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

 
We decided that the Plan does not have to pre-approve a group three wheelchair with two or more power seat 
options. 
 You asked the Plan to pre-approve a group three wheelchair with two or more power seat options. You say that 
you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee 
does not meet criteria for the requested device. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered for certain 
indications. 
 
While the file does show that the enrollee has Parkinson's, the documentation does not support that the enrollee 
meets criteria for a group three power wheelchair with two or more power seat options. Therefore, we decided 
that the Plan does not have to pre-approve a group three wheelchair with two or more power seat options.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower limb prosthesis with a K3 microprocessor knee 
and K3 foot. 
 
You asked the Plan to pre-approve a lower limb prosthesis with a K3 microprocessor knee and K3 foot. You 
say that this item is medically necessary for this patient. The Plan denied your request. The Plan says this item 
is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that lower limb prostheses are covered depending on the 
patient's potential functional ability. 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 
lower limb prosthesis with a K3 microprocessor knee and K3 foot. Our reviewer says that the requested lower 
limb prosthesis with a K3 microprocessor knee and K3 foot Our physician reviewer found the requested 
Ottobock Kenevo microprocessor knee (L5848, L5845, L5856, L5828) and the K3 L5981 foot exceed the 
patient's medical needs and do not meet Medicare medically necessary criteria. The requested microprocessor 
knee has features such as intuitive use of a stationary indoor bicycle, adjustments from a smartphone with the 
Cockpit app, and convenience features of charging without removing the foam cover. The documentation does 
not support that the patient is a K3 ambulator. The patient is noted to use a power wheelchair at home and a 
walker. Additionally, the requested Kenevo knee has deluxe features which are not medically necessary for the 
patient. 
 
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 lower limb prosthesis with a K3 microprocessor knee and K3 foot have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a lower limb prosthesis with a K3 
microprocessor knee and K3 foot.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the behavioral health services provided from January 5, 
2022, to January 19, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the behavioral health services provided by an OON provider. You say that you 
would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the 
services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-
network care. 
 
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 behavioral health services provided from 
January 5, 2022, to January 19, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a CGM to be provided by an OON provider. You say that you would like 
the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested CGM can be 
provided by 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 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 continuous glucose monitor (CGM) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation. 
 
You asked the Plan to pre-approve radiofrequency ablation. You say that the requested radiofrequency ablation 
procedure is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for the radiofrequency ablation procedure. 
 
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 radiofrequency ablation. Our reviewer 
says that the enrollee does not meet criteria for the radiofrequency ablation procedure. Our physician reviewer 
found the enrollee has chronic low back pain. She takes oxycodone for pain. She had ONE set of diagnostic 
medial branch blocks (MBBs) that produced 80% pain relief. The request is for radiofrequency ablation (RFA) of the medial branches. The LCD requires TWO sets of diagnostic MBBs that produce 80% pain relief.  Only 
one set has been performed.  Therefore, at this point, the request is deemed not medically necessary or 
reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ensure formula. 
 
You asked the Plan to pre-approve Ensure formula. You say that you are extremely skinny and you do not want 
to eat a this time. The Plan denied your request. The Plan says you do not meet criteria for the requested item. 
 
The Plan must follow Medicare rules. Medicare rules say that orally administered enteral nutrition products, 
related supplies and equipment are not covered. 
 
We looked at the file and Medicare rules. Review of the file shows that the requested item you are requesting is 
for oral administration. This is specifically not covered. Based on this information, we decided that Medicare 
rules for coverage of Ensure formula have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Ensure formula.
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 are appealing the denial of IRF. The Plan denied 
your request. The Plan says based on the medical records received, the enrollee's condition does not meet these 
Medicare guidelines. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was recently hospitalized for an ankle fracture requiring surgery.  The 
enrollee does not have the medical complexity requiring physician and rehabilitation nursing oversight in the 
acute inpatient rehabilitation setting. There are no complex nursing or rehabilitation needs. While then enrollee 
has a need for physical or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81402, 81400, 81321, 81318, 81314, 
81311, 81310, 81309, 81308, 81301, 81299, 81275, 81235, 81210, 81121, and 81120) provided on May 14, 
2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services (81402, 81400, 81321, 81318, 81314, 81311, 81310, 81309, 81308, 81301, 
81299, 81275, 81235, 81210, 81121, and 81120) provided on May 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat. 
 
You asked the Plan to pre-approve a raised toilet seat. You say that the requested raised toilet seat is medically 
necessary. The Plan denied your request. The Plan says a raised toilet seat is not covered by Medicare or the 
Plan. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 continuous glucose monitor (CGM) 
to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a FreeStyle Libre 2 CGM. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested device can be provided by a 
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 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 FreeStyle Libre 2 continuous glucose monitor (CGM) to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee will benefit from the 
admission in order to care for her acute needs. The Plan denied your request. The Plan says the enrollee does 
not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee should only require short-term additional acute care services that can 
safely be administered at the current facility until more appropriate for a lower level of care. The enrollee is 
receiving appropriate care at the present setting. The enrollee does not require services at the LTACH that are 
not available at the acute care hospital where they are currently receiving care. 
 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to reduce the copayment and provide reimbursement for the office surgical 
services provided from February 24, 2022, through June 10, 2022. 
 
You asked the Plan to reduce the copayment and provide reimbursement for the office surgical services. You 
say that the procedure was only about 10 minutes and was not surgical. You state that you are being treated in a 
doctor's office and not an operating room. The Plan denied your request. The Plan says that the claim was 
processed accordingly with your 2022 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
The EOC does not have anything mentioned that would inform you that the outpatient hospital surgery 
copayment would apply for services done in an office that is affiliated with the hospital. The Plan contract does 
not clearly say how much enrollees must pay for the office surgical services. This means that the Plan did not 
follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to 
reduce the copayment and provide reimbursement for the office surgical services provided from February 24, 
2022, through June 10, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the at-home COVID-19 testing kits provided on December 
20, 2021, and January 7, 2022. 
 
You asked the Plan to pay for the at-home COVID-19 testing kits. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. CMS says that Plans and insurers are required to cover at-home over the 
counter COVID-19 tests purchased on or after January 15, 2022.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the at-home COVID-19 testing kits have not been met. Specifically, the at-home COVID-19 
testing kits were purchased before the date of January 15, 2022. Therefore, we decided that the Plan does not 
have to pay for the at-home COVID-19 testing kits provided on December 20, 2021, and January 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient surgical services provided on January 7, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient surgical services provided by an OON provider. You say that you 
would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the 
services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-
network care. 
 
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 outpatient surgical services provided on 
January 7, 2022, by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management services (99239) 
provided on March 8, 2022. 
 
You asked the Plan to pay for the hospital discharge day management services. You say that you would like the 
Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the enrollee enrolled in 
hospice from February 8, 2022, through March 7, 2022. The Plan says, per Medicare guidelines, the provider 
must submit the bill to Original Medicare. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on March 7, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the hospital 
discharge day management services (99239) provided on March 8, 2022.
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 the enrollee needs medical monitoring and is at risk 
of further bleeding.  You said that the enrollee needs assistance maximizing her independence show she may 
safely return home. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria 
for IRF care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation.  The enrollees care needs can be met at a lower level of care. 
 
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: Favorable

 
We decided that the Plan has to pre-approve Actemra. 
 
You asked the Plan to pre-approve Actemra. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says that the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 
 
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 Actemra. Our reviewer says that the 
documentation supports that the requested drug is medically reasonable and necessary. Our physician reviewer 
found the enrollee has a diagnosis of seronegative rheumatoid arthritis. Based on the medical records provided 
and the Medicare-approved major drug compendia there is documentation that Actemra is medically reasonable 
and necessary for the patient. Drugdex/Micromedex has a citation reporting an off-label medically accepted 
indication for use of Actemra intravenous infusions at a dose of 8 mg/kg every 28 days for rheumatoid arthritis 
(moderate to severe), with no previous treatment failure. Therefore, the enrollee meets criteria for the requested 
drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Actemra have been met. Therefore, we decided that the Plan has to pre-approve 
Actemra.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.