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

 
We decided that the Plan does not have to pre-approve foot orthotics and compression stockings identified with 
code A6530. 
 You asked the Plan to pre-approve foot orthotics and the compression stockings. You say that the requested 
items would help the enrollee's medical condition. The Plan denied your request. The Plan says these items are 
not a covered benefit. 
 
The Plan must follow Medicare rules. 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 
rules also say that compression stockings described by code A6530 are noncovered because they do not meet 
the statutory definition of a surgical dressing.  
 
Although the compression stockings may be appropriate, it does not fall into a covered benefit category and 
cannot be paid for by Medicare or the Plan. Records show that the enrollee does not suffer from diabetic foot 
disease, and the enrollee does not wear a leg brace. Although orthotics may be appropriate for the enrollee, 
neither Medicare nor the Plan provides coverage of orthotics for their condition. Therefore, we decided that the 
Plan does not have to pre-approve foot orthotics and compression stockings identified with code A6530.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the non-emergent transportation over the 60-mile radius. 
 
You asked the Plan to pre-approve the non-emergent transportation over the 60-mile radius.. You say that you 
have a medical condition which requires you to see a specialist who is only at one specific location. The Plan 
denied your request. The Plan says transportation trips over the 60-mile limit is not a covered benefit. 
 
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 each one-way trip that must not exceed 60 miles.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided the 
service is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve the non-
emergent transportation over the 60-mile radius.
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 you need a replacement, and the orthotics 
should be covered. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingivectomy to allow access for restorative procedure 
provided on August 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that your provider did not inform you of all 
procedures that were going to be done on your tooth. The Plan denied your request. The Plan says this service 
is not a covered benefit under your dental plan. 
 
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 the 
gingivectomy to allow access for restorative procedure provided on August 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for renal disease services provided on October 29, 2022. 
 
You asked the Plan to pay for renal disease services. You say that you are requesting reconsideration. 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 renal disease services 
provided on October 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic CGM. 
 
You asked the Plan to pre-approve therapeutic CGM. You say that you are requesting a CGM to help with your 
insulin intake. The Plan denied your request. The Plan says the enrollee does not require insulin three or more 
times daily. 
 
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 
therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve 
therapeutic CGM.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction (92015) provided on September 19, 2022. 
 
You asked the Plan to pay for an eye refraction (92015). You say that this procedure was covered until January 
2022, at which time it was removed as a covered procedure. 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 eye refraction 
(92015) provided on September 19, 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 you are requesting an expedited reconsideration of 
the IRF admission as the enrollee currently meets full IRF criteria. The Plan denied your request. The Plan says 
based on Medicare guidelines, the IRF services you are requesting do not meet the requirements for approval. 
 
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 enrollee neither requires nor is able to participate in intensive therapy. The 
enrollee does not require frequent physiatry oversight. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre Kit 2 Sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre Kit 2 Sensor. You say that the records provided support 
the need for the requested item. The Plan denied your request. The Plan says the criteria for coverage have not 
been met. 
 
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 the enrollee uses insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
Freestyle Libre Kit 2 Sensor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre Kit 2 Sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 13, 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 October 13, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for therapeutic repetitive transcranial 
magnetic stimulation (TMS) treatments provided from September 22, 2022, to October 31, 2022. 
 
You asked the Plan to waive the copayments for the TMS treatments. You say that you were not advised of any 
copayments for the services. 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 $40 
copayment for outpatient mental health care.  
 
You have been asked to pay $24.86 for each date of service, which is less than the $40 copayment for the TMS 
treatments. This item/service falls within the outpatient mental health care 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 copayments for therapeutic repetitive transcranial magnetic stimulation (TMS) 
treatments provided from September 22, 2022, to October 31, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial inpatient hospital care (99222) provided on August 4, 
2022. 
 
You asked the Plan to pay for initial inpatient hospital care (99222). You say that this service was appropriately 
billed. The Plan denied your request. The Plan says the member was enrolled in a primary Plan for the August 
4, 2022, date of service. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer.  
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has requested 
that you bill the primary payor. As the secondary insurer, the Plan cannot be held responsible for initial 
inpatient hospital care (99222) until the primary insurer has denied the claim for these services. Therefore, we 
decided that the Plan does not have to pay for initial inpatient hospital care (99222) provided on August 4, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an in-network extrimity brace provided on 
June 27, 2022. 
 
You asked the Plan to waive the coinsurance for an in-network extrimity brace. You say that this is way too 
much money to pay for this item. 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 20% 
coinsurance for durable medical equipment (DME) and related supplies. 
 
You have been asked to pay 20% coinsurance for an in-network extrimity brace. This item/service falls within 
the durable medical equipment (DME) and related 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 coinsurance for an in-network extrimity brace provided on June 27, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Mounjaro. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
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 Mounjaro.  
 
Benefits for these services 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: 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 you would like reconsideration because the 
requested foot insert is medically necessary. 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve computed tomographic angiography (CTA), of the abdomen, with 
contrast material(s), including noncontrast images, if performed, and image postprocessing (74175). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says that the requested service is not medically necessary. 
 
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 this service. Our reviewer says that the 
requested service is medically necessary. Our physician reviewer found that you have two splenic artery 
aneurysms that have been stable since 2019. These are unusual in location and the request for an annual follow-
up is reasonable because if they were to enlarge, the risk of rupture and serious consequences would be 
catastrophic. If these aneurysms were found to have enlarged, intervention would be required. The request for 
this service should be approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have been met. Therefore, we decided that the Plan has to pre-
approve computed tomographic angiography (CTA), of the abdomen, with contrast material(s), including 
noncontrast images, if performed, and image postprocessing (74175).  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the clinical documentation shows that there was an acute clinical change (status 
post urinary tract infection). This would normally require ongoing skilled nursing; however, there is no 
recommendation for frequency specified. There are no functional changes or recommendation regarding need 
for skilled therapy made. Thus, based on the documentation, daily skilled services in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a peripheral nerve stimulation (PNS) system. 
 
You asked the Plan to pre-approve a PNS system. You say that the requested procedure is medically necessary. 
The Plan denied your request. The Plan says this procedure is not covered for the enrollee's condition. 
 
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 a PNS system. Our reviewer says that 
the PNS system is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has degenerative spine condition. A PNS device for degenerative spine pain and conditions 
is experimental. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a PNS system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a peripheral nerve stimulation (PNS) system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services (D4342, D7953, D4341). 
 
You asked the Plan to pre-approve the dental services (D7953, D4341, D4342). You say that you would like to 
request reconsideration of the denied authorization. The Plan denied your request. The Plan says your benefit 
for the requested dental services (D4341, D4342) have already been exhausted. The dental service (D7953) is 
not a covered benefit. 
 
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, certain limitations apply. The record 
shows your benefit for the requested dental services (D4341, D4342) were exhausted on date of service January 
15, 2021, and January 21, 2021. The dental service (D7953) is not a covered benefit. Therefore, we decided 
that the Plan does not have to pre-approve the dental services (D4342, D7953, D4341).