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

We decided that the Plan does not have to pay for wheelchair motors (E2311), expandable controller (E2377) 
and harness (E2313) 
 
You asked the Plan to pay for the wheelchair accessories. You say that the services should be covered. The 
Plan denied your request. The Plan says the upgraded electronics for the wheelchair is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that if a wheelchair has an electrical connection device 
described by code E2310 or E2311 and if the sole function of the connection is for a power seat elevation or 
power standing feature, it will be denied as non-covered. The upgraded electronics (expandable controller, 
harness and electronic connector to 2 power options) are not medically necessary. They are necessary when 
there is a medical need to control power options though the joystick. The notes do not show a medical need to 
control the power options through the joystick. The power options can be controlled using their own switches. 
Therefore, we decided that the Plan does not have to pay for wheelchair motors (E2311), expandable controller 
(E2377) and harness (E2313)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill that 
includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water 
and/or phone bill payments (debit card), home assistance services (repairs). 
 
You asked the Plan to pre-approve special supplemental benefits for the chronically ill that includes 
transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or 
phone bill payments (debit card), home assistance services (repairs). The Plan denied your request. The Plan 
says the certification dated October 8, 2021, documented that the enrollee has none of the qualifying diagnoses, 
does not require intense care coordination, and has no high risk for hospitalizations or high risk for adverse 
health outcomes. 
 
The Plan contract says that, in order to be eligible for special supplemental benefits for the chronically ill, you 
must have one or more comorbid and medically complex chronic conditions that are life-threatening or 
significantly limit your health or general functioning. In addition, you must have a high risk of hospitalization 
or other adverse health outcomes; and must require intensive care coordination.  
 
We looked at the file and Plan's rules. The file shows that your medical conditions are not eligible medical 
conditions for coverage under the Plan's benefit. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill that includes transportation for non-medical needs, 
an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home 
assistance services (repairs).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Adakveo. 
 
You asked the Plan to pre-approve Adakveo. You say that Adakveo is medically necessary. The Plan denied 
your request. The Plan says the records do not show that this drug is safe or effective for this enrollee. 
 
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 Adakveo. Our reviewer says that 
Adakveo is not medically necessary. Our physician reviewer found in this case the enrollee is maintained on 
Xarelto therapy. The combination of Xarelto and Adakveo has not been studied and potentially may lead to 
increased bleeding episodes. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Adakveo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Adakveo.
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 compression stockings. You say that compression stockings are
medically necessary. The Plan denied your request. The Plan says the requested compression stockings are not
covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6549
are not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression
stockings identified with code A6549.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuous glucose monitor and supplies.
You asked the Plan to pre-approve the continuous glucose monitor and supplies. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the member does not meet Medicare coverage criteria for the continuous glucose monitor and supplies.
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 or require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuous glucose monitor and supplies.
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 want to return to your senior living community. you
say that you will not be able to return home in 7-10 days if you do not go to an inpatient rehabilitation facility.
The Plan denied your request. The Plan says the services that are required can be provided in a skilled nursing
facility. The Plan says that these services do not need to be managed by a rehabilitation doctor.
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 treatment by multiple therapies, including either
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the
documentation does support a need for physical and/or occupational therapy, there is no documented need for
an intensive, multi-disciplinary rehabilitation program.
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation trips. 
 
You asked the Plan to provide coverage for additional routine transportation trips. You say that you need 
additional transportation trips for medical appointments. The Plan denied your request. The Plan says you have 
exceeded limits set in the subscriber agreement. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of personal care attendant (PCA) services.
You asked the Plan to pre-approve the PCA services. You say that you require this care. The Plan denied your request. The Plan says review of the records shows that you only need assistance on your bad days, which are not very often. You do not currently meet the criteria for the PCA services being requested.
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the PCA services have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve continuation of personal care attendant (PCA) services.
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 not able to take care of yourself without 
assistance from a physical and respiratory aspect. The Plan denied your request. The Plan says under Medicare, 
the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 
Our physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy visit provided on June 30, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy visit. You say that the service was medically necessary. The 
Plan denied your request. The Plan says no prior authorization was obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. 
Therefore, we decided that the Plan does not have to pay for the psychotherapy visit provided on June 30, 
2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies, materials, and clinical staff time provided from January 21, 2021, through March 13, 2021.
You asked the Plan to pay for the additional supplies, materials, and clinical staff time. You say that this code was established to report additional practice expenses incurred during a public health emergency including supplies and additional clinical staff time. You say that the claims should be reprocessed. The Plan denied your request. The Plan says bundled services are not eligible for separate reimbursement.
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, the CPT Code Manual definition of code 99072 is additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease.
We find that CPT code 99072 is not supported in the medical record. Specifically, CPT code 99072 has a status indicator of B. This means that CPT code 99072 is considered bundled and not separately payable. Based on this information, we decided that Medicare rules for coverage of the additional supplies, materials, and clinical staff time have not been met. Therefore, we decided that the Plan does not have to pay for the additional supplies, materials, and clinical staff time provided from January 21, 2021, through March 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture. 
 
You asked the Plan to pre-approve acupuncture. You say that you wanted to try acupuncture to help alleviate 
the pain to avoid taking more pills. The Plan denied your request. The Plan says you do not meet criteria for 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. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plan's rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the documentation does not support that you have a 
diagnosis of chronic low back pain. Therefore, we decided that the Plan does not have to pre-approve 
acupuncture.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for urology services.
You asked the Plan to pre-approve the referral. You say that there are not many urologists in the area. The Plan denied your request. The Plan says there are other providers in the 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 out-of-network referral for urology services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the oral hygiene instructions, inhalation of nitrous oxide, drugs or medicaments, application of desensitizing medicaments and occlusal adjustment.
You asked the Plan to pre-approve the oral hygiene instructions, inhalation of nitrous oxide, drugs or medicaments, application of desensitizing medicaments and occlusal adjustment. You say that the dentist said you will lose your teeth if the services are not performed. You say that you were told dental services were covered and now the services you need are being denied. The Plan denied your request. The Plan says the services are not covered benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's 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 pre-approve the oral hygiene instructions, inhalation of nitrous oxide, drugs or medicaments, application of desensitizing medicaments and occlusal adjustment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sit to stand table frame.
You asked the Plan to pre-approve a sit to stand table frame. You say that this item is medically necessary. The Plan denied your request. The Plan says this item is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. A sit to stand table frame does not serve a purpose that is primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve a sit to stand table frame.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical placement of an endosteal implants (D6010), custom fabricated abutments (D6057) and implant supported crowns (D6065) for teeth # 4 and 5.
You asked the Plan to pre-approve the dental services. You say that you cannot chew on your right side. You say that you only have 1 tooth on the upper left side of your mouth. You say that when you eat, the food gets stuck in the back since you have a lot of gaps between your teeth. You also say that you get pain regarding the gap. The Plan denied your request. The Plan says surgical placement of an endosteal implants are not listed as covered services. The Plan says custom fabricated abutments are not listed as covered services. The Plan also says implant supported crowns are not listed as covered services either.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested surgical placement of an endosteal implants, custom fabricated abutments, and implant supported crowns are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve surgical placement of an endosteal implants (D6010), custom fabricated abutments (D6057) and implant supported crowns (D6065) for teeth # 4 and 5.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the retainer crown (D6740) for tooth #'s 6 and 8.
You asked the Plan to pre-approve the retainer crown (D6740). The Plan denied your request. The Plan says the service is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's 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 pre-approve the retainer crown (D6740) for tooth #'s 6 and 8.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the complete upper denture. 
 
You asked the Plan to pre-approve the complete upper denture. You say that the previous denture does not stay 
in your mouth and food gets caught between the plate and the top of your mouth. You say that you are not 
asking for expensive implants just a denture that you can keep in your mouth. The Plan denied your request. 
The Plan says dentures are only covered once in a five-year period. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you also have a maximum benefit of 
one complete upper denture every five years. The Plan paid for the immediate upper denture provided on April 
1, 2019, which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve the 
complete upper denture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652). 
 
You asked the Plan to preapprove a pneumatic compression device. You say that the PCD should be covered. 
The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic 
pump that Medicare requires. The documentation also did not show the enrollee had lymphedema extending 
into the trunk of the abdomen. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device 
(E0652).