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

 
We decided that the Plan does not have to pre-approve Contour diabetic test strips. 
 
You asked the Plan to pre-approve the Contour diabetic test strips. You say that the items are medically 
necessary. The Plan denied your request. The Plan says this brand of diabetic test strip is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. 
 
We looked at the file and Medicare rules. The plan preferred brands are Abbott and Lifescan. No medical 
records were provided to show why these brands would be inappropriate for the enrollee. Based on this 
information, we decided that Medicare rules for coverage of the Contour diabetic test strips have been met. 
Therefore, we decided that the Plan does not have to pre-approve Contour diabetic test strips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device, nonsegmental home 
model (E0650). 
 
You asked the Plan to pre-approve a pneumatic compression device, home model. You say that the enrollee is 
no longer responsive to a compression hose and elevation. The Plan denied your request. The Plan says the 
enrollee does not meet the requirements for approval. The Plan also says the enrollee has not demonstrated a 
trial and failure of non-surgical/non-invasive therapy. 
 
The Plan follows Medicare rules. A PCD coded as E0650 or E0651 used to treat lymphedema that does not 
meet all of the requirements above is not eligible for reimbursement. Claims will be denied as not reasonable 
and necessary. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the enrollee has not demonstrated a trial and failure of a 
four-week trial. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression 
device, nonsegmental home model (E0650).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on December 6, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for drug testing. You say that you were not aware of the requirement of obtaining a 
prior authorization, specifically for this member's plan type at the time of rendering services. The Plan denied 
your request. The Plan says the rendering provider is a non-participating provider, and the referring provider 
involved in these services is a non-participating provider with the Plan. The Plan also says they did not 
authorize any services for this 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 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 drug testing provided on December 6, 2021, by an 
out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional outpatient physical therapy (PT) visits for the 
enrollee. 
 
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary until the 
enrollee can ambulate household distances up to 150 feet safely and reliably without a device. The Plan denied 
your request. The Plan says reasonable functional goals and expected outcomes have been achieved. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy.  
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 additional visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has improved with skilled therapy as per PT 
documentation. Continued therapy is repetitive. At this point, the enrollee does not need skilled therapist's 
intervention with additional visits. The enrollee has family support and has forgetfulness and additional therapy 
will not yield any further progress. 
 
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 additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional outpatient physical therapy (PT) visits for the enrollee.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to reimburse you at an OON benefit level for the wheelchair provided on 
November 8, 2021. 
 
You asked the Plan to reimburse you at an in-network benefit level for the wheelchair. You say that you 
purchased the wheelchair from the OON provider because the in-network provider would not submit your 
order. The Plan denied your request. The Plan says that there was no prior authorization in their system. 
 
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 does not say in clear and accurate terms 
that a prior authorization is needed for Out-of-Network Medicare-covered durable medical equipment.  
 
We looked at your contract with the Plan. We did not see where the contract says a prior authorization is 
needed for durable medical equipment over $500. This means that the Plan did not follow Medicare rules for 
disclosure of cost sharing information. The Plan contract clearly says that durable medical equipment from an 
out-of-network provider is covered at 30% coinsurance Therefore, we decided that the Plan has to reimburse 
you at an OON benefit level for the wheelchair provided on November 8, 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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for adenomatous polyposis coli (APC) (eg, familial 
adenomatosis polyposis (FAP), attenuated FAP) gene analysis; full gene sequence (81201) provided November 
12, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the services in question were clearly 
medically necessary, as evidence by the enclosed requisition form from the enrollee's treating physician. The 
Plan denied your request. The Plan says screening genetic testing are not a covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the laboratory services, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for adenomatous polyposis coli (APC) (eg, familial adenomatosis polyposis (FAP), attenuated FAP) gene 
analysis; full gene sequence (81201) provided November 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Genomic Profiling Test provided on October 31, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Genomic Profiling Test. You say that the provider is the sole provider of the test. 
The Plan denied your request. The Plan says the provider is out-of-network and authorization is required prior 
to an out-of-network visit. 
 
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 Genomic Profiling Test provided on October 31, 
2021 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. 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 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 care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not require skilled nursing services or 
skilled therapy services with the specialized skill, knowledge and judgment of a skilled professional nurse to 
safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not require 
skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a 
practical matter you do not require the necessary services 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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy (S9502) provided from November 11, 
2021, to November 14, 2021. 
 
You asked the Plan to pay for home infusion therapy. You say that this should be covered. The Plan denied 
your request. The Plan says this was not billed with a valid code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
 We find that CPT code S9502 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code S9502 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay 
for home infusion therapy (S9502) provided from November 11, 2021, to November 14, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. 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 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 care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing 
services or skilled therapy services with the specialized skill, knowledge and judgment of a skilled professional 
nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee 
does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily 
basis" in a SNF.  As a practical matter this enrollee does not require the necessary services 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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a segmental pneumatic appliance for use with a 
pneumatic compressor, full leg (E0667, E0661) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a segmental pneumatic appliance. You say that the requested device is 
medically necessary. The Plan denied your request. The Plan says there are in-network provider(s) within a 
reasonable distance from your location that can provide this service or item. 
 
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 
a segmental pneumatic appliance for use with a pneumatic compressor, full leg (E0667, E0661) to be provided 
by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. 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 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 care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing 
or skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to 
prevent deterioration of your condition. Your care needs, as a practical matter, can be provided at a lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction, erupted tooth or exposed root (elevation 
and/or forceps removal) (D7140), intravenous moderate (conscious) sedation/analgesia- first 15 minutes 
(D9239), intravenous moderate (conscious) sedation/analgesia  each subsequent 15-minute increment (D9243) 
and infiltration of sustained release therapeutic drug, per quadrant (D9613) provided December 2, 2021. 
 
You asked the Plan to pay for the tooth extraction, intravenous moderate sedation and infiltration of sustained 
release therapeutic drug. You say that you were advised by a customer service representative after the services 
were performed, that extractions are covered under your plan. The Plan denied your request. The Plan says 
these services are not covered under your benefits. 
 
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 pay for the 
extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140), intravenous moderate 
(conscious) sedation/analgesia- first 15 minutes (D9239), intravenous moderate (conscious) sedation/analgesia 
 each subsequent 15-minute increment (D9243) and infiltration of sustained release therapeutic drug, per 
quadrant (D9613) provided December 2, 2021.  
 
Your complaint about potentially receiving misinformation from a plan representative is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on October 12, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for drug testing. You say that you were not aware of the requirement of obtaining 
prior authorization, specifically for this member's plan type at the time of rendering services. The Plan denied 
your request. The Plan says the rendering provider is a non-participating provider, and the referring provider 
involved in these services is a non-participating provider with the Plan. The Plan also says that they did not 
authorize any services for the rendering 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 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 drug testing provided on October 12, 2021, by an 
out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. 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 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 care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not require skilled nursing services or 
skilled therapy services with the specialized skill, knowledge and judgment of a skilled professional nurse to 
safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not require 
skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a 
practical matter you do not require the necessary services 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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower eyelid blepharoplasty. 
 
You asked the Plan to pre-approve a lower eyelid blepharoplasty. 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 blepharoplasty, blepharoptosis and lid reconstruction 
may be defined as any eyelid surgery that improves abnormal function, reconstructs deformities, or enhances 
appearance. 
 
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 lower eyelid blepharoplasty. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the documentation 
does not support that the right lower eyelid is interfering with vision or the enrollee's visual field. 
 
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 lower eyelid blepharoplasty have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a lower eyelid blepharoplasty.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Drug test provided on December 10, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Drug test. You say that you would like to appeal the denial of the claim. The 
Plan denied your request. The Plan says prior authorization is required for an out-of-network visit. 
 
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 Drug test provided on December 10, 2021 by an 
out-of-network (OON) provider.