Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the member is ready for discharge to 
LTACH. The Plan denied your request. The Plan says the LTACH services you are requesting do 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 medical record does not indicate that the enrollee requires services that they are 
not currently receiving. The enrollee still requires acute care services before transitioning to 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you requested a portable 
oxygen system that you could use to leave the house to get some much-needed exercise and to visit friends and 
family. Your current system is heavy, creates problems with your balance, and allows for only very short times 
outside the home. You would like to be able to leave your home with the confidence that you will have enough 
oxygen available to continue to live your life doing the things you love. The Plan denied your request. The Plan 
says you have been provided with oxygen equipment that meets your needs. The Plan also says you have not 
been evaluated by respiratory therapy for a portable oxygen concentrator. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a stationary oxygen concentrator (E1390) and the portable Homefill system 
(K0739), with 2 D tanks and a backup M tank. A stationary oxygen concentrator and the portable Homefill 
system serves the same purpose as a portable oxygen concentrator. Therefore, we decided that the Plan does 
not have to pre-approve a portable oxygen concentrator (E1392).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) scan of the leg 
joint without contrast (73721). 
 
You asked the Plan to pre-approve this service. You say that this service is medically necessary for the 
enrollee. The Plan denied your request. The Plan says this service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
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 this service. Our reviewer says that this 
service is not medically necessary. Our physician reviewer found that the enrollee has left knee pain. She has 
tried non-steroidal anti-inflammatory drugs (NSAIDs). The exam findings included a positive McMurrays test, 
Bounce Home tests, joint lateral joint line tenderness, but no instability. The x-rays showed mild degenerative 
changes of the knees. An MRI of the left leg was requested. However, physical therapy was not ordered or 
attempted which is required prior to considering advanced imaging. Also, there was no signs of a red flag 
diagnosis or likely need for more immediate surgery to justify an MRI at this time. Therefore, MRI will be 
considered not 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 this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a magnetic resonance imaging (MRI) scan of the leg joint without contrast (73721).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service April 19, 
2022. 
 You asked the Plan to pay for procedure code 76700. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76700 is bundled into payment for 
code 93976. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76700 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76700 billed for date of service April 19, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service April 21, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76705 billed for date of service April 21, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
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 step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has age-related 
osteoporosis without current pathological fracture. She has not tried and failed the Plan's required drugs, oral 
and injectable bisphosphonate therapy. The records do not show that the required drugs would be 
contraindicated or less effective; therefore, the Prolia is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 19, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and 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 an office visit provided on April 19, 2022, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a combination, bilateral, lumbo-sacral, hip, femur orthosis 
providing adduction and internal rotation control, prefabricated, includes fitting and adjustment (L1690) 
provided on April 25, 2022. 
 
You asked the Plan to pay for back orthosis. You say that the records show the enrollee is positive for back 
pain as well as severe osteoarthritis pain in knees and hip. Claim meets all of Medicares DME requirements 
for payment. The Plan denied your request. The Plan says services were not documented in the enrollee's 
medical record. The Plan also says the payment is not allowed because review of this claim information 
showed this service was related to a prohibited telemarketing contact. The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order, or relevant medical records from the physician which 
support medical necessity for the supplies provided in this case. The record shows that the enrollee received the 
braces after getting a phone call about receiving free equipment from Medicare. The records also show that this 
service was related to a prohibited telemarketing call. Therefore, we decided that the Plan does not have to pay 
for a combination, bilateral, lumbo-sacral, hip, femur orthosis providing adduction and internal rotation control, 
prefabricated, includes fitting and adjustment (L1690) provided on April 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 19, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (87481-91, 87640-91, 87653-91, 87798-
91, 87801-91) provided on December 14, 2021. 
 
You asked the Plan to pay for laboratory services. You say that these services should be covered. The Plan 
denied your request. The Plan says these services cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that modifier 91 is used to indicate that a test was 
performed more than once on the same day for the same patient.  
 
We looked at the file and Medicare rules. The testing at issue was billed with modifier 91, but the records do 
not show that the testing was performed more than once. Based on this information, we decided that Medicare 
rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (87481-91, 87640-91, 87653-91, 87798-91, 87801-91) provided on December 14, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four months of temporary replacement for patient 
owned equipment being repaired (K0462). 
 
You asked the Plan to pre-approve 4 months of temporary wheelchair rental. You say that the enrollee is not 
eligible for a new wheelchair replacement until 2 more years, but he is eligible to have repairs made to the 
existing wheelchair. The Plan denied your request. The Plan says a length of time outside of the approved 
rental period is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Medicare allows for ONE month of wheelchair rental while a 
personal wheelchair is being repaired. The records also show that the Plan attempted outreach to the 
supplier/repair facility multiple times without success.  Based on this information, we decided that Medicare rules for coverage of 4 months of temporary wheelchair 
rental have not been met. Therefore, we decided that the Plan does not have to pre-approve four months of 
temporary replacement for patient owned equipment being repaired (K0462).
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 requested care is medically necessary. The Plan 
denied your request. The Plan says the information provided doesn't show the need for SNF care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there are no identifiable skilled nursing service needs or skilled therapy service 
needs. 
 
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 pay for a home visit provided on February 20, 2022. 
 
You asked the Plan to pay for a home visit. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
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 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 a home visit provided on February 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. 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 A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
 
 Although these items may be appropriate, 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 A6530.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pain management services provided on March 11, 2022, to 
March 14, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for pain management services. You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the provider is out-of-network, and it 
was determined these services can be received in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 pain management services provided on March 11, 
2022, to March 14, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite filling (D2391) provided on June 2, 
2022. 
 
You asked the Plan to pay for a filling. You say that you did not know this service was not covered. The Plan 
denied your request. The Plan says a resin-based composite filling (D2391) is not covered by your dental 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a resin-
based composite filling (D2391) provided on June 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics/inserts (L3020x2). 
 
You asked the Plan to pre-approve foot orthotics. You say that the enrollee suffers from rheumatoid arthritis 
and osteoarthritis of the 
left foot for many years. She also has pes planus of bilateral feet and peripheral neuropathy of bilateral feet due 
to a history of chemotherapy. Custom orthotics will make a significant difference in her ambulation ability, in 
addition to avoiding further complications and wounds. The Plan denied your request. The Plan says this item 
is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot 
orthotics/inserts (L3020x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for a continuous glucose monitor and supplies. 
 
You asked the Plan to provide coverage for a continuous glucose monitor and supplies. You say that this device 
is medically necessary to prevent you from needing insulin. The Plan denied your request. The Plan says 
Medicare coverage criteria are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees who use insulin with at least three daily injections and require frequent 
self-adjustment of insulin dosage based on the blood glucose testing results.   
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin.   Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor, and 
supplies have not been met. Therefore, we decided that the Plan does not have to provide coverage for a 
continuous glucose monitor and supplies.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Covid-19 OTC test kit provided on January 25, 2022. 
 
You asked the Plan to pay for Covid-19 OTC test kit. The Plan denied your request. The Plan says this 
pharmacy is not listed as a participating pharmacy per covidtests.gov. 
 
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 did not pre-approve the 
item at issue. We found no exception that would require the Plan to pay for this item. Therefore, we decided 
that the Plan does not have to pay for Covid-19 OTC test kit provided on January 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
14-day sensor kit. 
 
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 criteria for coverage are not 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 treat with 
insulin three or more times per day or use an insulin pump. 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 a Freestyle Libre continuous glucose monitor (CGM) 14-day sensor kit.