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

 
We decided that the Plan does not have to pre-approve a F3 base corpus, power wheelchair, group 3 standard, 
multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0861) 
and accessories (E2311, E2377, E2313, E2361, E1007, E1028, E1012, E2208, E2603, E0955). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the wheelchair is 
medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not have a 
medical need for the requested wheelchair. 
 
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.  
 
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 a power wheelchair. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found there is documentation that the 
enrollee has a personal mobility deficit that impairs participation in mobility related activities of daily living 
such as toileting, feeding, grooming, and bathing in customary locations within the home. His mobility deficit 
cannot be helped using a walker, cane, or manual wheelchair due to his level of weakness and instability. The 
enrollee does not meet all of the Local Coverage Determination (LCD): Power Mobility Devices 33789 criteria 
for the group 3 power wheelchair with multiple power option and power tilt and power recline. Provided 
records do not fully support that the enrollee is high risk for developing pressure ulcers and cannot perform a 
functional weight shift, requires bladder catheterization, or has increased muscle tone or spasticity. 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a F3 base corpus, power wheelchair, group 3 standard, multiple power option, 
sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0861) and accessories (E2311, 
E2377, E2313, E2361, E1007, E1028, E1012, E2208, E2603, E0955).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wig (A9282) provided on July 17, 2021. 
 
You asked the Plan to pay for a wig. You say that the item at issue was a medical necessity for you. The Plan 
denied your request. The Plan says the item at issue is not a covered benefit. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
 
 
 
 
 
 
 In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pay for a wig (A9282) 
provided on July 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued use of a home ventilator. 
 
You asked the Plan to pre-approve continued use of a home ventilator. You say that the requested continued 
use of a home ventilator is medically necessary. The Plan denied your request. The Plan says the enrollee does 
not meet criteria for the requested continued use of a home ventilator. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 continued use of a home ventilator. Our 
reviewer says that the enrollee does not meet criteria for the requested continued use of a home ventilator. Our 
physician reviewer found this enrollee has chronic obstructive pulmonary disease (COPD) with frequent 
hospitalizations in the past, but not in the past year.  The enrollee has had a Trilogy ventilator since July 13, 
2021, but usage data from January 6 - April 5, 2022, show very little usage of the device, certainly not enough for it to be effective.  There is no documentation of CO2 retention, and no pulmonary function tests to 
determine severity of airways obstruction. Bipap with AVAPS has not been tried. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued use of a home ventilator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve continued use of a home ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the vision care provided by an ophthalmologist (99214) on February 7, 2022.
You asked the Plan to reduce the copayment for vision care. You say that you were expecting to only owe a $35 copayment for a specialist office visit. The Plan denied your request. The Plan says the care provided in this case is medical vision care, and therefore the $45 copayment for physician services for the diagnosis and treatment of diseases and injuries of the eye applies in this case.
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 each Medicare-covered visit for the diagnosis and treatment of diseases and injuries of the eye. 
You have been asked to pay a $45 copayment for vision care. Vision care falls within the Medicare-covered visit for the diagnosis and treatment of diseases and injuries of the eye 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 reduce the copayment for the vision care provided by an ophthalmologist (99214) on February 7, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ofev 150 mg capsule. 
 
You asked the Plan to pre-approve Ofev. You say that this is medically necessary. The Plan denied your 
request. The Plan says this drug is not covered under the enrollee's medical benefit. 
 
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 Ofev 150 mg capsule.  
 
Benefits for Ofev 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the deluxe frames (V2025) and sphere, bifocal, plano to plus or minus 4.00d, per lens (V2200) provided January 11, 2022.
You asked the Plan to provide additional payment for the frames and lenses. You say that the claim is confusing, and you don't feel you should have to pay anything. The Plan denied your request. The Plan says the claim was processed correctly.
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 covers these services up to a $100 benefit. 
We looked at the file and the Plan's rules. The Plan has applied your $100 benefit to the retail cost of the routine frames and lenses. Additionally, the Plan applied a 20% off discount to the remaining cost. You have been asked to pay a total of $251.20 ($414.00 total cost - $100 vision benefit = $314. $314 remaining cost x 20% discount = $62.80. $314 remaining cost - $62.80 discount = $251.20 enrollee cost). This means you have been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to provide additional payment for the deluxe frames (V2025) and sphere, bifocal, plano to plus or minus 4.00d, per lens (V2200) provided January 11, 2022.
Your complaint about the Explanation of Benefits being written in a way that is confusing to understand is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve WoundFix. 
 
You asked the Plan to pre-approve WoundFix. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
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 WoundFix. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the review indicates that under Medicare guidelines, the request is not medically necessary 
because the records do not show that you do not have evidence of adequate circulation/oxygenation to support 
tissue growth. Additionally, the specific treatment requested, WoundFix, is not listed on the CMS list of 
products considered to be skin substitutes. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of WoundFix have not been met. Therefore, we decided that the Plan does not 
have to pre-approve WoundFix.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (ESI).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a repeat ESI is covered when specific criteria are
met.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain
and received an ESI at T12 to L1 on April 7, 2022 with 80 percent pain relief for four weeks. The Medicare
criteria requires documentation of 50 percent pain relief for three months. This was not achieved; therefore, the
requested repeat ESI is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a repeat epidural steroid injection (ESI).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee needs to go into a SNF due to health 
issues. The Plan denied your request. The Plan says rules for 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. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found that the medical records do not document that 
you require services on an inpatient basis, only in a skilled nursing facility. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SNF services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve excision, excessive skin and subcutaneous tissue 
(includes lipectomy); abdomen, infraumbilical panniculectomy (CPT code 15830). 
 
You asked the Plan to pre-approve the services. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the enrollee's request is not medically necessary because the enrollee's 
records show they do not have skin rashes, chronic pain, ulceration, dermatitis, or an inability to walk, or 
infection. 
 
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 services. Our physician reviewer 
found the record indicates that the enrollee has excessive pannus. The record does not indicate the presence of 
intertrigo refractory to treatment or functional limitations due to the pannus. The elements of the coverage 
criteria are not satisfied. The requested service is not 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, 
infraumbilical panniculectomy (CPT code 15830).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Granix. 
 
You asked the Plan to pre-approve Granix. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Granix. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the Food and Drug Administration 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 
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 Granix have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Granix.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered by the out-of-network 
(OON) provider on November 29, 2021. 
 
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 services were rendered by an out of 
network provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered by the out-of-network (OON) provider on 
November 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dermatology visit to be provided by an out-of-network
(OON) provider.
You asked the Plan to pre-approve an OON dermatology visit. You say that you disagree with the plan's
decision. The Plan denied your request. The Plan says the requested services can be provided by a network
provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
a dermatology visit 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 the power seat elevation system (CPT code E2300).
You asked the Plan to pre-approve the power seat elevation system. You say that the power seat elevation system is necessary. The Plan denied your request. The Plan says the power seat elevation system does not serve a medical purpose and cannot be covered.
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 (CPT code E2300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the home ventilator is necessary. The Plan 
denied your request. The Plan says the request for a home mechanical ventilator set in intelligent volume-
assured pressure support (iVAPS) mode with Auto-EPAP (AE) that could be delivered by bilevel positive 
airway pressure (BiPAP) is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our physician 
reviewer found the record indicates that you have chronic respiratory failure from chronic obstructive 
pulmonary disease. The provided primary source documentation does not contain sufficient detailed 
information in the medical record to justify the treatment selected. You could be treated with a BiPAP machine 
with average volume-assured pressure support (AVAPS) capability. The plan has indicated such a device is 
covered. 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 the home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services provided on October 22, 2021.
You asked the Plan to pay for the acupuncture services. You say that you would like this claim reprocessed based on the medical records submitted. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. The rules say that auxiliary personnel furnishing acupuncture must be under the appropriate level of supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist.
We looked at the file and Medicare rules. In this case, there is no documentation that the acupuncture in question was provided under the supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Therefore, we decided that the Plan does not have to pay for the acupuncture services provided on October 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for computed tomography CT scan of abdomen and pelvis without contrast on January 31, 2022.
You asked the Plan to waive the copayment for CT scan. You say that you should not have to pay for the CT scan as this was not the one the doctor wanted. The Plan denied your request. The Plan says $175 copayment for each in-network Medicare-covered service. Diagnostic imaging (CT scan, MRI/MRA, Myocardial Nuclear Perfusion Imaging and PET scans).
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 $175 copayment for in-network CT scans.
You have been asked to pay a $175 copayment for CT scan. CT scans fall within the health plan contract that says you must pay a $175 copayment for covered services. The provider billed for a CT scan in the amount of $4,873.00 and the plan allowed $221.86. The plan's share was $46.86. Per your benefits, you are responsible for a $175 copayment for in-network radiological diagnostic test. 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 of abdomen and pelvis without contrast on January 31, 2022.