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

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
applieance (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not have lymphedema extending onto 
chest, trunk, and/or abdomen. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
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 record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and segmental applieance (E0667).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laparoscopy, surgical, esophageal sphincter 
augmentation procedure, placement of sphincter augmentation device (LINX). 
 
You asked the Plan to pre-approve the LINX procedure.. You say that the service is medically necessary. The 
Plan denied your request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage is not available for LINX Reflux 
Management System, which is not a true endoluminal treatment but is also not considered reasonable and 
necessary for the diagnosis or treatment of an injury or disease. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the LINX procedure. have not been met. Therefore, we decided that the Plan does not have to pre-
approve laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter 
augmentation device (LINX).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (K0823) and batter (E2365). 
 
You asked the Plan to pre-approve a power wheelchair and battery. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the documentation that the members physician 
provided states that the member is able to walk steadily without any assistance and that the member walks for 
exercise. The documentation also does not mark that the member has any impairments with mobility relating to 
any activities of daily living within the home. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that you do not have a mobility deficit that impairs your participation in MRADLs. This means 
that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power wheelchair (K0823) and batter (E2365).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the blepharoplasty, blepharoptosis and brow repair 
(15823, 697904, and 67900). 
 
You asked the Plan to pre-approve the eyelid surgery. You say that the service is medically necessary. The Plan 
denied your request. The Plan says they did not receive any pictures that show upper eyelids and brows taped 
up to demonstrate that vision will improve with the requested surgery and the vision test did not improve when 
eyebrows were manually elevated. 
 
The Plan must follow Medicare rules. Medicare rules say that the criteria in section A (patient signs and 
symptoms), and section B (visual field) below must be documented to demonstrate medical necessity for 
blepharoplasty, blepharoptosis and brow repair 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the eyelid surgery have not been met. Therefore, we decided that the Plan does not have to pre-
approve the blepharoplasty, blepharoptosis and brow repair (15823, 697904, and 67900).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation, nerves innervating the 
sacroiliac joint, with imaging guidance (CPT 64625). 
 
You asked the Plan to pre-approve radiofrequency ablation, nerves innervating the sacroiliac joint, with 
imaging guidance. The Plan denied your request. The Plan says radiofrequency ablation, nerves innervating the 
sacroiliac joint, with imaging guidance is experimental. 
 
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 radiofrequency ablation, nerves 
innervating the sacroiliac joint, with imaging guidance. Our reviewer says that the requested radiofrequency 
ablation, nerves innervating the sacroiliac joint, with imaging guidance is not considered medically reasonable 
and necessary in this case. Our physician reviewer found this is considered an experimental/ investigational 
procedure because of the variation in efficacy in the peer reviewed literature.  Therefore, the request is 
considered 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 radiofrequency ablation, nerves innervating the sacroiliac joint, with imaging 
guidance have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency 
ablation, nerves innervating the sacroiliac joint, with imaging guidance (CPT 64625).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power seat elevation system (E2300), cup holder 
(A9900), and joystick (A9900). 
 
You asked the Plan to pre-approve the power seat elevation system, cup holder, and joystick. You say that the 
items are medically necessary. The Plan denied your request. The Plan says the joys stick is included in the 
base wheelchair and the power seat elevation system and cup holder do not primarily serve a medical purpose.  
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the power seat elevation system (E2300), cup holder 
(A9900), and joystick (A9900).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SitnStand Portable Smart Rising Seat (E1399). 
 
You asked the Plan to pre-approve the SitnStand Portable Smart Rising Seat. You say that the item is medically 
necessary. The Plan denied your request. The Plan says this item is considered a comfort or convenience item, 
and not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the SitnStand Portable Smart Rising Seat (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 14, 2021 to March 18, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the provider told you that they were in-network with 
the Plan. The Plan denied your request. The Plan says the services were provided out-of-network and were not 
approved in advance. 
 
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 the office visit provided on January 14, 2021 to 
March 18, 2021 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from October 29, 2021, to November 27, 2021. 
 You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says custodial care is not covered by Medicare. 
 
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 pay for the services. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee no longer qualified for SNF 
coverage after 10/28/21. The enrollee did not have documented skilled nursing needs. The enrollee did not 
have documented skilled therapy needs. Daily skilled services were not required to establish a maintenance 
program or to prevent deterioration of the enrollees condition. 
 
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 pay for skilled nursing facility (SNF) services provided to the enrollee from October 29, 2021, to 
November 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve therapeutic CGM. You say that the enrollee has advanced dementia so 
pricking a finger has become very hard to do. The Plan denied your request. The Plan says the enrollee does 
not meet the Medicare coverage criteria for a therapeutic 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 perform blood glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of therapeutic CGM have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diagnostic facet joint injections. 
 
You asked the Plan to pre-approve diagnostic facet joint injections. You say that this procedure is medically 
reasonable and necessary. The Plan denied your request. The Plan says this procedure is not covered given the 
enrollee's medical history. 
 
The Plan must follow Medicare rules. Medicare rules say that facet joint procedure performed after anterior 
lumbar interbody fusion or ALIF will be considered not reasonable and necessary and therefore will be denied. 
Based on this information, we decided that Medicare rules for coverage of diagnostic facet joint injections have 
not been met. Therefore, we decided that the Plan does not have to pre-approve diagnostic facet joint 
injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ROMtech Portable connect adaptive rehab device 
(E1399), and goniometer (A9900). 
 
You asked the Plan to pre-approve the ROMtech Portable connect adaptive rehab device and goniometer. You 
say that the items are medically necessary. The Plan denied your request. The Plan says these items are not 
primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the ROMtech Portable connect adaptive rehab device 
(E1399), and goniometer (A9900).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upright walker, CPAP cleaner, and safety footstep, to 
be provided by an out-of-network (OON) provider.  
You asked the Plan to pre-approve an upright walker, CPAP cleaner, and safety footstep. You say that the 
items are medically necessary. The Plan denied your request. The Plan says the items were obtained through an 
out of network provider and do not primarily serve a medical purpose. 
 
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 
an upright walker, CPAP cleaner, and safety footstep, to be provided by an out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane. 
 
You asked the Plan to pre-approve Durolane. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says step therapy criteria have not been met. 
 
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 Durolane. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the record indicates 
that the enrollee has osteoarthritis of the knees. The requested medication is a new start.  The provided records 
do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does 
not indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred 
step one alternative. The elements of the coverage criteria are not satisfied. The requested service cannot be 
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 Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durolane.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan (70480) 
provided on July 21, 2021. 
 
You asked the Plan to waive the copayment for the CT scan. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly 
based on the services provided. 
 
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 $325 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $251.63 copayment for a CT scan, which is less than the standard $325. CT 
scans fall within the Outpatient diagnostic tests and therapeutic services and supplies 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 computed tomography (CT) scan (70480) provided on 
July 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital visit provided from 
November 23, 2021, to November 26, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital visit. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
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 $300 
copayment for Inpatient hospital care.  
 
 You have been asked to pay a $300 copayment for an inpatient hospital visit. 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 an inpatient hospital visit provided from November 23, 2021, to November 26, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Continuous Glucose Monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that you would like reconsideration because the CGM is 
medically necessary. The Plan denied your request. The Plan says you do not meet Medicare criteria for 
coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the CGM have 
not been met. Therefore, we decided that the Plan does not have to pre-approve the Continuous Glucose 
Monitor (CGM).
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. The Plan denied your request. The Plan says you do not need care 
coordinated by an interdisciplinary team. 
 
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 physician reviewer found 
that you have a past medical history of cerebellar stroke, diabetes, and COPD. You are living in an assisted 
living facility with a recent fall which did not require inpatient admission. Your medical problems are stable. 
The complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation 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 waive the coinsurance for a Part B drug provided by a network 
provider on September 22, 2021. 
 
You asked the Plan to waive the coinsurance for the Part B drug. You say that you have had cortisone 
injections in the past and have not had to pay separately for them. The Plan denied your request. The Plan says 
you have been asked to pay 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 20% 
coinsurance for Medicare Part B non-chemotherapy prescription drugs.  
 You have been asked to pay $2.08 which is 20% of the allowed amount for the Part B drug. The allowed 
amount is $10.41. ($10.41 x 20% = $2.08). The Part B drug falls within the Medicare Part B prescription 
drugs 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 a Part B drug provided by a 
network provider on September 22, 2021.