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

 
We decided that the Plan does not have to pre-approve Freestyle Libre continuous glucose monitor (CGM) 
supplies. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the criteria for coverage are not 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 the enrollee does not treat with 
insulin three or more times per day or use an insulin pump. When the criteria for a CGM are not met, the supplies are also not covered. Therefore, we decided that the Plan does not have to pre-approve Freestyle Libre 
continuous glucose monitor (CGM) supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dialysis services to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve dialysis services. You say that you do not want to change facilities. The 
Plan denied your request. The Plan says they will transition your dialysis services with a contracted dialysis 
center. 
 
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 dialysis services to be provided by an out-of-
network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dialysis services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the dialysis services. You say that it is medically necessary for the enrollee 
to obtain the services. The Plan denied your request. The Plan says the requested provider is an OON provider 
and there is an approved authorization for an in-network provider who provides the same quality of service. 
Also, the Plan says they temporary approved services with the OON provider until February 5, 2022, while the 
enrollee transitions to the in-network 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 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 
the dialysis services to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chest X-ray (71045) provided on October 27, 2021. 
 
You asked the Plan to pay for a chest X-ray. You say that the service at issue was a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the claim at 
issue is a duplicate of a prior claim that has been processed and paid. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a chest X-ray have not been met. Specifically, the Plan has documented that the claim at issue is a 
duplicate of a prior claim that has been processed and paid.  
 
 
 
  
Therefore, we decided that the Plan does not have to pay for a chest X-ray (71045) provided on October 27, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neurology services from an out of network (OON) 
provider. 
 
You asked the Plan to pre-approve the OON neurology services. You say that you have been struggling with 
your balance for some time. You say that you have two friends who have experienced the same symptoms as 
you and recovered after seeing the requested out of network provider. You say that you are interested in 
improving your quality of life. The Plan denied your request. The Plan says the records show that you have 
entered into hospice. The Plan says that any requests for coverage must be submitted to Medicare directly for 
further processing. 
 
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 records show that you are under the Medicare hospice benefit at the time your request for coverage and 
your appeal were made. Therefore, we decided that the Plan does not have to pre-approve neurology services 
from an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
 
You asked the Plan to pre-approve a Freestyle Libre CGM. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested 
CGM. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre continuous glucose monitor (CGM)
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that the enrollee needs relief from her ongoing pain. 
The Plan denied your request. The Plan says that the clinical value and effectiveness of the Intracept procedure 
in the setting of chronic vertebrogenic low pain has not been demonstrated in the peer-reviewed literature. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. There are multiple 
plausible pathologic sources of significant pain generation. Overall, documentation is lacking regarding 
reasonably detailed and/or evidenced findings supportive of the spinal vertebral bodies as being the 
overwhelming primary generators of the enrollees chronic persistent pain. The non-radiating midline back 
pain, the noted pain-aggravating and pain-relieving factors, and intact neurologic exam are all non-specific to 
any pathologic entities. In this case, there are multiple plausible pathologic sources of significant pain 
generation. Documentation does not support actual formal surgical ablation of pre-designated basivertebral 
nerves as being medically necessary and/or reasonable at this time. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Our 
physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for massage therapy provided on January 1, 2021. 
 
You asked the Plan to reimburse you for massage therapy. You say that massage therapy is medically 
necessary for your upper and lower spine. The Plan denied your request. The Plan says deep tissue massage 
services are not covered under the Wellness Allowance benefit. In addition, deep tissue massage services are 
not a covered benefit by Medicare. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to reimburse you for massage therapy provided on January 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter accessory package. 
 
You asked the Plan to pre-approve these services. You say that you need bigger tires, reflectors, and lights to 
be able to get around outside. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter accessory package.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested IRF care is medically necessary. The 
Plan denied your request. The Plan says the requested IRF care does not meet criteria. 
 
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 the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical and/or occupational therapy, there is not a reasonable expectation that the 
enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. Medically necessary care can be provided in a different 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya for the enrollee. 
 
You asked the Plan to pre-approve Ilumya. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is no indication their preferred drugs would likely be less effective, and/or 
cause adverse effects for the member. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Ilumya. Our reviewer says that Ilumya 
is not medically reasonable and necessary. The enrollee has not tried and failed the preferred step therapy 
drugs, Remicade, Inflectra, infliximab or Stelara. The documentation does not support that the preferred step 
therapy drugs would likely be less effective, and/or would likely have adverse effects for the enrollee in this 
case. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Ilumya. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Ilumya for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wig (A9282) provided on January 28, 2022. 
 
You asked the Plan to pay for a wig. You say that it is clear under the benefit coverage that the item is 
reimbursable and prothesis not for cosmetic purposes. The Plan denied your request. The Plan says the 
requested item is not a covered benefit. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pay for a wig (A9282) 
provided on January 28, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided to the enrollee on 
December 2, 2021. 
 
You asked the Plan to pay for the services. You say that the services provided were medically necessary, and 
meet all applicable professionally recognized standards of healthcare. The Plan denied your request. The Plan 
says there was no documentation of contact in the patient record. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for outpatient mental health services provided to the 
enrollee on December 2, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from November 5, 2021, 
through January 3, 2022. 
 
You asked the Plan to pay for the home health services. You say that this enrollee has out-of-network benefits 
that should apply here. The claim should be reprocessed to pay. The Plan denied your request. The Plan says 
this was not billed with a valid TOB code for home health agency billing. 
 The Plan must follow Medicare rules. Medicare rules say that valid TOB codes for home health claims include 
0327, 0328, and 0329. In addition, the rule indicate that payment is made based on 30-day episodes of care. 
 
We looked at the file and Medicare rules. This was billed with TOB 0323, which is not a valid TOB for home 
health claims. This episode of care was billed for 60 days, which is not appropriate for Medicare billing for 
dates of service after January 1, 2020. Based on this information, we decided that Medicare rules for coverage 
of the home health services have not been met. Therefore, we decided that the Plan does not have to pay for the 
home health services provided from November 5, 2021, through January 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve portable oxygen. 
 
You asked the Plan to pre-approve these services. You say that you need the oxygen to leave your house for 
daily errands. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve portable oxygen.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc (J7325). 
 
You asked the Plan to pre-approve Synvisc. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for the requested viscosupplement device. 
 
  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Synvisc. Our reviewer says that 
Synvisc is not reasonable and necessary. Our physician reviewer found the case file does not contain 
documentation of trial and failure of Orthovisc or Supartz FX. Our reviewer also found that the documentation 
does not support that Orthovisc or Supartz FX would likely be less effective, and/or would likely have adverse 
effects for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Synvisc (J7325).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder testing provided on January 13, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that CPT codes 0012M and 0013M are non-covered 
for CxBladder testing.  
 
We looked at the file and Medicare rules. The requested CxBladder testing was billed with code 0012M. Per 
LCD L35396, this code is non-covered. Based on this information, we decided that Medicare rules for coverage 
of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the CxBladder 
testing provided on January 13, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided December 22, 2021. 
 
You asked the Plan to pay for the ambulance response. You say that it was determined that you were not 
having a heart attack, so you chose not to be transported to the hospital due to concerns about COVID-19. The 
Plan denied your request. The Plan says this service is not covered when there is no transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.   
The ambulance company did not provide transport services on December 22, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The trip report in this case shows that the enrollee refused transport to the hospital and thus the wavier criteria 
is not met. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, 
no transport (A0998) provided December 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
October 25, 2021, to October 29, 2021. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that the stay would not have 
happened if your pacemaker was checked the first time. 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 $350 per 
day for days 1-5 and $0 after day 5 for each inpatient admission.  
 
The file shows that you were in the hospital from October 25, 2021, to October 29, 2021, but there is no 
copayment for the discharge date. Therefore, you have been asked to pay $350 per day for the first 4 days of 
inpatient care. The total for your stay is $1,400 ($350 copayment x 4 days = $1,400). The inpatient care falls 
within the Inpatient Hospital Care 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 
inpatient hospital care provided from October 25, 2021, to October 29, 2021.