Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve selective catheter placement. 
 
You asked the Plan to pre-approve selective catheter placement. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
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 selective catheter placement. 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 a report of bilateral leg pain with walking, resolved with 
rest. Ankle-brachial (ABI) index is showing right ABI 0.67 and left 0.49 suggestive of peripheral vascular 
disease (PVD). The enrollee appears to have a diagnosis that meets criteria for the requested service. However, 
the provided records did not clearly show the enrollee has tried and failed first line lifestyle and medical 
therapies for the PVD before considering invasive testing and intervention as requested. Therefore, the enrollee 
does not meet criteria for the request for angiography with intervention. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of selective catheter placement have not been met. Therefore, we decided that the 
Plan does not have to pre-approve selective catheter placement.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home healthcare services provided from June 4, 2021, to 
July 3, 2021. 
 
You asked the Plan to pay for the home healthcare services. You say that you would like this denial to be 
overturned. The Plan denied your request. The Plan says the initial Request for Anticipated Payments (RAP) 
claim was not received within 5 calendar days from the start of care. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period.  
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home healthcare services have not been met. Specifically, the record indicates the RAP was not 
submitted within 5 days of the from the start of care date. Therefore, we decided that the Plan does not have to 
pay for the home healthcare services provided from June 4, 2021, to July 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an interrogation device evaluation provided on May 31, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an interrogation device evaluation. You say that the service that was provided 
does not need a referral and you would like the claim reprocessed. The Plan denied your request. The Plan says 
the rendering provider is an OON 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 an interrogation device evaluation provided on 
May 31, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care provided on May 19, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for wound care. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 wound care provided on May 19, 2022, by an out-
of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a FreeStyle Libre 2 CGM. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested device. 
 
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 and 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 a FreeStyle 
Libre 2 CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle 
Libre 2 continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Boost Glucose Control enteral formula (B4154). 
 
You asked the Plan to pre-approve Boost Glucose Control enteral formula. You say that this service should be 
covered because you are on dialysis and need additional protein due to the protein being removed from your 
blood. The Plan denied your request. The Plan says the request does not meet Medicare guidelines because 
there is no record that you need feedings through a device in order to maintain your weight and strength. There 
is no record that you have a permanent problem that affects the structures that allow food to reach your 
intestines or that affects your ability to digest and absorb what you eat. There is no record that you cannot get 
enough nutrition by changing your diet. 
 
The Plan must follow Medicare rules. Medicare rules say that enteral nutrition is covered for a beneficiary who 
requires feedings via an enteral access device to provide sufficient nutrients to maintain weight and strength. We looked at the file and Medicare rules. The medical records received are incomplete. The records do not 
show that you meet the Medicare guidelines for an enteral formula. Based on this information, we decided that 
Medicare rules for coverage of Boost Glucose Control enteral formula have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Boost Glucose Control enteral formula (B4154).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the debridement of nails provided on March 2, 2022. 
 
You asked the Plan to pay for the debridement of nails. You say that the services rendered to the enrollee out of 
medical necessity, and you would like the claim reprocessed for payment. The Plan denied your request. The 
Plan says that the original claim was denied for no authorization. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the debridement of nails by a contract provider. The file does not show that the 
plan provided notice that the debridement of nails would not be covered. Under Medicare rules, this means the 
debridement of nails is considered approved by the plan. Therefore, we decided that the Plan has to pay for the 
debridement of nails provided on March 2, 2022.  
 
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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. There is no documentation provided indicating the 
medical necessity for admission to a LTACH. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to preapprove an additional 12 routine transportation trips. 
 
You asked the Plan to preapprove an additional 12 routine transportation trips. You say that you need to get to 
physical therapy twice per week, but you do not have any rides left. You also say that you do not feel safe 
traveling by yourself. The Plan denied your request. The Plan says the requested service is covered under the 
Plan, but the requested amount exceeds the limit listed by the Plan. 
 
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 up to 36 one-way 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 preapprove an additional 12 routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous carotid angioplasty and stent placement 
services. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee is not at high risk for a 
carotid endarterectomy. The Plan denied your request. The Plan says the enrollee is at risk for a stroke. 
 
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 requested services. Our physician 
reviewer found that the enrollee has a history of previous stroke, now asymptomatic, with evidence of carotid 
artery disease. Guidelines indicate that the percutaneous carotid angioplasty and stent placement are reserved 
for those who are high risk for carotid endarterectomy. The documentation does not indicate that the enrollee 
would be at high risk for endarterectomy. As such, percutaneous carotid angioplasty and stent placement would 
not be considered medically appropriate and necessary in this enrollees clinical management. 
 
 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve percutaneous carotid angioplasty and stent placement services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on April 20, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for drug testing. You say that you trust the physician's professional opinion of what 
is medically necessary for the patient. You also say that you test the submitted specimens according to their 
orders. The Plan denied your request. The Plan says the services are not authorized because this provider is a 
non-network provider who does not work with the Plan, and the member was referred by a provider, who also 
does not work with the Plan. 
 
 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 drug testing provided on April 20, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve viscosupplementation therapy for the knee, Trivisc 
injection. 
 You asked the Plan to pre-approve viscosupplementation therapy for the knee, Trivisc injection. You say that 
viscosupplementation therapy for the knee, Trivisc injection is medically necessary. The Plan denied your 
request. The Plan says viscosupplementation therapy for the knee, Trivisc injection does not meet the Medicare 
coverage criteria. 
 
The Plan follows Medicare rules.  
 
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 viscosupplementation therapy for the 
knee, Trivisc injection. Our reviewer says that viscosupplementation therapy for the knee, Trivisc injection is 
not medically necessary. Our physician reviewer found that you have not had a steroid injection and you have 
minimal pain complaints. Therefore, the request is considered not medically reasonable or necessary and does 
not meet the Medicare LCD coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of viscosupplementation therapy for the knee, Trivisc injection have not been met. 
Therefore, we decided that the Plan does not have to pre-approve viscosupplementation therapy for the knee, 
Trivisc injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with power tilt and 
accessories. 
 
You asked the Plan to pre-approve a group 3 power wheelchair with power tilt and accessories. You say that 
you disagree with the Plan's denial. The Plan denied your request. The Plan says you do not meet criteria for 
the requested device. 
 
The Plan must follow Medicare rules. Group 3 power wheelchairs and accessories are only covered for certain 
indications. 
 
The rules say that group 3 power wheelchairs with single power option are covered when there is a medical 
need for a special drive control (including, but not limited to, head control, sip and puff, switch control) or for 
single power option: power tilt or power recline. The wheelchair evaluation states that you are able to perform 
pressure relief. Also, the documentation does not support that you are high risk for development of pressure 
ulcer. You have been using a manual wheelchair for years and has no current pressure ulcer, no history of 
pressure ulcer and no history of flap surgery. Therefore, you are not considered high risk for development of 
pressure ulcer. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair 
with power tilt and accessories.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six physical therapy visits. 
 
You asked the Plan to pre-approve therapy visits. You say that the enrollee would benefit from therapy prior to 
hip replacement surgery. The Plan denied your request. The Plan says that additional therapy is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 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 therapy visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that based on the available records the enrollee appears to have 
plateaued with therapy. Further utilization of a home exercise program appears appropriate at this point. 
Repetitive exercise does not require the expertise of a professional skilled physical therapist. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapy visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve six physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the arthrocentesis provided on April 12, 
2022. 
 
You asked the Plan to waive the copayment for the arthrocentesis. You say that if you had known there would 
be such a high copayment, you would not have had this procedure done. The Plan denied your request. The 
Plan says the copayment that was applied was 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 $300 
copayment for surgery services at an outpatient hospital.  
 
You have been asked to pay the allowed amount of $239.57, which is less than the $300 copayment for the 
arthrocentesis. The arthrocentesis falls within the Outpatient Hospital 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 the arthrocentesis provided on April 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth office visit provided on April 27, 2022, by an 
OON provider. 
 
You asked the Plan to pay for a telehealth office visit. You say that no primary care physician referral is needed 
and you are requesting reconsideration of the denied charges. The Plan denied your request. The Plan says the 
out-of-network services were not authorized. 
 
 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 a telehealth office visit provided on April 27, 
2022, by an OON provider.