Persius/hicric huggingface dataset:
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) 
sensor and reader 
 
You asked the Plan to pre-approve a Freestyle Libre 2 CGM sensor and reader. You say that the requested 
supplies should be covered. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
approval of the requested CGM and supplies. 
 
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 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 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) sensor and reader
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on October 
04, 2022. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you were seen by a nurse in 
your primary care providers office. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for urgently needed services. 
 
You have been asked to pay a $45 copayment for an urgent care visit. This item/service falls within the 
urgently needed 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 an urgent 
care visit provided on October 04, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anti-reflective coating (V2750) and trifocal eyeglass lens 
(V2303) provided on November 2, 2022. 
 You asked the Plan to pay for anti-reflective coating (V2750) and trifocal eyeglass lens (V2303). You say that 
you have not claimed this vision benefit for over two years, to the best of your recollection. The Plan denied 
your request. The Plan says you are responsible for any amount over your benefit of $250. 
 
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 up to $250 eyewear to correct vision every calendar year. 
 
We looked at the file and the Plan's rules. The Plan rules say that there is a $250 allowance every calendar year 
that you can use to pay for eyewear to correct vision. The Plan contract also says that if the eyewear you 
purchase costs more than the allowance listed, you pay the difference. The record shows this benefit was 
exhausted on November 2, 2022. Based on this information, we decided that the Plan's rules for coverage of 
anti-reflective coating (V2750) and trifocal eyeglass lens (V2303) have not been met. Therefore, we decided 
that the Plan does not have to pay for anti-reflective coating (V2750) and trifocal eyeglass lens (V2303) 
provided on November 2, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lower 
extremity/ankle. 
 
You asked the Plan to pre-approve an MRI of the lower extremity/ankle. You say that the requested MRI is 
medically necessary. The Plan denied your request. The Plan says the requested MRI is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of the lower extremity/ankle. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the progress note 
enclosed for review demonstrates a normal ankle physical examination, with normal range of motion and ankle 
alignment. X-rays are noted of the right ankle in this chart however there is no x-ray findings note in the chart 
note. It is difficult to ascertain due to the image quality if there is overt fracture or bone lesion to the right foot 
or ankle. Regardless, it does not appear that an MRI is medically reasonable or necessary as the physical 
examination of the right foot and ankle was noted to be normal.  Medicare guidelines advise that MRIs are 
covered when medically necessary and reasonable for the diagnosis or treatment of the specific enrollee 
involved. It does not appear that this enrollee's foot and ankle pain meets coverage criteria for MRI at this 
point. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the lower extremity/ankle have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lower extremity/ankle.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient diagnostic services provided on 
March 14, 2022. 
 
You asked the Plan to waive the copayment for outpatient diagnostic services. You say that you cannot afford 
the copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $195 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay a $195 copayment for outpatient diagnostic services. This item/service falls within 
the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for outpatient diagnostic services provided on March 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF 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 at the current functional level the enrollee does not need intensive therapies 
consisting of at least three (3) hours of therapy per day at least five (5) days per week with multidisciplinary 
approach in an IRF. The documentation does not support necessity for admission to an IRF and the complexity 
of the enrollee's nursing, and medical needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitative care. While the enrollee may benefit from physical therapy (PT), and occupational therapy (OT), the enrollee's rehabilitation needs can be provided in a lower intensity and 
alternate setting such as in a skilled nursing facility (SNF). 
 
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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of instrumentation T6-L1 and Extension of 
Fusion T4-L1. 
 
You asked the Plan to pre-approve the removal of instrumentation T6-L1 and Extension of Fusion T4-L1. You 
say that you have had 10 surgeries for your back and have degenerative disc disease. You say that your back 
will continue to get worse until you have his surgery. You say that the screws have unscrewed, and the 
requested surgery is required to fix this. The Plan denied your request. The Plan says it is unclear if the mild 
loosening of the instrumentation in your back is causing your symptoms of back pain or placing you at risk for 
harm. The Plan says that the note supplied did not indicate that you have trialed the required non-operative 
therapies or confirm the absence of any untreated health issues that could be contributing to your back pain. 
 
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 removal of instrumentation T6-L1 
and Extension of Fusion T4-L1. Our reviewer says that the removal of instrumentation T6-L1 and Extension of 
Fusion T4-L1 is not considered medically reasonable and necessary in this case. Our physician reviewer found 
detailed documentation is not evident regarding a trial and failure of recent, reasonable, comprehensive less invasive conservative care measures. There is no clear documentation of any failed physical therapy and/or 
injections for the thoracic spine. The computed tomography (CT) from February 8, 2023, showed right T6 
pedicle screw is somewhat laterally positioned with evidence of mild loosening. However, this has not been 
confirmed as a source of pain, as the most recent exam did not demonstrate any tenderness to palpation. There 
was no hardware block noted to have been trialed. Moreover, there are no dynamic flexion/extension films 
provided in order to potentially assess the amount of movement (instability) at the requested surgical level. 
Detailed documentation is not evident regarding potential impending/inevitable temporary intra-operative 
instability. There are limited large-scale, long-term references showing the safety and efficacy of the requested 
surgery in this clinical setting. There is no compelling rationale presented or extenuating circumstances noted 
to support the medical necessity of this request as an exception. 
 
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 removal of instrumentation T6-L1 and Extension of Fusion T4-L1 have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the removal of instrumentation T6-
L1 and Extension of Fusion T4-L1.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 06, 2022. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on September 06, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care visit provided on November 29, 2022. 
 
You asked the Plan to pay for wound care visit. You say that these services were medically neccesary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for wound care visit 
provided on November 29, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for insulin for pump use provided on June 14, 2022. 
 
You asked the Plan to pay for the insulin. You say that it was your understanding that insulin was covered. The 
Plan denied your request. The Plan says unauthorized, out-of-network care is not covered. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this appeal were not provided in an emergency or urgent care situation. These services 
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not 
have to pay for insulin for pump use provided on June 14, 2022.
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 have been falling daily and the services are 
needed to assist you in building strength to help you walk. The Plan denied your request. The Plan says you can 
receive your care in another 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 you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete denture - mandibular (D5120) provided on 
September 20, 2022. 
 
You asked the Plan to pay for a complete denture - mandibular (D5120). You say that you are seeking a refund 
for the denture. The Plan denied your request. The Plan says this service is not covered under the benefit 
package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
complete denture - mandibular (D5120) provided on September 20, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Darzalex Faspro. 
 
You asked the Plan to pre-approve Darzalex Faspro. You say that the records provided support the need for the 
drug being requested. The Plan denied your request. The Plan says the enrollee does not have any stated 
contraindications to the preferred products. The Plan says that the enrollee has not tried any of the preferred 
agents. The Plan says that the provider does not provide a rationale for use of the non-preferred product for 
safety or efficacy.  
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 Darzalex Faspro. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found the Plan requires a trial of drugs 
Bortezomib or Velcade before they will approve the requested drug. In this case, the enrollee has not tried and 
failed the required drugs. There is no documentation provided indicating that the Plans required drugs likely 
be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Darzalex Faspro have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Darzalex Faspro.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an urgent care office visit provided on 
September 26, 2022. 
 
You asked the Plan to reduce the copayment for an urgent care office visit. You say that last year your 
copayment was only $25. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for each Medicare-covered urgent care facility visit.  
 
You have been asked to pay a $30 copayment for an urgent care office visit. This item/service falls within the 
urgently needed 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 reduce the copayment for an urgent 
care office visit provided on September 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on May 19, 2022. 
 
You asked the Plan to pay for wound care supplies. You say that wound care supplies are a separately billable 
expense that does not require authorization or referral. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for wound care supplies 
provided on May 19, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on November 1, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you were 
unaware that this service would not be covered if you did not go to the hospital. The Plan denied your request. 
The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on November 1, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on November 1, 2022.