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

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), a harness (E2313), an expandable controller (E2377), a 
joystick (K0108), a width extension for footplates (K0108) and a tapered gel footplate cover for width 
extension (K0108). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the equipment was recommended by 
occupational therapy and the enrollee's doctor agreed the enrollee needs this DME. The Plan denied your 
request. The Plan says although there are three approved power options on this wheelchair, there is not a 
medical need to control these power options through the joystick. 
 
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 wheelchair accessories. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has multiple sclerosis (MS) and is able to control her current chair with 
her right arm. She has full movement in her right forearm and hand. There is no record of right-hand weakness. 
The requested footplate is miscoded and must not be used for items that have a specific HCPS code. The gel 
pads do not serve a medical need and cannot be covered. The enrollee has adequate strength in her right hand to 
manage standard switches for the power drives on her chair per Chapter 13 section 13.5.4 NMN. The request 
exceeds what is necessary to meet the enrollee's needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection between wheelchair controller and two or more power 
seating system motors (E2311), a harness (E2313), an expandable controller (E2377), a joystick (K0108), a 
width extension for footplates (K0108) and a tapered gel footplate cover for width extension (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on August 
15, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $450 
copayment for inpatient hospital care. 
 
You have been asked to pay a $450 copayment for inpatient hospital care. This item/service 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 on August 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services provided on 
November 8, 2022. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that this service should be 
covered because you pay a monthly premium. The Plan denied your request. The Plan says this cost sharing 
was charged correctly. 
 
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 $10 
copayment for Medicare-covered laboratory tests.  
 
You have been asked to pay a $10 copayment for the laboratory services. This item/service falls 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 the laboratory services provided on November 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve the bone marrow aspirate. You say that the service is medically necessary. 
The Plan denied your request. The Plan says medical studies have not proven that this procedure is helpful for 
treatment of the enrollee's health problem. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate is experimental. More research is needed to show safety and 
efficacy when used as bone graft material in spine surgery. 
 
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 bone marrow aspirate have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the bone marrow aspirate (20939).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation and cleaning (D1110, D0120) 
provided on November 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 10, 2022 and July 
12, 2022. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation and cleaning 
(D1110, D0120) provided on November 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 10, 2022. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and should be covered. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on November 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
October 31, 2022. 
 
You asked the Plan to pay for the dental services. You say that you don't know why the Plan won't help you 
pay this bill. You say this is a big bill and if you try to pay it, you won't have food. The Plan denied your 
request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service July 28, 2020. Therefore, 
we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
October 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided on  
July 15, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says your benefit for the service provided has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the service provided was exhausted on date of service July 15, 2022.  

Specifically, the Plan provides coverage for one intraoral-complete series of radiographic images or one 
panoramic radiographic image every three years. On this day, the record indicates that you received both 
services, in which the Plan issued payment for the intraoral-complete series of radiographic images provided. 
Therefore, you have exhausted the allowable benefit for this service. Therefore, we decided that the Plan does 
not have to pay for the panoramic radiographic image (D0330) provided on July 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an occlusal guard (D9944) provided on November 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 pay for an 
occlusal guard (D9944) provided on November 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic care provided on November 21, 2022. 
 
You asked the Plan to pay for chiropractic care. You say that you were unaware this was an out-of-network 
service. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for chiropractic care 
provided on November 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81455). 
 
You asked the Plan to pre-approve genetic testing. You say that the medical testing is medically necessary. The 
Plan denied your request. The Plan says your request is not medically necessary because your records show 
your ordering provider did not select the specific biomarkers to be tested and could not ensure that they are 
clinically actionable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 81455 is not supported in the medical record. Specifically, the ordering provider did not 
select the specific biomarkers to be tested. Furthermore, we need more information such as doctors notes 
confirming medical necessity for the genetic testing being requested. Based on this information, we decided 
that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve genetic testing (81455).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for computed tomography (CT) scan provided 
on November 09, 2022. 
 
You asked the Plan to waive the copayment for computed tomography (CT) scan. You say that you disagree 
with the copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $250 
copayment for outpatient diagnostic tests/Medicare-covered diagnostic radiology services. 
 
You have been asked to pay a $250 copayment for computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic tests/Medicare-covered diagnostic radiology services 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 computed tomography (CT) scan provided on November 09, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis tablets. 
 
You asked the Plan to pre-approve Eliquis tablets. The Plan denied your request. The Plan says Eliquis is a 
self-administered drug, and does not fall under Part B coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eliquis tablets.  
 
  Benefits for Eliquis tablets may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the positron emission tomography (PET) 
scan provided on August 3, 2022. 
 
You asked the Plan to waive the copayment for the PET scan. You say that the provider told you this service 
would be covered with no copay. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
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 per day for other Medicare-covered diagnostic radiology services including PET scans. 
 
You have been asked to pay a $325 copayment for a PET scan. This item/service falls 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 the positron emission tomography (PET) scan provided on August 3, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy (PT) services provided on April 18, 
2022, to April 28, 2022. 
 
You asked the Plan to pay for the physical therapy (PT) services. You say that the records provided support 
medical necessity. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the physical therapy 
(PT) services provided on April 18, 2022, to April 28, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve physical therapy services. You say that this should be covered. The Plan 
denied your request. The Plan says there are other physical therapists accepting new patients who are in-
network. 
 
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 
physical therapy services to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from June 13, 
2022, through June 14, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient hospital care provided was 
not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 these services. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee presented with chest pain for two weeks on and off and underwent a workup 
for acute coronary syndrome which revealed normal troponins, an unremarkable chest x-ray, an 
electrocardiogram without acute ST-T changes, and an unremarkable myocardial perfusion imaging (MPI) 
single-photon emission computed tomography (SPECT) test. Her vital signs were stable, and she was not in 
acute distress during the workup. Her physical examination was unremarkable. She denied any other signs or 
symptoms suggestive of a condition that would require inpatient treatment. Therefore, at the time of admission, 
it was not expected that the enrollee would require hospital services that would likely cross two midnights 
based on the provided documentation. 
 
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 pay for the acute inpatient hospital care provided from June 13, 2022, through June 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the items denied correctly as you do not meet the clinical 
requirements to be approved. 
 
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 take insulin. 
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 a continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 14-day reader. 
 
You asked the Plan to pre-approve a FreeStyle Libre 14-day reader. You say that the enrollee does not like to 
check their blood sugars three times a day because their fingers hurt doing this. You also say that the enrollee is 
checking only once a week max. The Plan denied your request. The Plan says the enrollee does not meet the 
prior authorization 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 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 14-day reader have not been met. Therefore, we decided that the Plan does not have to pre-
approve a FreeStyle Libre 14-day reader.