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

 
We decided that the Plan does not have to pre-approve a breath test for possible bacterial overgrowth (91065). 
 
You asked the Plan to pre-approve a breath test. You say that you have bacteria in your small intestine that 
cause bloating and loss of appetite. You also say that you have to have this breath test done. The Plan denied 
your request. The Plan says the requested test is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that lactulose breath hydrogen for diagnosing small 
bowel bacterial overgrowth is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a breath test have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
breath test for possible bacterial overgrowth (91065).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) to be provided 
by an oral surgeon. 
 
You asked the Plan to pre-approve the dental service. You say that you have a jaw infection. You say that you 
were in the hospital. You also say that the infection is eating away at your jaw. The Plan denied your request. 
The Plan says services must be performed by a participating general dentist. 
 
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 evaluation to be provided 
by an oral surgeon is not among those covered under this benefit. The Evidence of Coverage clearly states that 
services must be performed by a participating general dentist. Therefore, we decided that the Plan does not 
have to pre-approve a comprehensive oral evaluation (D0150) to be provided by an oral surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the semi-electric hospital bed (CPT code E0260). 
 
You asked the Plan to pre-approve the semi-electric hospital bed. You say that the bed is necessary. The Plan 
denied your request. The Plan says the Medicare rules have not been met. 
 
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 semi-electric hospital bed. Our 
physician reviewer found there is no documentation that you meet all of the requirements listed in the LCD: 
Hospital Beds and Accessories (L33820) for Medicare coverage. Records do not show that you require 
frequent changes in body position and/or has an immediate need for a change in body position. 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 semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the semi-electric hospital bed (CPT code E0260).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you've had two surgical setbacks and feel IRF 
admission is medically necessary. The Plan denied your request. The Plan says your ongoing skilled therapy 
and nursing needs can be provided 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 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 walker with rubber wheels (a Nitro Drive walker) to 
be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the DME. You say that you would love to just be able to get rubber wheels 
or a different rollator with rubber wheels for the break to grip properly. The Plan denied your request. The Plan 
says there are in-network DME providers that can supply mobility devices, whether walker or wheelchair, that 
can meet your mobility needs. 
 
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 walker with rubber wheels (a Nitro Drive walker) to be provided by an out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
November 12, 2021 and November 14, 2021. 
 
You asked the Plan to waive the copayment for ambulance transportation. You say that you were told this 
would be covered under medical transportation. The Plan denied your request. The Plan says copayment is 
correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $300 
copayment for each separate Medicare-covered ambulance service. 
 
  You have been asked to pay $600 for ambulance transportation ($300/transport x 2 = $600). Ambulance 
transportation falls 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 transportation provided on November 12, 2021 and November 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 5, 2021, by an 
OON provider. 
 
You asked the Plan to pay for the laboratory services. You say that medical records were sent to support billed 
charges. The Plan denied your request. The Plan says the rendering and referring providers are both OON 
providers and there was no referral from an in-network provider. Also, the service rendered was not urgent or 
emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on November 5, 
2021, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollees orthopedic surgeon as well as the 
rehab team agree the enrollee would benefit from prosthetic and rehab training. The Plan denied your request. 
The Plan says the enrollee's medical condition requires further evaluation and treatment in the acute care 
hospital. 
 
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 there is not a reasonable expectation that the enrollee 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that you would like the Plan to reconsider their denial. The 
Plan denied your request. The Plan says the requested Prolia will be supplied by a pharmacy and will not be 
provided via Buy and Bill. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Prolia.  
 
Benefits for Prolia 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rocklatan Dro. 
 
You asked the Plan to pre-approve Rocklatan Dro. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says Rocklatan Dro is not covered under the enrollee's Medicare 
Part B benefit. 
 
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 Rocklatan Dro.  
 
Benefits for Rocklatan Dro 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission. 
 
The Plan must follow Medicare rules. The rules say that an 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 the complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee has a past medical history of a stroke with residual hemiplegia, atrial fibrillation and chronic kidney 
disease, and is living at home with worsening weakness. The enrollees medical problems are stable. There are 
no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While she has a need for physical and/or occupational 
therapy, there is no documentation of a need for an intensive rehabilitation program.  
 
Additionally, there is not a reasonable expectation that this enrollee will be able to fully participate in and 
benefit from an 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 an 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 an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and it was 
determined these services can be received in-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 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 
an office visit to be provided by an out-of-network (OON) provider.
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 the enrollee has not improved to a point where he 
can perform activities independently and physical therapy (PT) is still needed. The Plan denied your request. 
The Plan says the enrollee has continued care needs and his current functional and medical condition does not 
support the continuation of SNF care. 
 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 daily 
skilled services are not necessary. Our physician reviewer found that the enrollee does not have daily skilled 
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The 
enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on 
an inpatient basis in a skilled nursing facility (SNF) setting. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 18, 2021, by an OON 
provider. 
 
You asked the Plan to pay for the office visit. You say that you would like a retro authorization and the enrollee 
was admitted out of medical necessity. The Plan denied your request. The Plan says the rendering provider is 
an OON provider and there was no referral from an in-network provider or an approved authorization. Also, the 
service rendered was not urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on November 18, 2021, by 
an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Accu-check test strips (A4253). 
 
You asked the Plan to pre-approve the Accu-check test strips. You say that the items are medically necessary. 
The Plan denied your request. The Plan says the requested item is not the Plan's preferred brand. 
 
The Plan must follow Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers 
as preferred and charge lower cost-sharing for the preferred brands or may limit the Durable Medical 
Equipment (DME) to only those preferred brands and manufacturers. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Accu-check test strips have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the Accu-check test strips (A4253).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tradjenta tablets. 
 
You asked the Plan to pre-approve Tradjenta tablets. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says Tradjenta tablets are not covered under the enrollee's 
Medicare Part B benefit. 
 
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 Tradjenta tablets.  
 Benefits for Tradjenta tablets 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 the intermittent limb compression device (E0652 and 
E0667). 
 
You asked the Plan to pre-approve the intermittent limb compression device. You say that you would like 
reconsideration because this device is medically necessary. The Plan denied your request. The Plan says the 
enrollee does not meet criteria for coverage. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. 
 
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 intermittent limb compression 
device. Our reviewer says that the enrollee does not meet the local coverage determination criteria for coverage 
of the requested PCD. Our physician reviewer found records do not show trial and failure of at least four weeks 
of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and 
supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. 
 
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 intermittent limb compression device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the intermittent limb compression device (E0652 and 
E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar facet joint radiofrequency ablation (RFA) 
procedure to the L2-L3 level. 
 
You asked the Plan to pre-approve the lumbar facet joint RFA. You say that you would like reconsideration 
because the requested service is medically necessary. The Plan denied your request. The Plan says the enrollee 
has not had a second confirmatory medial branch block. 
 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 lumbar facet joint RFA. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found a second confirmatory procedure was not completed at the left L2-L3 level. 
The review has determined that the enrollee does not have a covered indication for the requested L2-L3 medial 
branch blocks as requested. 
 
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 lumbar facet joint RFA have not been met. Therefore, we decided that the 
Plan does not have to pre-approve lumbar facet joint radiofrequency ablation (RFA) procedure to the L2-L3 
level.