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

 
We decided that the Plan does not have to pre-approve a wheelchair and accessories (E0986, E1028, E2201, 
E2203, E2609, E2617, K0108). 
 
You asked the Plan to pre-approve a wheelchair and accessories. You say that you need this. The Plan denied 
your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a wheelchair and accessories is being requested for use in a SNF or hospital. Therefore, we 
decided that the Plan does not have to pre-approve a wheelchair and accessories (E0986, E1028, E2201, 
E2203, E2609, E2617, K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued coverage of a continuous passive motion 
device. 
 
You asked the Plan to pre-approve continued coverage of a continuous passive motion device. You say that 
continued coverage of this equipment is medically necessary. The Plan denied your request. The Plan says 
coverage for the first 21 days was approved. This device is not eligible for coverage beyond the first 3 weeks 
following surgery. 
 
The Plan must follow Medicare rules. The rules say that coverage for CPM devices is limited to the three-week 
period following total knee replacement surgery during which the device is used in the home. 
 
Records show that knee replacement surgery was received on September 19, 2022. The file shows that a CPM 
device was used for three weeks following this surgery. Therefore, we decided that the Plan does not have to 
pre-approve continued coverage of a continuous passive motion device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric treatment. 
 
You asked the Plan to pre-approve inpatient psychiatric treatment. 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 inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric treatment. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based upon review 
of the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of October 28, 2022, forward and could have been treated in a lesser 
restrictive setting. He was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, 
delusions and was not showing any behaviors or aggression. He was being cooperative and compliant while not 
showing any acute threats to safety as the enrollee awaited placement. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric treatment have not been met. Therefore, we decided that 
the Plan does not have to pre-approve inpatient psychiatric treatment.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to allow the copayment charges to be counted toward your total  
out-of-pocket amount for the year for the hearing aids (V5257) purchased on April 13, 2022. 
 
You asked the Plan to allow the copayment charges to be counted toward your total out-of-pocket amount for 
the year. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. 
The Plan says that copayments, coinsurances, and deductibles paid for supplemental benefits do not count 
toward your maximum out-of-pocket amount for the year. 
 
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 copayments, coinsurances, and deductibles paid for supplemental 
benefits do not count toward your maximum out-of-pocket amount for the year.  
 
We reviewed the case file and the Plans rules. Based on this information, we find that the copayment charges 
applied to the hearing aids purchased in this case, do not count toward your maximum out-of-pocket amount 
for the year. 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 allow the copayment charges to be counted toward your 
total out-of-pocket amount for the year for the hearing aids (V5257) purchased on April 13, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee cannot care for themselves, and the 
enrollee can gain more progress with more days in a SNF. The Plan denied your request. The Plan says a 
continue stay at a SNF 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 based on the medical records provided there is no documentation that further daily 
skilled services are required. 
 
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 SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stereotactic body radiation therapy (SBRT) for the 
enrollee. 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested service is not covered by Medicare or the health plan. 
 
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 therapy. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that for metastatic disease, SBRT is generally indicated for patients with oligometastatic disease of for 
those undergoing palliation after prior radiation to the same site. Oligometastases are defined as a state of 
metastatic disease with metastases few in number and extent. For this patient, two sites of adjoining spine 
metastases are to be treated with radiotherapy. However it is unclear if the patient has widespread disease 
particularly given the enlarged thoracic lymph nodes. The clinic motes mention a positron emission 
tomography/computed tomography (PET/CT) for staging, yet those results are not provided in the case file. Even the PET/CT were to demonstrate this to oligometastatic disease, results from NRG BR002 (presented as 
ASCO) do not support routine use of SBRT for oligometastases from breast cancer. In summary, SBRT would 
not be considered to be furnished in accordance with accepted standards of medical practice in the absence of 
PET imaging showing no other sites of disease. 
 
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 therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve stereotactic body radiation therapy (SBRT) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0554). 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose 
monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has 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 does not use insulin 
with at least three daily injections.  Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor 
(K0554).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99205) with a urologist to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you need to see this provider for a second 
opinion. You need someone with experience with alternative treatment for prostate cancer. The Plan denied 
your request. The Plan says the requested visit can be managed within the primary network. You may seek a 
second opinion with another urologist within the plan's 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 (99205) with a urologist to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the crutch substitute knee scooter device. 
 
You asked the Plan to pre-approve the crutch substitute knee scooter device. You say that this device is 
medically reasonable and necessary. The Plan denied your request. The Plan says this device is not covered by 
Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that there is insufficient published clinical literature 
demonstrating safety and effectiveness in the Medicare population to establish the medical necessity for crutch 
substitutes. Based on this information, we decided that Medicare rules for coverage of the crutch substitute 
knee scooter device have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
crutch substitute knee scooter device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says these items are not covered under your contractual policy 
or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
 
 Although these items may be appropriate for you, they do not fall into a covered benefit category and cannot be 
paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve 
compression stockings identified with code A6549.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 20, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on May 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. 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 ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. This enrollee was admitted with a leg fracture and arterial blood gases (ABG) was consistent with 
chronic carbon dioxide (CO2) retention. This enrollee likely has a combination of obesity-hypoventilation 
syndrome and chronic obstructive pulmonary disease (COPD), leading to chronic hypercarbic respiratory 
failure. The enrollee may benefit from bilevel positive airway pressure (BiPAP) during sleep as an outpatient, with or without average volume-assured pressure support (AVAPS). But Medicare does not cover a home 
ventilator when used as BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
May 17, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service May 17, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) guidance for needle 
placement for a bone marrow biopsy (38222, 77012) to be rendered by the out-of-network (OON) provider. 
 
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 this service is available with an in-network provider. 
 
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 service at issue in this appeal. We found no exception that would require the 
Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve computed 
tomography (CT) guidance for needle placement for a bone marrow biopsy (38222, 77012) to be rendered by 
the out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
May 4, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service May 4, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for and pay for an ER visit and self-
administered drugs provided on July 6, 2022. You asked the Plan to waive the copayment for and pay for an ER visit and self-administered drugs. You say 
that you are appealing the emergency room copayment and what you paid out-of-pocket for prescription 
medications. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The rules also 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 $120 copayment for Medicare-covered emergency room visits.  
 
You have been asked to pay a $120 copayment for an ER visit. This item/service falls within the Medicare-
covered emergency room visits 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. Additionally, 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 waive the 
copayment for and pay for an ER visit and self-administered drugs provided on July 6, 2022.  
 
Benefits for self-administered prescription drugs 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture services (97810, 97813). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says you do not meet criteria for coverage of the 
requested services. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the requested acupuncture services have not been met.  Specifically, the acupuncture services in this case were not requested due to a diagnosis of chronic low back 
pain. Therefore, we decided that the Plan does not have to pre-approve acupuncture services (97810, 97813).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Saphnelo. 
 
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 the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found you have a history of lupus since 2013. 
All of your current laboratory results confirm that the lupus is not active and you are currently not on any 
treatment. Although Saphnelo is indicated for the treatment of lupus, the records do not support that you have 
current moderate to severe disease. The Saphnelo is therefore not considered safe and effective or reasonable 
and medically necessary at this time. 
 
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 Saphnelo.