Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency taxi transportation (A0100). 
 
You asked the Plan to pre-approve additional taxi transportation. You say that you need transportation to your 
dialysis appointments because you do not have transportation. The Plan denied your request. The Plan says you 
have 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 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 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 non-emergency taxi transportation (A0100).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
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 or 
therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria 
for an inpatient basis in a SNF 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 SNF care.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for injections (codes J2250, J3010, and J1100) provided 
on January 4, 2022. 
 
You asked the Plan to waive the coinsurance for the injections. You say that this last injection should be 
covered. The Plan denied your request. The Plan says that you have been charged the correct cost sharing 
amount. 
 
The Plan says you must pay 20% coinsurance for the injections. According to Medicare, codes J2250, J3010, 
and J1100 are considered packaged codes and are not separately payable. Therefore, we decided that the Plan 
has to waive the coinsurance for injections (codes J2250, J3010, and J1100) provided on January 4, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says the 
device is not medically necessary. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the custom breast prosthesis, post mastectomy, molded 
to patient model (CPT code L8035). 
 
You asked the Plan to pre-approve the custom breast prosthesis. You say that the item is medically necessary. 
The Plan denied your request. The Plan says custom made breast prostheses have extra features that are not 
shown to be needed for health reasons. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The rules say that the medical necessity for the additional features of a custom fabricated prosthesis (L8035) 
compared to a prefabricated silicone breast prosthesis has not been established, and therefore, if an L8035 
breast prosthesis is billed, it will be denied as not reasonable and necessary. Therefore, we decided that the Plan does not have to pre-approve the custom breast prosthesis, post 
mastectomy, molded to patient model (CPT code L8035).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar decompression surgery for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested services are not reasonable and necessary, and the health plan has no 
contractual obligation to cover services that are not covered by Medicare. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found distraction devices in the interspinous process region remain experimental. More research is needed. 
Surgery with these devices should not be approved. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve lumbar decompression surgery for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve AQMBF, PET, rest and pharmacologic stress (List 
separately in addition to code for primary procedure) (CPT code 78434). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the enrollee's health plan does not cover the requested study. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans 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 the service. Our physician reviewer found the record indicates that the requested test is to determine myocardial viability. The record does not 
indicate that the requested test is for cancer management. The record indicates that the enrollee has atypical 
chest pain with speed walking. Electrocardiogram demonstrates a incomplete right bundle branch. The record 
provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the 
requested service. A chemical stress test can be performed. The elements of the coverage criteria are not 
satisfied. The requested service is not recommended. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve AQMBF, PET, rest and pharmacologic stress (List separately in addition to code for 
primary procedure) (CPT code 78434).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transfeminine hair removal. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says the requested procedure is cosmetic. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the record indicates that you have hypertrichosis and gender dysphoria. The record provided is 
insufficient to establish that the requested procedure is not cosmetic in nature and is medically necessary. The 
record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of 
the requested service. The elements of the coverage criteria are not satisfied. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transfeminine hair removal.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hereditary hemochromatosis (HFE) genetic testing. 
 
You asked the Plan to pre-approve HFE genetic testing. You say that the requested genetic testing (81256) for 
HFE gene analysis is medically necessary. The Plan denied your request. The Plan says the requested genetic 
testing (81256) for HFE gene analysis 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 HFE genetic testing. Our reviewer says 
that the requested genetic testing (81256) for HFE gene analysis is not medically necessary. Our physician 
reviewer found the enrollee is with diagnoses of thrombocytopenia and portal hypertension. The enrollee's 
platelet count on March 7, 2022, was 49K. The documentation in the case file does not support that HFE gene 
analysis is medically reasonable and necessary for the enrollee in this case. HFE gene analysis may be 
medically reasonable and necessary to establish or confirm the diagnosis of hereditary hemochromatosis in 
individuals with clinical symptoms, and for patients with increased transferrin-iron saturation and serum 
ferritin. There is insufficient evidence of iron overload in this enrollee. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HFE genetic testing have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Hereditary hemochromatosis (HFE) genetic testing.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional days in a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve additional SNF days. The Plan denied your request. The Plan says you no 
longer meet the health conditions to stay in a SNF. 
 
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 additional SNF days. Our reviewer says 
that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily 
skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. Our reviewer found that you do not have daily skilled therapy needs that require the specialized skill, 
knowledge, and judgment of a skilled professional therapist. Our physician reviewer also found that you do not 
require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Although you have skilled therapy needs, 
these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of 
additional SNF days have not been met. Therefore, we decided that the Plan does not have to pre-approve 
additional days in a skilled nursing facility (SNF).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the non-emergency ambulance transport (CPT code 
A0428). 
 
You asked the Plan to pre-approve the non-emergency ambulance transport. You say that the service is 
medically necessary. The Plan denied your request. The Plan says the requested non-emergency ambulance 
transportation is not medically reasonable and necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same 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 pre-approve the non-emergency ambulance 
transport. Our physician reviewer found the documentation does not support that other means of transport (such 
as stretcher van, wheelchair van) were contraindicated for this enrollee on May 26, 2022. The documentation 
does not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment 
that only a fully-equipped ambulance can provide for safe transport on May 26, 2022. The documentation does 
not support that the ambulance transport on May 26, 2022, was medically reasonable and necessary for the 
enrollee. 
 
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 non-emergency ambulance transport have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the non-emergency ambulance transport (CPT code A0428).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve replacement of implantable loop recorder (33285 
Insertion, subcutaneous cardiac rhythm monitor, including programming) for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this 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 the procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found two previous implantable loop recorders (ILRs) had been placed to search for an arrhythmic 
etiology of syncope, which has never been observed over the life of two devices. As such, based on current 
guidelines and the documentation provided, there is insufficient clinical evidence to support the medical 
appropriateness and necessity of replacing the patients old ILR with a new ILR. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve replacement of implantable loop recorder (33285 Insertion, subcutaneous cardiac rhythm 
monitor, including programming) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abdominoplasty, mastoplexy, and brachioplasty. 
 You asked the Plan to pre-approve the surgical services. You say that the service is necessary due to you 
having excess skin. The Plan denied your request. The Plan says removing extra skin on your arms, stomach 
and lifting your breasts is considered cosmetic surgery and is not a covered benefit. 
 
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 surgical services. Our physician 
reviewer found the record indicates that you have undergone weight loss. The record indicates that your weight 
has fluctuated over ten (10) pounds in the past several months. The record as provided does not indicate the 
failure of conservative treatments for intertrigo or the presence of any functional impairments. The elements of 
the coverage criteria are not satisfied. The requested service is not recommended. 
 
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 surgical services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve abdominoplasty, mastoplexy, and brachioplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a cardiology specialist office visit provided 
on February 4, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you have never been 
charged a copayment in the past for these services. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing amount. 
 
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 a specialist office visit.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay 
the allowed amount of $25.90, which is less than the $45 copayment for a specialist office visit. A specialist 
office visit falls within the Physician/Practitioner Services, Including Doctors 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 a cardiology specialist office visit provided on February 4, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a blepharoplasty of the upper eyelid 
provided on December 17, 2021. 
 
You asked the Plan to waive the copayment for a blepharoplasty. You say that you were told that Medicare 
covered this type of vision enlargement procedure. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing amount. 
 
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 $450 
copayment for outpatient surgery at an outpatient hospital.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$450 copayment for a blepharoplasty. A blepharoplasty falls within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 a blepharoplasty of the upper eyelid provided on December 
17, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve 5051 advance barrier film wands. 
 
You asked the Plan to pre-approve the items. You say that this is medically necessary due to unhealthy skin 
under the ileostomy bag. The Plan denied your request. The Plan says that an alternative item - Cavilon Barrier 
Film - can be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 the items. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation provides evidence that the approved cavilon barrier is not allowing a functional seal. 
Advance barrier film wands is needed to prevent further ostomy leaking and skin damage around ostomy; thus, 
the advance barrier film wands are medically reasonable and appropriate. 
 
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 items have been met. Therefore, we decided that the Plan has to pre-approve 
5051 advance barrier film wands.  
 
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.