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

 
We decided that the Plan does not have to pre-approve the Freestyle Libre 2 sensor. 
 
You asked the Plan to pre-approve the Freestyle Libre 2 sensor. You say that the medical records provided 
support the necessity of the services in dispute. The Plan denied your request. The Plan says the enrollee does 
not meet the Medicare criteria. 
 
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 perform blood glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the Freestyle Libre 2 sensor have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the Freestyle Libre 2 sensor.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient skilled nursing facility (SNF) care provided 
from February 7, 2022, through March 8, 2022. 
 You asked the Plan to pay for the SNF care. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the enrollee did not meet criteria for coverage 
of the inpatient skilled nursing facility care provided. 
 
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 pay for the SNF care. Our reviewer says that the 
SNF care provided was not medically reasonable and necessary based on Medicare guidelines. Our physician 
reviewer found that the enrollee did not require skilled nursing or skilled therapy services on a daily basis. 
Additionally, as a practical matter, the enrollee did not meet severity of illness or intensity of service criteria 
for an inpatient basis in a skilled nursing facility 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 the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the inpatient skilled nursing facility (SNF) care provided from February 7, 2022, through  
March 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglass upgrades: Sphere, trifocal, plano to plus or minus 
4.00d, per lens (code V2300), Anti-reflective coating, per lens (code V2750) and Lens, polycarbonate or equal, 
any index; per lens (V2784) provided on July 11, 2022. 
 You asked the Plan to pay for eyeglass upgrades. The Plan denied your request. The Plan says the eyeglass 
upgrades are not a covered vision benefit. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
We looked at the file and the Plan's rules. The file shows that the Plans vision benefit does not cover upgrades. 
Therefore, we decided that the Plan does not have to pay for eyeglass upgrades: Sphere, trifocal, plano to plus 
or minus 4.00d, per lens (code V2300), Anti-reflective coating, per lens (code V2750) and Lens, polycarbonate 
or equal, any index; per lens (V2784) provided on July 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care (99223), psychiatric diagnostic 
evaluation with medical services (90792), subsequent hospital care (99233, 99231), and drug testing (80307) 
provided from March 8, 2022, to March 29, 2022, by the out-of-network (OON) provider.  
You asked the Plan to pay for the inpatient care. You say that the services should be covered. The Plan denied 
your request. The Plan says the claims denied correctly. 
 
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 in this case is not a network provider with the Plan. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Additionally, there was no 
documentation provided to support that the services were medically necessary. Therefore, we decided that the 
Plan does not have to pay for the initial hospital care (99223), psychiatric diagnostic evaluation with medical 
services (90792), subsequent hospital care (99233, 99231), and drug testing (80307) provided from March 8, 
2022, to March 29, 2022, by the out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on June 8, 2022. 
 
You asked the Plan to pay for an eye refraction. The Plan denied your request. The Plan says an eye refraction 
is not covered under the medical plan, as it is considered part of a routine eye exam. 
 
The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye 
exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. 
 
We looked at the file and the Medicare rules. Medicare does not pay for procedures performed in the course of 
any eye exam to determine the refractive state of the eyes. Therefore, we decided that the Plan does not have to 
pay for an eye refraction provided on June 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Coflex lumbar interspinous decompression device 
(22867). 
 
You asked the Plan to pre-approve the Coflex device. You say that the enrollee discussed with their physician, 
and they agree that the most appropriate course of action was to proceed with direct open decompression 
followed by insertion of the Coflex device. The Plan denied your request. The Plan says the requested Coflex 
lumbar interspinous decompression device is unproven and not medically necessary due to insufficient 
evidence of efficacy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Coflex device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the Coflex lumbar interspinous decompression device (22867).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the knee orthosis (L1843). 
 
You asked the Plan to pre-approve the orthosis. You say that the unloader brace is necessary for the enrollee to 
perform activities of daily living in a safe manner. The Plan denied your request. The Plan says the request is 
not medically necessary because the records do not show that the enrollee has instability. 
 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 orthosis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee was being treated for unilateral primary osteoarthritis of the left knee. The enrollee 
presented with bilateral knee pain that has been present for 20 years with a recent influx in pain. The pain is 
aggravated by standing, walking, and going up or down stairs, with an occasional feeling of giving way. The 
exam reveals a mildly antalgic gait. Range of motion is symmetric and approximately 0-120 degrees with 
crepitus present. X-rays were noted to show complete collapse of the medial joint space bilaterally; she has loss 
of the patellofemoral space. However, detailed documentation is not evident regarding any recent injury to or a 
surgical procedure on the knee. There is no instability documented on the objective exam. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception to guidelines. Therefore, the medical records provided do not meet the medically 
necessary requirements listed in the LCD for Medicare 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 the orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the knee orthosis (L1843).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assessment of and care planning provided on May 4, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for assessment of and care planning. 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 authorization is required prior to an out-of-network visit. 
 
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 assessment of and care planning provided on May 
4, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need IRF level of care. The Plan denied your 
request. The Plan says you do not meet criteria for an IRF admission 
 
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 the complexity of your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for 
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 
rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone stimulator. 
 
You asked the Plan to pre-approve the stimulator. You say that this is medically necessary after the last foot 
surgery, to avoid a repeat surgery. The Plan denied your request. The Plan says there is no long bone fracture or 
congenital pseudoarthrosis. 
 
The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion 
of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs 
have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the 
electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs 
separated by a minimum of 90 days.  
 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 stimulator. Our reviewer says that 
the requested stimulator is not medically reasonable or necessary. Our physician reviewer found that detailed 
documentation is not evident regarding serial radiographs that demonstrate lack of callus progression or failure 
of the fusion. There was only one x-ray noted on the 8/2/22 exam, with no formal diagnostic report provided or 
any other x-rays of the left foot. There is no compelling rationale presented or extenuating circumstances noted 
to support the medical necessity of this request as an exception to guidelines. Therefore, the requested electric 
bone stimulator, in this case, is not medically reasonable or 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 the stimulator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a bone stimulator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) and the chiropractic manipulative 
treatment (98941) rendered by the out-of-network (OON) provider on August 15, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out-of-
network provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the office visit (99213) and the chiropractic manipulative treatment (98941) 
rendered by the out-of-network (OON) provider on August 15, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation (90791) provided on June 
2, 2022 to June 28, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation. You say that the services should be 
covered as you disagree with the denial. The Plan denied your request. The Plan says the services denied 
correctly as they were non-emergent and prior authorization was not obtained. 
 
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 a psychiatric diagnostic evaluation (90791) 
provided on June 2, 2022 to June 28, 2022 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Romiplostim. 
 
You asked the Plan to pre-approve Romiplostim. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Romiplostim. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found based on the medical records provided, 
guidelines of the National Comprehensive Cancer Network and the Medicare-approved major drug compendia 
there is no documentation that the romiplostim at issue in this case meets all Medicare criteria for safe and 
effective for the enrollee. As stated in Drugdex/Micromedex: "Romiplostim is not indicated for the treatment of 
thrombocytopenia due to myelodysplastic syndrome. After conducting a meta-analysis of randomized, placebo-
controlled trials, a systematic review recommended against the routine use of romiplostim for the treatment of 
thrombocytopenia in patients with myelodysplastic syndrome due to an unclear risk of progression to acute 
myeloid leukemia." 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Romiplostim have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Romiplostim.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 21, 2021. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says this service is not 
covered under any normal circumstance. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for an office visit provided on October 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for inpatient hospital care provided on April 
18, 2022, to April 20, 2022. 
 
You asked the Plan to reduce the copayment for inpatient service. You say that you felt that you should not pay 
another $295 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 $295 per 
day, days 1-4 for inpatient hospital care. This inpatient hospital stay lasted 2 days, resulting in a copayment 
amount of $590 ($295 per day for 2 days = $590). 
 
You have been asked to pay $295 per day, days 1-4 for inpatient service. This item/service falls within the 
inpatient hospital 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 reduce the copayment for inpatient 
hospital care provided on April 18, 2022, to April 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (99335, J2426, 96372, 90833) provided 
on April 1, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not obtained. 
 
  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 home health services (99335, J2426, 96372, 
90833) provided on April 1, 2022 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for outpatient surgery provided on March 7, 
2022. 
 
You asked the Plan to reduce the copayment for surgery. You say that you were quoted $270.00 for a 
copayment for services received by the receptionist at the hospital. 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 $370 
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 $370 copayment for surgery. This item/service falls within the 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. 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 outpatient surgery provided on March 7, 2022.