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

 
We decided that the Plan does not have to waive the coinsurance for wound care supplies provided from July 
20, 2021, to August 4, 2021. 
 
You asked the Plan to waive the coinsurance for wound care supplies. You say that the supplies should not be 
labeled as durable medical equipment. You also say that the supplies should be covered at 100%. The Plan 
denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay 20% coinsurance for durable medical equipment.  
 The enrollee has been asked to pay a total of $59.59, which is 20% of the allowed amount for durable medical 
equipment.  
 
Date of Service Code Allowed Amount Coinsurance 
July 20, 2021 A6252 $73.80 $14.76 
July 20, 2021 A6216 $6.00 $1.20 
July 20, 2021 A4216 $33.00 $6.60 
July 20, 2021 A6443 $20.16 $4.03 
July 20, 2021 A6223 $9.20 $1.84 
July 20. 2021 A6402 $16.00 $3.20 
July 20, 2021 A4322 $4.48 $0.90 
July 28, 2021 A4216 $19.80 $3.96 
July 28, 2021 A4450 $2.40 $0.48 
July 28, 2021 A6197 $24.88 $4.98 
August 4, 2021 A6212 $88.20 $17.64 
Total  $59.59 
 
Wound care supplies fall within the Durable Medical Equipment (DME) and Related Supplies benefit category. 
This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This 
cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we 
decided that the Plan does not have to waive the coinsurance for wound care supplies provided from July 20, 
2021, to August 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
  
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation 
that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical nutrition therapy; initial assessment and 
intervention (97802). 
 
You asked the Plan to pre-approve medical nutrition therapy services. You say that you feel that you need the 
counseling of a dietician, instead of surgery and medical replacement programs. You need a dietician so you 
can lose weight and not develop diabetes. The Plan denied your request. The Plan says the enrollee does not 
meet the Medicare criteria for the requested service. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does 
not have to pre-approve medical nutrition therapy; initial assessment and intervention (97802).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer (CPT code J1439). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary for the 
member. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred step 
therapy drug(s) Infed (iron dextran) and Venofer (iron sucrose). The Plan states there is no indication the Plan's 
preferred drug(s) would likely be: less effective, and/or cause adverse effects for the enrollee. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 medication. Our physician reviewer 
found the record indicates that the enrollee has iron deficiency anemia. The requested medication is a new start. 
The provided records do not indicate that the enrollee has tried and failed the plan's preferred step one 
alternative. The record does not indicate that the enrollee has a contraindication to/or would have an adverse 
effect from the plan's preferred step one alternative. 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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Injectafer (CPT code J1439).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 23, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says these services were billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on June 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee can safely receive the services she needs in other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
enrollee is medically stable and does not need physical medicine and rehabilitation physician supervision 3 
times per week (at a minimum) for the ongoing management of any active or acute exacerbation of chronic 
medical conditions. At the current high functional level, the enrollee does not need intensive therapies, 
consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to 
daily therapy in an IRF. The enrollee's rehab needs can be safely met in an alternate and lower intensity setting. 
Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stationary bike. 
 
You asked the Plan to pre-approve the bike. You say that this is needed for a test. The Plan denied your 
request. The Plan says this is not primarily medical in nature. 
 
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 stationary bike.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for individual psychotherapy sessions (90837). 
 
You asked the Plan to pay for the psychotherapy services. You say that you have a well-established working 
relationship and the enrollee desires to continue working with you, in treatment for both chronic and acute 
stressors which exacerbates her diagnoses. The Plan denied your request. The Plan says the Plan does not cover 
outpatient mental health services with a licensed professional counselor. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for individual psychotherapy sessions 
(90837).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for non-emergent wheelchair van transport. 
 
You asked the Plan to provide coverage for non-emergent wheelchair van transport. You say that you have 
very bad arthritis and have bone on bone on your knees and have a very hard time walking. You say that you 
do not drive, and there is a service in your area that will provide wheelchair transportation to your doctor's 
appointments. You say this service will put you seated in the wheelchair into the van and then make sure you 
get to the doctor's office. The Plan denied your request. The Plan says non-emergent ambulance transportation 
to doctor's offices are not a covered location. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to provide coverage for are wheelchair van transport services. Therefore, 
we decided that the Plan does not have to provide coverage for non-emergent wheelchair van transport.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hearing aids to be provided by the requested  
out-of-network provider. 
 
You asked the Plan to pre-approve hearing aids to be provided by the requested out-of-network provider. The 
Plan denied your request. The Plan says your Plan requires you to contact the Plan's hearing vendor to provide 
you with all routine hearing related services. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased through the Plans hearing vendor.  
 
We looked at the file and the Plan's rules. The file shows that the requested provider is not a participating 
hearing provider. Therefore, we decided that the Plan does not have to pre-approve hearing aids to be provided 
by the requested out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing (81479) provided on August 10, 
2021. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like reconsideration because 
this testing was medically necessary and billed correctly. The Plan denied your request. The Plan says the POS 
code on this claim is incorrect. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Guardant360 testing have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the Guardant360 testing (81479) provided on August 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing (81479) provided on July 28, 2021. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like reconsideration because 
this testing was medically necessary and billed correctly. The Plan denied your request. The Plan says this 
claim was billed with the incorrect POS code. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Guardant360 testing have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the Guardant360 testing (81479) provided on July 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the requested home ventilator with non-invasive interface provides CPAP 
and/or bi-level PAP (BiPAP). The request is not medically necessary, and the enrollee has been approved for a 
E0471 machine which is capable of back up rate with AVAPS and would meet the enrollees needs. 
 
The Plan must follow Medicare rules. The rules say that claims for ventilators used to provide CPAP or bi-level 
CPAP therapy for conditions described in this RAD policy [restrictive thoracic disorders (for example: neuro 
muscular diseases or severe thoracic cage abnormalities), severe chronic obstructive pulmonary disease, central 
sleep apnea or complex sleep apnea, or hypoventilation syndrome] will be denied as not reasonable and 
necessary. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-
approve a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Libre Sensors (K0553). 
 
You asked the Plan to pre-approve the Freestyle Libre Sensors. You say that the item is medically necessary. 
The Plan denied your request. The Plan says you are not using insulin injections 3 or more times a day. 
 
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 the Freestyle Libre Sensors have not been met. Therefore, we decided that the Plan does not have to pre-
approve the Freestyle Libre Sensors (K0553).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a back brace (L0650), to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a back brace. You say that the item is medically necessary. The Plan denied 
your request. The Plan says there are in network providers that can supply this item. 
 
  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 back brace (L0650), to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xarelto. 
 
You asked the Plan to pre-approve Xarelto. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for 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 Xarelto.  
 
Benefits for Xarelto 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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the continuous glucose monitor (CGM) sensors. 
 
You asked the Plan to pre-approve the CGM sensors. You say that the item is medically necessary. The Plan 
denied your request. The Plan says that they do not have office visit notes from the most recent visit with the 
provider; these documents are needed for CGM sensor requests. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
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 CGM sensors. Our reviewer says 
that the item is medically necessary. Our physician reviewer found the member has been seen by the treating 
physician within six months of the order. They are using insulin four time a day and adjusting the dose based 
on their blood glucose level. 
 
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 CGM sensors have been met. Therefore, we decided that the Plan has to pre-
approve the continuous glucose monitor (CGM) sensors.  
 
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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan (Mako robot) for a robotic total 
knee arthroplasty. 
 
You asked the Plan to pre-approve the scan. You say that this scan is necessary for establishing the integrity of 
the involved arthritic bones. The Plan denied your request. The Plan says that medical studies do not support 
the need for a CT scan to plan for this type of surgery, unless patient x-rays showed certain abnormal findings, 
and has had a certain type of knee surgery in the past. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 the scan. Our reviewer says that the 
requested device is medically reasonable or necessary. Our physician reviewer found if the left total knee 
arthroplasty is approved using the Mako robotic device a CT will be necessary as part of the procedure and is 
needed to comply with the device software requirements. 
 
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 scan have been met. Therefore, we decided that the Plan has to pre-approve 
a computed tomography (CT) scan (Mako robot) for a robotic total knee arthroplasty.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWO) (E0483). 
 
You asked the Plan to pre-approve a high frequency chest wall oscillation device. You say that the item is 
medically necessary. The Plan denied your request. The Plan says this device is not covered for the members 
diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that a high frequency chest wall oscillation devices 
(HFCWO) (E0483) are covered for beneficiaries who meet the criteria listed in the Medicare Rules section of 
the letter.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a high frequency chest wall oscillation devices have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a high frequency chest wall oscillation device (HFCWO) (E0483).