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

 
We decided that the Plan does not have to pre-approve a motorized wheelchair (K0823). 
 
You asked the Plan to pre-approve a motorized wheelchair. You say that a motorized wheelchair is medically 
necessary. The Plan denied your request. The Plan says that there is not standard written order or face-to-face 
evaluation on file for a power operated vehicle. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery. The rules also state that if the treating practitioner does not conduct the 
face-to-face encounter or write the SWO for the PMD base item, the claim will be denied as non-covered.  The record does not contain a valid physician order or face-to-face evaluation recommending the requested 
motorized wheelchair. Therefore, we decided that the Plan does not have to pre-approve a motorized 
wheelchair (K0823).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown-porcelain fused to high noble metal (D2750) 
for tooth #21, #22, #23, #24, #25, #26, and #27. 
 
You asked the Plan to pre-approve the dental services. You say that you are requesting reconsideration for the 
denial of a crown (D2750 x7). The Plan denied your request. The Plan says this service is not medically 
necessary, and criteria has not been met. 
 
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 a crown 
(D2750) 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 a crown (D2750 x7).  Our reviewer 
says that the documentation provided does not meet the criteria for coverage for D2750 for teeth #'s 21-27. 
Our physician reviewer found that a review of the documentation does not indicate that teeth #'s 21-27 have 
significant coronal breakdown due to caries or fracture to warrant crown restorations. 
  
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 a crown (D2750 x7) have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a crown-porcelain fused to high noble metal (D2750) for tooth #21, #22, #23, 
#24, #25, #26, and #27.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for medical supplies provided on October 28, 
2022, to October 31, 2022. 
 
You asked the Plan to waive the coinsurance for medical supplies. You say that you have not received a bill in 
the past year. 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 20% 
coinsurance for durable medical equipment (DME).  
 
You have been asked to pay a $19.01 coinsurance for medical supplies ($95.14 allowed amount x 20% 
coinsurance = $19.01, rounded down). This item/service falls within the durable medical equipment (DME) 
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 coinsurance for medical supplies provided on 
October 28, 2022, to October 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SSBCI. 
 
You asked the Plan to pre-approve SSBCI. You say that you do not have alcohol dependency or dementia. The 
Plan denied your request. The Plan says there is no documentation submitted that the member meets criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI have not been met. Specifically, we have confirmed that you do not have one of the eligible 
conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to pre-
approve SSBCI.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repatha Sureclick. 
 
You asked the Plan to pre-approve Repatha Sureclick. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says Medicare Part B is not responsible for self-administered drugs. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Repatha Sureclick.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 72-trip limit. 
 
You asked the Plan to pre-approve additional trips beyond the Plan's 72-trip limit. You say that you need 
additional transportation to dialysis appointments. The Plan denied your request. The Plan says the requested 
trips exceed your trip limit. 
 
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 72 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 trips for routine transportation beyond the Plan's 
72-trip limit.
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 you need the pads daily. The Plan 
denied your request. The Plan says the Health Plan and Medicare 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 incontinence supplies.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 4, 2022, to July 
29, 2022. 
  You asked the Plan to pay for the home health services. You say that you submitted proof of the NOA 
submission, and the claim should be reconsidered for coverage. The Plan denied your request. The Plan says 
the NOA was not received, and the final claim was correctly denied. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the claim lists the start of care date as June 4, 2022, and the NOA was not received by the Plan. As 
more than 30 days passed from the timely filing date for the NOA, no payment can be made on this claim. 
Therefore, we decided that the Plan does not have to pay for the home health services provided from July 4, 
2022, to July 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of arm joint 
(73221). 
 
You asked the Plan to pre-approve an MRI of arm joint. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 an MRI of arm joint. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found detailed documentation is not evident 
regarding a trial and failure of formal physical therapy for the left elbow. There is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of arm joint have not been met. Therefore, we decided that the Plan 
does not have to pre-approve magnetic resonance imaging (MRI) of arm joint (73221).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an osteogenesis stimulator (E0760). 
 
You asked the Plan to pre-approve an osteogenesis stimulator. You say that the enrollee needs a bone simulator 
to assist in healing from bone fracture. The Plan denied your request. The Plan says the first series of left foot 
x-ray that showed a fracture on the enrollee's foot was noted on January 10, 2023, and the last left foot x-ray 
was on March 9, 2023. The Plan also says the gap between both x-rays showing fracture and non-union still 
does not exceed 90 days. 
 
The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion 
of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs 
have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the 
electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs 
separated by a minimum of 90 days.  
 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 an osteogenesis stimulator. Our 
reviewer says that the requested bone stimulator is not medically reasonable or necessary for this enrollee at 
this time. Our physician reviewer found the medical documentation establishes that x-rays dated January 10, 
2023, revealed an incomplete fracture of the proximal fifth metatarsal left side. X-rays on March 9, 2023, also 
noted a fracture of the fifth metatarsal diaphyseal metaphyseal junction consistent with a Jones fracture with a 
2-millimeter displacement. Our reviewer found that a possible nonunion was diagnosed. Our physician 
reviewer also found that the medical documentation does not support that this enrollee has two sets of x-rays 
separated by 90 days which demonstrate a nonunion of the fifth metatarsal fracture. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an osteogenesis stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an osteogenesis stimulator (E0760).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the laminectomy with decompression coded as 63030 
and 63035. 
 
You asked the Plan to pre-approve the back surgery. You say that the enrollee needs thoracic as well as lumbar 
lumpectomies as soon as possible to prevent worsening loss of lower limb function. The Plan denied your 
request. The Plan says the records do not show that the enrollee meets the criteria for the requested back 
surgery. 
 
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 back surgery. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found detailed documentation is not evident regarding a trial and failure of recent, 
reasonable, comprehensive less invasive conservative care measures including medications. There is no 
documentation of any injection therapy having been tried and failed for the lumbar spine. Moreover, there are 
no advanced diagnostic imaging studies provided for review to corroborate pathology at the requested surgical 
levels of L3-L5. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested laminectomy at L3-L5, in this case, 
is not medically reasonable or 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 back surgery have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the laminectomy with decompression coded as 63030 and 63035.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on November 11, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing.
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
November 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 7, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported as 
billed. 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 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you have mobility issues, and your spouse cannot 
assist you with activities of daily living. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary, and your needs can be met at an alternate level of care. 
 
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 you do not need physician supervision 3 times a week or intensive therapy 3 
hours a day and 5 days per week with a multidisciplinary approach in an IRF. While you may benefit from 
physical and occupational therapy your needs can be provided in an alternate setting such as skilled nursing 
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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 12, 2021. 
 
You asked the Plan to pay for the lab services. You say that this claim should be covered. 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 October 12, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the SSBCI benefits. 
 
You asked the Plan to pre-approve the SSBCI benefits. You say that you feel you are eligible for the SSBCI 
benefits. The Plan denied your request. The Plan says that you do not meet the criteria to be eligible for SSBCI 
benefits. 
 
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. Specifically, the plan did not send us medical records. You say that you should 
be eligible for SSBCI benefits due to your health issues. Without medical records, we cannot determine 
whether or not you are eligible for the benefits. Therefore, the Plan has not shown that their decision to deny 
the benefit is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pre-
approve the SSBCI benefits.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intensity modulated radiation therapy (IMRT). 
 
You asked the Plan to pre-approve IMRT. You say that IMRT is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
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 IMRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found without a dosimetric justification for IMRT over standard 3-dimensional conformal 
radiotherapy, IMRT would not be furnished in accordance with accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IMRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve intensity modulated radiation therapy (IMRT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14 continuous glucose monitor 
system. 
 
You asked the Plan to pre-approve a Freestyle Libre 14 continuous glucose monitor system. You say that the 
medical records provided support the need for the continuous glucose monitor system. The Plan denied your 
request. The Plan says the enrollee does not require insulin three or more times daily. 
 
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 14 continuous glucose monitor system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Freestyle Libre 14 continuous glucose monitor system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endocrinology services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that shrinking of nodules is time sensitive. The Plan 
denied your request. The Plan says services are available with a contract 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 OON services. Therefore, we decided that the Plan does not have to pre-approve 
endocrinology services to be provided by an out-of-network (OON) provider.