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

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve PET scan. You say that the enrollee needs this for evaluation of the 
enrollee's condition. The Plan denied your request. The Plan says the denial of authorization for this service is 
correct, because the enrollee does not meet the diagnostic criteria for both Alzheimer's disease and fronto-
temporal dementia. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan may be considered reasonable and 
necessary under certain circumstances for enrollees who meet diagnostic criteria for both Alzheimers disease 
and fronto-temporal dementia. 
 
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 PET scan. Our reviewer says that the 
enrollee does not meet the Medicare criteria for this PET scan. Our physician reviewer found the 
documentation does not clearly describe the enrollee as having a required covered indication (Alzheimer's 
disease and fronto-temporal dementia). Also, the documentation does not show that the enrollee is in an 
approved trial.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PET scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a positron emission tomography (PET) scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99214) provided on July 13, 2021 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient office visit. You say that you have never had to get a referral to 
receive an eye exam. The Plan denied your request. The Plan says the treating provider is not a network 
provider with the Plan. The Plan also says that these services are not urgent or emergent, nor were they 
approved in advance. 
 
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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99214) provided on 
July 13, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

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

 
We decided that the Plan does not have to pre-approve an enema bag with tubing, reusable (A4458). 
 
You asked the Plan to pre-approve an enema bag. You say that the requested item is medically necessary. The 
Plan denied your request. The Plan says the requested item is not covered by the enrollee's plan. 
 
The Plan must follow Medicare rules. Medicare rules say that enema systems (gravity and manual pump), 
codes A4458 and A4459 respectively, will be denied as statutorily non-covered.  
 
While an enema bag may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve an enema bag with tubing, reusable (A4458).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of onabotulinum toxin (Botox). 
 
You asked the Plan to pre-approve Botox. You say that 100 units is just not working for the enrollee. The Plan 
denied your request. The Plan says the denial of authorization for this drug is correct, because 200 units of 
Botox is more than what is recommended to treat the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Botox. Our reviewer says that the 
enrollee does not meet the Medicare criteria for the requested use of Botox. Our physician reviewer found 
based on the records provided and the Medicare-approved major drug compendia there is no documentation 
that Botox at a dose of 200 units for overactive bladders meets criteria for safety, efficacy, and medical 
necessity as required by Medicare coverage rules. The maximum recommended dose of Botox for this 
indication is 100 units. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve use of onabotulinum toxin (Botox).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance service, advanced life 
support, emergency transport (A0427) provided on October 13, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 he must pay a 
$250 copayment for each one-way Medicare-covered ground ambulance trip.  
 
 
 The enrollee has been asked to pay a $250 copayment for the one-way Medicare-covered ground ambulance 
trip provided. 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 when he enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for the ambulance service, advanced 
life support, emergency transport (A0427) provided on October 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you've had major surgery and need a shower 
chair in order to assist you for showers. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve orthotic shoes and inserts. 
 
You asked the Plan to pre-approve the requested items. The Plan denied your request. The Plan says medical 
necessity for benefit coverage has not been established. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
The records do not show that you suffer from diabetic foot disease or that you wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve orthotic shoes and inserts.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy services. 
 
You asked the Plan to pre-approve massage therapy services. You say that you have been advised that massage 
therapy would be beneficial for your condition. The Plan denied your request. The Plan says massage therapy 
services are not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve massage therapy services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the MRI provided on November 23, 2021. 
 
You asked the Plan to waive the copayment for the MRI. You say that no one told you that you have a $150 
copayment. You say that the EOB you received has a zero balance. The Plan denied your request. The Plan 
says you have been charged the correct copayment 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). Your contract with the Plan clearly says that you must pay a $150 
copayment for Medicare-covered diagnostic radiology services (not including x-rays). $150 copayment for all 
other diagnostic and nuclear medicine radiological services. 
 
 You have been asked to pay a $150 copayment for the MRI. The MRI 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 MRI provided on November 23, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 home health skilled nursing visits (G0299). 
 
You asked the Plan to pre-approve 4 home health skilled nursing visits. You say that home health skilled 
nursing care is medically necessary. The Plan denied your request. The Plan says there is no medical necessity 
for the home health skilled nursing visits. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 4 home health skilled nursing visits. 
Our reviewer says that the requested home health services are not medically reasonable and necessary. Our 
physician reviewer found that the documentation does not support that you require additional skilled nursing 
services to provide treatment that is medically necessary. You do not require additional skilled nursing services 
to effectively provide treatment, care, and/or services in order to improve your condition, perform a 
maintenance program to maintain your condition and/or prevent deterioration. You have been medically stable 
without any recent exacerbations of chronic medical problems or hospitalizations. The requested home health 
services are not 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 4 home health skilled nursing visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 4 home health skilled nursing visits (G0299).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on November 
6, 2021. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you should not have to pay 
the copayment because the hospital never gave you other options for transportation to rehab. 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). Your contract with the Plan clearly says that you must pay a $250 
copayment for ground ambulance services.  
 
You have been asked to pay the allowed amount of $204.26, which is less than the $250 copayment for 
ambulance services. Ambulance services fall within the Ambulance 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 ambulance services provided on November 6, 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 enrollee is uncomfortable going home and she 
does not feel safe with nobody there to help her. The Plan denied your request. The Plan says IRF care is not 
medically necessary and the enrollee's needs can be met at a lower level of care such as at a skilled nursing 
facility, on an intermittent basis at home with home health care, or in a long-term care setting. 
 
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 that while the enrollee may benefit from physical therapy, and occupational therapy, 
her rehab needs can be safely addressed at a low intensity alternate setting such as in a skilled nursing facility 
or in-home with services. 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transport (A0428-RP, -PR), 
and ground mileage (A0425-RP, -PR) provided on November 8, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that these are covered destinations. The Plan 
denied your request. The Plan says that ambulance transport to or from an outpatient office or facility for a 
scheduled non-urgent visit is not a Medicare covered benefit. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctors office is not a covered destination.  
 
The services you have asked the Plan to pay for are ambulance transport services to a doctors office. The 
record shows that the transport was to a scheduled follow up appointment. Therefore, we decided that the Plan 
does not have to pay for the non-emergency ambulance transport (A0428-RP, -PR), and ground mileage 
(A0425-RP, -PR) provided on November 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the rheumatology office visit to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve the rheumatology office visit. You say that you do not want to switch 
doctors because your current doctor knows your situation. The Plan denied your request. The Plan says the 
provider is out-of-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 office visit at issue in this appeal. We found no exception that would require the 
Plan to pre-approve the office visit. Therefore, we decided that the Plan does not have to pre-approve the 
rheumatology office visit 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 pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you require intense therapy. The Plan denied your 
request. The Plan says IRF care is not medically necessary and you can be managed at a lower level of care. 
 
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 The complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for sepsis and pyelonephritis. Your medical problems are stable. There are no complex nursing or rehabilitation 
needs. You do not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says you do 
not meet the requirements for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation does not indicate that you use insulin with at least 
three daily injections or 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 the requested device have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: 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 IRF care is medically necessary as it will prevent 
unplanned readmission to the acute care hospital and ensure a safe discharge home. The Plan denied your 
request. The Plan says IRF care is not medically necessary and the enrollee's needs can be met in an alternate 
setting such as in a skilled nursing facility, at home with home health services or at home with outpatient 
therapy. 
 
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 that while the enrollee may benefit from physical therapy, and occupational therapy, 
his rehab needs can be safely addressed at a low intensity alternate setting such as in a skilled nursing facility 
or in-home with services. 
 
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 waive the coinsurance for an injection provided on February 10, 
2021. 
 
You asked the Plan to waive the coinsurance for an injection. You say that this should be covered because you 
had no way of knowing your cost share. You say that it's a lot on top of your other expenses. The Plan denied 
your request. The Plan says you have been charged the correct coinsurance 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). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare Part B non-chemotherapy prescription drugs.  
 
 
 You have been asked to pay $259.64, which is 20% of the allowed amount for the injection. The allowed 
amount is $1298.20 (20% x 1298.20 = $295.64). The injection falls within the Medicare Part B prescription 
drugs 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 coinsurance for an injection provided on 
February 10, 2021.