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

 
We decided that the Plan does not have to pre-approve seat elevator (E2300) electronic connection (E2311) 
wheelchair component or accessory, not otherwise specified, personal item pouch (K0108) wheelchair 
component or accessory, not otherwise specified, new push handle Assy (K0108). 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that please see the below outlined 
reasons the enrollee requires a Group 3 power wheelchair with power tilt and why a simpler power wheelchair 
will not meet his in-home mobility needs. The Plan denied your request. The Plan says a power seat elevation 
feature is not primarily medical in nature and the electronic connection cannot be covered if the sole function is 
for the power seat elevation feature. The push handles and pouch do not serve a medical purpose and cannot be 
covered. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the wheelchair accessories have not been met. Therefore, we decided that the Plan does not have to 
pre-approve seat elevator (E2300) electronic connection (E2311) wheelchair component or accessory, not 
otherwise specified, personal item pouch (K0108) wheelchair component or accessory, not otherwise specified, 
new push handle Assy (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 31, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the services provided were medically necessary. 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 March 31, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on April 11, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for drug testing. You say that you do not personally see the patients, so you are 
dependent on receiving patient information from the ordering provider. The Plan denied your request. The Plan 
says this provider is not a network provider with the Plan. The Plan also says that they have 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 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 drug testing provided on April 11, 2022, by an 
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient stay provided on June 25, 2022. 
 
You asked the Plan to pay for the acute inpatient stay. You say that you needed medical care, the hospital was 
able to assist you, and the Plan should pay for these services. The Plan denied your request. The Plan says you 
did not meet the rules for coverage. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
 
  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 acute inpatient stay. Our reviewer says 
that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the record did show that at the time of inpatient admission the admitting physician 
reasonably expected that your necessary hospital care (including earlier emergency department and/or 
observation care) would span two midnights. 
 
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 acute inpatient stay have not been met. Therefore, we decided that the Plan 
does not have to pay for the acute inpatient stay provided on June 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is medically reasonable 
and necessary. The Plan denied your request. The Plan says the requested procedure is considered 
experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is experimental. More research is needed before coverage can be 
approved. 
 
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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CxBladder genetic testing services provided on October 18, 
2021. 
 
You asked the Plan to pay for CxBladder genetic testing services. You say that you would like this claim 
reprocessed based on the medical records. The Plan denied your request. The Plan says this testing is not 
covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a non-coverage policy in place for 
CxBladder testing services. Based on this information, we decided that Medicare rules for coverage of 
CxBladder genetic testing services have not been met. Therefore, we decided that the Plan does not have to pay 
for CxBladder genetic testing services provided on October 18, 2021.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Promethazine. 
 
You asked the Plan to pre-approve Promethazine. 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. Medicare rules say that oral anti-emetic drugs that are used as full 
replacement for intravenous dosage forms of a cancer regimen are covered under specific circumstances. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Promethazine have not been met. Therefore, we decided that the Plan does not have to pre-approve 
Promethazine.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder genetic testing services provided on January 
13, 2022. 
 
You asked the Plan to pay for the CxBladder genetic testing services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says there is a non-coverage 
policy in place for CxBladder testing services. 
 
The Plan must follow Medicare rules. Medicare rules say that that there is a non-coverage policy in place for 
CxBladder testing services. Based on this information, we decided that Medicare rules for coverage of the 
CxBladder genetic testing services have not been met. Therefore, we decided that the Plan does not have to pay 
for the CxBladder genetic testing services provided on January 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for acupuncture services from December 8, 
2021, to March 30, 2022. 
 
You asked the Plan to waive the copayments for acupuncture services. You say that the copayment applied is 
correct. The Plan denied your request. The Plan says the copayments applied are correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copayment per visit for Medicare-covered acupuncture services for chronic low back pain and a $20 copayment 
per visit for Medicare-covered acupuncture services for chronic low back pain for acupuncture services.  
 You have been asked to pay a $10 copayment per visit for Medicare-covered acupuncture services for chronic 
low back pain and a $20 copayment per visit for Medicare-covered acupuncture services for chronic low back 
pain for acupuncture services. Acupuncture services fall within the acupuncture for chronic low back pain 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayments for acupuncture services from 
December 8, 2021, to March 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treat with insulin three or more times per day or use an 
insulin pump 
 
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 you do not a Freestyle Libre 
continuous glucose monitor (CMG) sensor kit.. 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 
treat with insulin three or more times per day or use an insulin pump
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hip brace and addition (L1686 and L2624) provided on 
March 24, 2022. 
 
You asked the Plan to pay for the hip brace and addition. You say that you would like this claim reprocessed 
based on the medical necessity. The Plan denied your request. The Plan says the records do not support the 
medical necessity of the ordered equipment. 
 
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 relevant medical records which support medical necessity for the supplies provided 
in this case. In this case, the medical records do not support that the provider discussed the need for the ordered 
equipment with the enrollee. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the hip brace and 
addition (L1686 and L2624) provided on March 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Proidgy diabetic testing equipment. 
 
You asked the Plan to pre-approve Proidgy diabetic testing equipment. You say that this is medically necessary 
for the enrollee's condition. The Plan denied your request. The Plan says this is a non-preferred brand of 
diabetic testing equipment. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of Proidgy diabetic testing equipment. 
have been met. Specifically, no records were provided that support why the non-preferred testing equipment 
would not be sufficient in this case. We requested additional medical records from the Plan but none were 
available at this time. Therefore, we decided that the Plan does not have to pre-approve Proidgy diabetic testing 
equipment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on April 11, 2022. 
 
You asked the Plan to pay for the durable medical equipment. 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 follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone 
regarding the furnishing of a covered item except under specific circumstances. 
 
We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an 
unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the 
enrollee's treating physician. The record does not show that written permission was obtained to make contact 
by telephone regarding the furnishing of this item. The record does not show that contact was initiated 
regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the 
past 15 months. Based on this information, we decided that Medicare rules for coverage of the durable medical equipment have not been met. Therefore, we decided that the Plan does not have to pay for the durable medical 
equipment provided on April 11, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that [the enrollee needs SNF services. The Plan denied 
your request. The Plan says that the rules for SNF care have not been met. 
 
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 
enrollee does have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a 
skilled professional nurse. The enrollee does have daily skilled therapy needs that require the specialized skill, 
knowledge, and judgment of a skilled professional therapist. The enrollee does require daily skilled nursing 
and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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 pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve a total electric hospital bed. 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. Medicare rules say that total electric beds will be denied as not 
reasonable and necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a total electric hospital bed have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a total electric hospital bed (E0265).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left heart catheterization. 
 
You asked the Plan to pre-approve left heart catheterization. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 left heart catheterization. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical records provided do not support the rationale for this invasive imaging 
study. Guidelines do not support a need for cardiac catheterization in this setting. As a result, at this time left 
heart catheterization would not be considered medically appropriate and necessary in this enrollees clinical 
management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of left heart catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve left heart catheterization.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Novolog Inj Penfill. 
 
You asked the Plan to pre-approve Novolog Inj Penfill. You say that the medication is necessary. The Plan 
denied your request. The Plan says your plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Novolog Inj Penfill.  
 
Benefits for Novolog Inj Penfill 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee on 
February 8, 2022. 
 
You asked the Plan to pay for home health 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. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. The rules say the Type of Bill is a required 
data element needed to submit a claim under home health PPS. This 4-digit code gives two pieces of 
information. The first three digits indicate the base type of bill. The fourth digit indicates the sequence of this 
bill in this particular episode of care. The type of bill accepted for HH PPS requests for anticipated payment are 
either 7, 8, or 9 as defined above. HHAs must submit HH PPS claims with the 4th digit of "9." Therefore, we 
decided that the Plan does not have to pay for the home health services provided to the enrollee on February 8, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77062 billed for date of service January 20, 
2022. 
 
You asked the Plan to pay for procedure code 77062. You say that ou would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 77062 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 77062 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code 77062 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 77062 billed for date of service January 20, 2022.