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

 
We decided that the Plan does not have to pre-approve pneumatic compressor, segmental home model with 
calibrated gradient pressure (CPT code E0652) and segmental pneumatic appliance for use with pneumatic 
compressor (CPT code E0667 x2). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says there is no documentation for a 4-week trial of basic pneumatic compression device as 
required by Medicare criteria. 
 
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 DME. Our physician reviewer 
found there is no documentation that the enrollee meets the requirements listed in the LCD: Pneumatic 
Compression Devices (L33829) for Medicare coverage for the requested segmental pneumatic compression device (E0652). Provided records do not document that the enrollee has failed at least four weeks of regular, 
daily, multiple-hour home usage of a basic pump (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 device as required by 
the LCD. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve pneumatic compressor, segmental home model with calibrated gradient pressure (CPT code 
E0652) and segmental pneumatic appliance for use with pneumatic compressor (CPT code E0667 x2).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says medical studies have not proven that this procedure is helpful. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that this procedure 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 the procedure have not been met.  
 
 
 
  
Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Renflexis. 
 
You asked the Plan to pre-approve Renflexis. You say that the plan's required drugs cost significantly more per 
vial than the requested drug. You also say that this would be a financial burden for the enrollee. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, Avsola and 
Inflectra. 
 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 Renflexis. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the medical records provided do not 
indicate that the enrollee has tried and failed the required drugs. The reviewer found that the there is no 
indication that the plan's required drugs would likely be less effective and/or likely have adverse effects for the 
enrollee. Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Renflexis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Renflexis.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of a subcutaneous cardiac rhythm monitor for 
the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says the records do not show 30-day ambulatory heart monitoring which failed to detect 
arrhythmia, or a rare and frequent arrythmia which is unlikely to be detected by external monitor. 
 
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 procedure. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is no history of an ambulatory electrocardiogram (ECG) monitor having been 
performed to assess a possible arrhythmic etiology of syncope. In summary, there is insufficient documentation 
to support the medical necessity of this procedure in the enrollee's clinical management. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve insertion of a subcutaneous cardiac rhythm monitor for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a nebulizer, with compressor (E0570) 
provided on August 22, 2020. 
 
You asked the Plan to waive the copayment for the nebulizer, with compressor. You say that the services 
should be covered as you disagree with the charges, were not made aware of them, and they accumulated over 
time. The Plan denied your request. The Plan says the coinsurance applied correctly based on the services 
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). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Durable Medical Equipment (DME) and related supplies.  
 
 
  You have been asked to pay a 20% coinsurance for the nebulizer, with compressor (allowed is $136.32 x 20% 
= $27.26). Nebulizers, with compressors fall 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 copayment for a nebulizer, with 
compressor (E0570) provided on August 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the orthopedic footwear (CPT code L3250). 
 
You asked the Plan to pre-approve the orthopedic footwear. You say that you have a condition- drop foot, 
where your toes point downward, and you were given a prosthesis which helped; however, you need shoes you 
can wear with the prosthesis. The Plan denied your request. The Plan says you have foot drop, but you have not 
had an amputation. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the orthopedic footwear have not been met. The records do not 
show you have had an amputation. The rules say prosthetic shoes (L3250) are covered if they are an integral 
part of a prosthesis for a beneficiary with a partial foot amputation. Claims for prosthetic shoes for other 
diagnosis codes will be denied as not medically necessary. Therefore, we decided that the Plan does not have to 
pre-approve the orthopedic footwear (CPT code L3250).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (K0812). 
 
You asked the Plan to pre-approve the power scooter. You say that the power scooter is medically necessary. 
The Plan denied your request. The Plan says coverage rules have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power scooter. Our reviewer says 
that the power scooter is not medically necessary. Our physician reviewer found the enrollee's needs are met by 
a cane or walker. Use of a power scooter outside the home is not covered. 
 
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 power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power scooter (K0812).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trulance. 
 
You asked the Plan to pre-approve Trulance. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug is not a covered 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 Trulance.  
 
Benefits for Trulance 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
array, epidural (63650) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that this will give the enrollee a better health 
outcome. The Plan denied your request. The Plan says that your request is not medically necessary because the 
enrollee's records show there was concern from the enrollee's neuropsychologist that the enrollee did not 
understand the treatment plan involved with the spinal cord stimulator and that the enrollee would not be able 
to independently manage the device due to dementia. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The psychological 
evaluation does not support a trial of a spinal cord stimulator in this patient. Our physician reviewer found that 
the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous implantation of neurostimulator electrode array, epidural (63650) for the 
enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the FreeStyle Libre 2 sensor (CPT code K0553). 
 
You asked the Plan to pre-approve the sensor. You say that the CGM is necessary. The Plan denied your 
request. The Plan says the Medicare rules 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 show that the enrollee is using insulin 
three or more times per day and the documentation does not show the enrollee is using a Medicare-covered 
continuous subcutaneous insulin infusion (CSII) pump. Based on this information, we decided that Medicare rules for coverage of the sensor have not been met. Therefore, we decided that the Plan does not have to pre-
approve the FreeStyle Libre 2 sensor (CPT code K0553).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the FreeStyle Libre sensor (CPT code K0554). 
 
You asked the Plan to pre-approve the sensor. You say that the CGM is necessary. The Plan denied your 
request. The Plan says the Medicare rules 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 indicates that the enrollee only uses insulin two 
times a day. Based on this information, we decided that Medicare rules for coverage of the sensor have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the FreeStyle Libre sensor (CPT 
code K0554).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve segmental pneumatic appliance for use with pneumatic 
compressor (CPT code E0667) and pneumatic compressor, segmental home model without calibrated gradient 
pressure (CPT code E0651) to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the DME. You say that the in-network providers do not provide the DME 
the enrollee needs. The Plan denied your request. The Plan says the records received do not indicate that the 
enrollee has an emergent or urgent medical condition or are in in need of specialized service(s) that are not 
available in the network. The Plan states you request a brand specific lymphedema pump, but the enrollee's 
records do not indicate that this specific device is necessary to avoid an adverse medical outcome. 
 
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 
segmental pneumatic appliance for use with pneumatic compressor (CPT code E0667) and pneumatic 
compressor, segmental home model without calibrated gradient pressure (CPT code E0651) to be provided by 
an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cala Trio device (K1018) and related supplies 
(K1019). 
 
You asked the Plan to pre-approve a Cala Trio device and supplies. You say that the requested items are a 
necessity for your care. The Plan denied your request. The Plan says medical necessity rules for coverage have 
not been met because the requested items are experimental/investigational. 
 
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 Cala Trio device and supplies. Our 
reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that at the present time there remains a need for well-designed studies of the 
requested device/technology to be performed in order to permit conclusions on the overall efficacy and utility 
of the therapy compared with other methods of treatment. The requested device would still be considered to be 
investigational and therefore not eligible for coverage. 
 
 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 Cala Trio device and supplies have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Cala Trio device (K1018) and related supplies (K1019).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Oxygen equipment (E0431, E1390) 
provided on February 22, 2021 
 
You asked the Plan to waive the copayment for the oxygen equipment. You say that the services should be 
covered as you disagree with the charges, were not made aware of them, and they accumulated over time. The 
Plan denied your request. The Plan says the coinsurance applied correctly based on the services 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). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Durable Medical Equipment (DME) and related supplies.  
 
 
  You have been asked to pay a 20% coinsurance for the oxygen equipment. Allowed amount is $112.35 x 20% 
= $22.47) Oxygen equipment 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 copayment for Oxygen equipment (E0431, E1390) provided 
on February 22, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair repairs. 
 
You asked the Plan to pre-approve the repairs. You say that your current wheelchair needs repaired. The Plan 
denied your request. The Plan says that Medicare does not cover repairs when the expense for repairs exceeds 
the estimated expense for replacement of the wheelchair/scooter. 
 
The Plan must follow Medicare rules. Medicare rules say that DME repairs are not covered if the cost exceeds 
what replacing the item would cost. 
 
The cost of the requested wheelchair repairs exceeds the allowable amount for a new power wheelchair. Based 
on this information, we decided that Medicare rules for coverage of the repairs have not been met. Therefore, 
we decided that the Plan does not have to pre-approve power wheelchair repairs.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cortisone injection provided on March 1, 
2022. 
 
You asked the Plan to waive the copayment for cortisone injection. You say that you were referred to this 
doctor for hand surgery. The doctor told you the insurance company would require a cortisone shot first. The 
Plan denied your request. The Plan says the coinsurance 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 $245 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges.  
 
  You have been asked to pay $245 copayment for the cortisone injection. The cortisone injection falls within the 
Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory 
Surgical Centers 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 cortisone injection 
provided on March 1, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the electrocardiogram (ECG) with 
interpretation and report (93000) provided on March 22, 2022. 
 
You asked the Plan to waive the copayment for the ECG. You say that your contract says there is a $0 
copayment for lab services received at the time of your annual well visit, and you feel your contract is unclear. 
The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was 
assessed in accordance with your contract. 
 
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 $10 
copayment for Medicare-covered outpatient diagnostic tests. The contract also clearly states that if you receive 
services that address a medical condition during the same office visit as an annual wellness visit, additional 
cost-sharing may apply. You have been asked to pay a $10 copayment for the ECG. An ECG falls within the Medicare-covered 
outpatient diagnostic tests 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 
electrocardiogram (ECG) with interpretation and report (93000) provided on March 22, 2022.