Persius/hicric huggingface dataset:
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 
enrollee did not meet the criteria. 
 
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 the enrollee uses insulin 
with at least three daily injections or requires 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 pay for a pneumatic compression device (E0676\5 and E0673). 
 
You asked the Plan to pay for a pneumatic compression device. You say that the items are medically necessary. 
The Plan denied your request. The Plan says the pneumatic compression device is not covered to prevent deep 
vein thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
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, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676\5 and E0673).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence liners and a power seat elevation feature 
for the enrollee. 
 
You asked the Plan to pre-approve incontinence liners and a power seat elevation feature. You say that these 
items are medically necessary. The Plan denied your request. The Plan says that these items are not covered by 
Medicare. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable. Medicare rules also say that a power seat elevation 
feature is non-covered because it is not primarily medical in nature. 
 
While incontinence supplies and a power seat elevation feature may be appropriate in this case, neither the Plan 
nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve 
incontinence liners and a power seat elevation feature for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need transportation 
to get to medical appointments. The Plan denied your request. The Plan says you have utilized the maximum 
number of transportation trips allowed per year. 
 
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 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 routine transportation trips (A0120).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation (A0170). 
 
You asked the Plan to pre-approve additional mileage for routine transportation. You say that you need to get 
to your medical appointments. The Plan denied your request. The Plan says your benefit only allows 36 one-
way trips with each one-way trip not exceeding 50 miles of driving distance. 
 
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 routine transportation when the driving distance for a one-way trip is within 50 miles.  
 
   
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, the provider is 
located 69 miles away from your residence. The Plan only covers distances up to 50 miles. Therefore, we 
decided that the Plan does not have to pre-approve additional mileage for routine transportation (A0170).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve homecare services-personal care to be provided by your 
friend (CPT code T1019). 
 
You asked the Plan to pre-approve the services. You say that you are requesting homecare services-personal 
care to be provided by a friend because you will be starting chemo/radiation soon. The Plan denied your 
request. The Plan says the services are not covered by Medicare or the health plan. The Plan must follow 
Medicare rules. 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. Your EOC specifically lists homemaker services as being 
excluded from coverage Therefore, we decided that the Plan does not have to pre-approve homecare services-
personal care to be provided by your friend (CPT code T1019).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the custodial care services provided on October 26, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the custodial care services. You say that the enrollee is an established patient. 
The Plan denied your request. The Plan says the rendering provider is an out-of-network provider and there 
was no referral from an in-network provider or an approved authorization. Also, the service rendered was not 
urgent or emergent. 
 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 custodial care services provided on October 
26, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prostate cancer screening; prostate specific antigen test 
(psa) provided November 22, 2021. 
 
You asked the Plan to pay for prostate cancer screening. You say that you are appealing the denial of the PSA 
blood testing. The Plan denied your request. The Plan says the maximum benefit has been covered by the Plan 
for this service. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The health Plan contract says that this service is covered once every 12 months. The records show that this 
service was already provided on February 26, 2021. Therefore, the benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pay for the prostate cancer screening; prostate specific antigen test (psa) 
provided November 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography colonography (CTC). 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the test 
is not reliable. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The requested testing is not covered by Medicare. Therefore, we 
decided that the Plan does not have to pre-approve a computed tomography colonography (CTC).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) device and 
supplies, provided on October 30, 2020, to October 30, 2021. 
 
You asked the Plan to pay for the CPAP device and supplies. You say that the items should be covered. The 
Plan denied your request. The Plan says in order for the claims to be processed they need to be billed to the 
primary insurance carrier on file prior to being billed to the secondary insurance carrier. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible 
for the CPAP device and supplies until the primary insurer has denied the claim for these services. Therefore, 
we decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) device and 
supplies, provided on October 30, 2020, to October 30, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasounds of the breasts (76641-RT, 76641-LT) 
provided on December 3, 2021. 
 
You asked the Plan to pay for the ultrasounds. You say that these services were necessary and should be paid. 
The Plan denied your request. The Plan says this is a duplicate claim. The first submission of this claim has 
already been paid under a separate claim number. 
 
The Plan must follow Medicare rules. Medicare rules say that claims that have been determined to be an exact 
duplicate are rejected and do not have appeal rights.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ultrasounds have not been met.  
 
 Specifically, documentation supports that an identical claim for these exact services rendered by the same 
provider on the same date for the same beneficiary have already been paid. Therefore, we decided that the Plan 
does not have to pay for the ultrasounds of the breasts (76641-RT, 76641-LT) provided on December 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional drainage bags (A4358). 
 
You asked the Plan to pre-approve additional drainage bags. You say that additional leg begs are necessary. 
The Plan denied your request. The Plan says additional quantities are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare covers a quantity of two vinyl drainage bags at a time.  
Quantities over the allowed amount will be denied as non-covered. Therefore, we decided that the Plan does 
not have to pre-approve additional drainage bags (A4358).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on August 8, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you did 
not feel it was necessary to go to the emergency room and were not told that the decision would cost you 
$500.00. The Plan denied your request. The Plan says the ambulance was called, and you were not transported 
to an emergency facility. The Plan also says that the Medicare ambulance benefit is a transport benefit, and if 
no transport of a Medicare beneficiary occurs, then there is no Medicare covered services. 
 
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 August 8, 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 the ambulance response and treatment with no 
transport (A0998) provided on August 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) (K0554) and 
supplies (K0553). 
 You asked the Plan to pre-approve a CGM and supplies. You say that the items are medically necessary. The 
Plan denied your request. The Plan says there is no evidence the requested items are medically necessary. 
 
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 a continuous glucose monitor (CGM) 
(K0554) and supplies (K0553) have been met. Medical records were not submitted in order to determine the 
medical necessity of the requested items. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor (CGM) (K0554) and supplies (K0553).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power lift toilet seat. 
 
You asked the Plan to pre-approve a power lift toilet seat. You say that a power lift toilet seat is medically 
necessary. The Plan denied your request. The Plan says a power lift toilet seat is not covered by Medicare. 
 
The Plan covers all items that Medicare covers. Medicare rules state that toilet seats (all types) are not covered 
because they are not primarily medical in nature. While the requested toilet seat may be appropriate in this 
case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not 
have to pre-approve a power lift toilet seat.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a rolling knee walker (A9270). 
 
You asked the Plan to pre-approve a rolling knee walker. You say that the item is medically necessary. The 
Plan denied your request. The Plan says this item does not meet the definition of durable medical equipment. 
 
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 a rolling knee walker (A9270).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 
You asked the Plan to pre-approve Evenity. You say that the enrollee has a high fracture risk and long exposure 
to bisphosphonate medication. The Plan denied your request. The Plan says the records did not show a history 
of fracture. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Evenity. Our physician reviewer found 
that in this case, the record indicates the enrollee has a diagnosis of osteoporosis. The enrollee has had 
traumatic fractures but does not indicate a high osteoporotic fracture risk. The FDA has not stated that the 
requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia do not contain 
a supportive citation for the use of the requested drug in the enrollee's clinical situation. The documentation 
does not support that the requested drug is safe and effective and otherwise reasonable and necessary for 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 Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the addition, endoskeletal system, below knee (BK), 
alignable system (L5910). 
 
You asked the Plan to pre-approve the addition, endoskeletal system, below knee (BK), alignable system. You 
say that the item is medically necessary. The Plan denied your request. The Plan says the requested alignable 
system is not consistent with the function of the current, approved preparatory prosthesis. 
 
The Plan must follow Medicare rules. Medicare rules say that a prosthesis as well as 
additional and components are approvable in accordance with the functional level of the beneficiary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the addition, endoskeletal system, below knee (BK), alignable system have not been met. 
Specifically, the member was approved for a non-alignable system, the requested item is for an alignable 
system. Therefore, we decided that the Plan does not have to pre-approve the addition, endoskeletal system, 
below knee (BK), alignable system (L5910).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan. 
 
You asked the Plan to pre-approve Hyalgan. The Plan denied your request. The Plan says the enrollee has not 
had a bad side effect with Orthovisc, and Synvisc or Synvisc One. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage for any 
service, the information submitted 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. In this case, there are no medical records to show that coverage 
criteria have been met. The file shows that the Plan requested additional information with no success. 
Therefore, we decided that the Plan does not have to pre-approve Hyalgan.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested SNF care is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says that medical necessity rules for the requested SNF 
care have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is medically reasonable and necessary in this case. Our physician reviewer found that the 
enrollee does have documented skilled nursing needs. Ongoing monitoring of the enrollees bowel movements, 
fluid status, electrolytes and vital signs is medically necessary and reasonable. The enrollee also has 
documented skilled therapy needs. The enrollee is functioning below her baseline. Daily skilled services are 
required to establish a maintenance program and/or to prevent deterioration of the enrollees condition. The 
provided documentation does not yet show that the enrollee has reached a new, lower, permanent, level of 
function. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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.