 
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 $45 
copayment for Physician/Practitioner services, including doctor's office visits.  
 
You have been asked to pay a $45 copayment for the office visits. This service falls within the 
Physician/Practitioner services, including doctor's office visits benefit category. 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 copayment for office visits provided on September 13, 2022 and September 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for presumptive drug testing (80307) provided on October 18, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for out-of-network testing. You say that these services were reasonable and 
necessary. The Plan denied your request. The Plan says out-of-network services are only covered in certain 
limited circumstances which have not been met in this case. 
 
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 presumptive drug testing (80307) provided on 
October 18, 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 subsequent hospital inpatient or observation care provided on 
July 30, 2022 and July 31, 2022. 
 
You asked the Plan to pay for subsequent hospital inpatient or observation care. The Plan denied your request. 
The Plan says an Explanation of Benefits (EOB) from the member's primary insurance carrier is needed before 
this claim can be considered. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has not received 
an EOB from the primary insurer. As the secondary insurer, the Plan cannot be held responsible for subsequent 
hospital inpatient or observation care until the primary insurer has denied the claim for these services. 
Therefore, we decided that the Plan does not have to pay for subsequent hospital inpatient or observation care 
provided on July 30, 2022 and July 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an exercise bike. 
 
You asked the Plan to pre-approve the exercise bike. You say that this equipment is medically necessary. The 
Plan denied your request. The Plan says this item is not primarily medical in nature and is therefore non-
covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an exercise bike.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve face masks. 
 
You asked the Plan to pre-approve the face masks. You say that these masks are needed for providers coming 
to your home. The Plan denied your request. The Plan says disposable face masks are not a covered item. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve face masks.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a DyAnsys auricular stimulator. 
 
You asked the Plan to pre-approve a DyAnsys auricular stimulator. You say that the services are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that no payment may be made for the implantation of 
dorsal column or depth brain stimulators or services and supplies related to such implantation, unless specific 
criteria are 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 a DyAnsys auricular stimulator. Our reviewer says that the services are not medically necessary. Our physician reviewer found this is considered an 
experimental/investigational approach to the treatment of diabetic peripheral neuropathy. Therefore, the request 
is deemed not medically reasonable and 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 DyAnsys auricular stimulator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a DyAnsys auricular stimulator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic radiology procedures of the spine provided on 
October 10 2022. 
 
You asked the Plan to pay for diagnostic radiology procedures of the spine. The Plan denied your request. The 
Plan says all services other than manual manipulation of the spine for treatment of subluxation of the spine are 
excluded when ordered or performed by a Doctor of Chiropractic. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for diagnostic radiology procedures of the spine provided on October 10 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) scan and x-ray (74176, 71045) 
provided on August 5, 2022. 
 
You asked the Plan to pay for the CT scan and x-ray. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says original Medicare would be responsible 
for payment of all Medicare covered services related or unrelated to the members terminal condition.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for a computed tomography (CT) scan and x-ray (74176, 71045) 
provided on August 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CGM. 
 
You asked the Plan to pre-approve a CGM. You say that you disagree with the denial for a glucose monitor. 
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 you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a CGM.