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

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6533. 
 
You asked the Plan to pre-approve the compression stockings. You say that the stockings are medically 
necessary to treat your bulging and painful veins. The Plan denied your request. The Plan says this is not a 
covered benefit. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
 
 Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6533.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant supported porcelain/ceramic crown (D6065) 
and a prefabricated abutment (D6056). 
 
You asked the Plan to pre-approve an implant supported porcelain/ceramic crown (D6065) and a prefabricated 
abutment (D6056). You say that the enrollee has already had the metal placed in their mouth.  The enrollee 
needs the crown and abutments because they are not eating well and losing weight. The Plan denied your 
request. The Plan says this service is not covered by the Plan's dental 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 pre-approve an 
implant supported porcelain/ceramic crown (D6065) and a prefabricated abutment (D6056).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical nutrition therapy services. 
 
You asked the Plan to pre-approve medical nutrition therapy services. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that you do not have a covered diagnosis for the 
requested services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes. 
 
Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does 
not have to pre-approve medical nutrition therapy services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit with a specialist (99204, 
99214) provided on September 9, 2021, through December 10, 2021. 
 
You asked the Plan to waive the copayment for office visits. You say that you disagree with the copayment 
amount. You would like the Plan to pay the full amount for the two dates of service. The Plan denied your 
request. The Plan says the copayment you are being assessed is correct. 
 
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 $25 
copayment for each non-preventive Medicare-covered outpatient physician services visit for the diagnosis and 
treatment of diseases and injuries of the eye, including treatment for age-related macular degeneration.  You have been asked to pay a $25 copayment for each office visit. The EOC confirms that $25 is the required 
copayment for this service. 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 office visit with a 
specialist (99204, 99214) provided on September 9, 2021, through December 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional routine transportation trips to healthcare locations 
other than your primary care physician's office. 
 
You asked the Plan to provide additional transportation. You say that you cannot drive or use public 
transportation due to health concerns, and this transportation is necessary for you to see your doctors. You need 
more rides as you will run out soon. The Plan denied your request. The Plan says your benefit covers up to 48 
trips to health care locations other than your primary care provider's office. Additional trips are not a covered 
benefit. 
 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 48 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that your request exceeds the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to provide additional routine transportation trips to healthcare locations 
other than your primary care physician's office.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an osteogenic stimulator. 
 
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says you do 
not have a broken long bone. 
 
The Plan must follow Medicare rules. The rules say that an electrical bone growth stimulator is covered for 
nonunion of long bone fractures.  
 
The file shows that you have a fracture of the proximal phalanx of the left great toe. In this case, nonunion of a 
long bone fracture is not considered to exist under Medicare rules. Based on this information, we decided that 
the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-
approve an osteogenic stimulator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement prosthesis and features to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a replacement prosthesis. You say that the enrollee's primary care physician 
referred him to you for these services. The enrollee is a great candidate for your technology. The Plan denied 
your request. The Plan says enrollees must receive their medical services from an in-network provider with the 
exception being urgent or emergent services. Non-emergent services with non-contracted providers require 
prior authorization before services being rendered. 
 
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 replacement prosthesis and features to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external upper limb tremor stimulator of peripheral 
nerves of the wrist (K1018) and monthly supplies for use of device coded at K1018 (K1019). 
 
You asked the Plan to pre-approve an external upper limb tremor stimulator and monthly supplies. You say that 
the requested device is medically necessary. The Plan denied your request. The Plan says the requested device 
does not meet criteria. 
 
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 an external upper limb tremor 
stimulator and monthly supplies. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the Cala Trio is a noninvasive 
neuromodulation device that is worn on the wrist for the treatment of essential tremor. The limited available 
evidence suggests that the Cala Trio device may reduce tremor severity during three months of use. However, 
no published studies compare Cala Trio with other treatments for essential tremors. It has not been shown that 
this therapeutic modality is at least as beneficial as an existing and available medically appropriate alternative. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an external upper limb tremor stimulator and monthly supplies have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an external upper limb tremor stimulator 
of peripheral nerves of the wrist (K1018) and monthly supplies for use of device coded at K1018 (K1019).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro 2, Motion G orthotic device (L8702). 
 
You asked the Plan to pre-approve the orthotic device. You say that the MyoPro is a covered device within the 
DME benefit category under Original Medicare. The Plan denied your request. The Plan says this item is 
considered experimental and investigational. There is insufficient evidence of its effectiveness in those with 
stroke and hemiparesis. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the MyoPro 2, Motion G orthotic device (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression garments. 
 
You asked the Plan to pre-approve compression garments. You say that the requested items are a medical 
necessity for you. The Plan denied your request. The Plan says rules for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of compression garments. have been met. 
Therefore, we decided that the Plan does not have to pre-approve compression garments.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided to the enrollee on August 26, 
2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says this claim must be submitted to Original Medicare first. 
 
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 enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for medical services provided to the enrollee on August 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on January 20, 
2022. 
 
You asked the Plan to waive the copayment for laboratory services. You say that you should not have to pay 
anything for the lab work. You also say this is not a hospital lab. 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 in-network lab services 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 
$45 copayment for laboratory services. Laboratory services 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 
laboratory services provided on January 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laboratory testing. 
 
You asked the Plan to pre-approve laboratory testing. You say that you need this to be diagnosed. The Plan 
denied your request. The Plan says this testing was not ordered by your doctor. 
 
The Plan must follow Medicare rules. Medicare rules say that in order to be covered, laboratory services must 
be related to a patients illness or injury (or symptom or complaint) and ordered by a physician. 
 
We looked at the file and Medicare rules. The submitted documentation does not indicate the requested testing 
was ordered by a physician. Based on this information, we decided that Medicare rules for coverage of 
laboratory testing have not been met. Therefore, we decided that the Plan does not have to pre-approve 
laboratory testing.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT scan (70450) provided on January 14, 2021. 
  You asked the Plan to pay for the CT scan (70450). You say that the patient had multiple exams on this date of 
service and the reports support the level of service. You say that the claim should be reconsidered for 
processing. The Plan denied your request. The Plan says an appropriate modifier was not billed with this code 
edit. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the CT scan (70450) provided on January 14, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an exercise/strength training program with an exercise 
coach. 
 
You asked the Plan to pre-approve an exercise/strength training program. You say that the two physical therapy 
sessions per week have not been sufficient for your medical concerns. You would like the Plan to cover an 
exercise/strength training program, which you have been completing with an exercise coach, because you have 
been seeing results from this alternative treatment. The Plan denied your request. The Plan says that neither 
Original Medicare nor the Plan cover services from exercise coaches, gym memberships or personal trainers 
who are not licensed therapists. You may be referred to a physical therapist if you would like to resume in-plan 
physical therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover gym benefits.  
 
The services at issue in this appeal are gym benefits. Therefore, we decided that the Plan does not have to pre-
approve an exercise/strength training program with an exercise coach.
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. You say that you are taking oral medications that can 
lower blood sugars. The Plan denied your request. The Plan says criteria has not been 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 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response with no transport provided on December 
26, 2021. 
 
You asked the Plan to pay for ambulance response with no transport. You say that this bill should be paid by 
the Plan. The Plan denied your request. The Plan says ambulance response with no transport is not covered by 
Medicare. 
 
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 26, 2021. The 
ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays 
for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response 
with no transport provided on December 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a routine ophthalmologist exam (S0620), an eye refraction 
(92015), eyeglass frames (V2020) and bifocal lenses (V2200) provided on October 4, 2021. 
 You asked the Plan to pay for vision services. You say that you are requesting reconsideration for payment on 
the enrollee's vision claim. The Plan denied your request. The Plan says vision services will only be covered 
when they are received from a provider in the specified vision network. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan contract says the enrollee has a $100 allowance every calendar year for covered eye wear 
purchased from a network provider. The Plan also says the member is responsible for all costs for eye wear 
purchased from an out-of-network provider. 
 
We looked at the file and the Plan's rules. The provider in this case is not part of the Plans vision network. The 
Plan covers vision services when they are received from a provider who participates in the Plans specified 
vision network. Based on this information, we decided that the Plan's rules for coverage of vision services have 
not been met. Therefore, we decided that the Plan does not have to pay for a routine ophthalmologist exam 
(S0620), an eye refraction (92015), eyeglass frames (V2020) and bifocal lenses (V2200) provided on October 
4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve infrared therapy. 
 
You asked the Plan to pre-approve infrared therapy. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that infrared therapy is non-covered.  
 
We looked at the file and Medicare rules. Infrared therapy is non-covered. Based on this information, we 
decided that Medicare rules for coverage of infrared therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve infrared therapy.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient mental health services provided on November 
16, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there was no 
documented contact with the attending/primary care physician.  
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 the outpatient mental health services provided on 
November 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SPRINT peripheral nerve stimulation (PNS) system 
(64555, 76942). 
 
You asked the Plan to pre-approve the SPRINT PNS system. You say that the denial for this procedure is 
unwarranted and unsupported. The Plan denied your request. The Plan says this procedure is unproven as there 
is insufficient evidence in its effectiveness and overall support for use in chronic pain management. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the SPRINT PNS system have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the SPRINT peripheral nerve stimulation (PNS) system (64555, 76942).