Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve an MRI of the lumbar spine. 
 
You asked the Plan to pre-approve an MRI of the lumbar spine. You say that the MRI was requested to 
determine if there are any neurological reasons other than diabetic nephropathy that is causing the loss of 
feeling in your legs. The Plan denied your request. The Plan says that an MRI of the lumbar spine 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 an MRI of the lumbar spine. Our 
reviewer says that an MRI of the lumbar spine is medically necessary. Our physician reviewer found that you 
have a history of lumbar fusions in 2021. While you have diabetic neuropathy the lower extremity muscle 
wasting is a process which should be evaluated especially given the lumbar fusion less than 2 years ago. 
Therefore, the MRI of the lumbar spine should 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 an MRI of the lumbar spine have been met. Therefore, we decided that the Plan 
has to pre-approve an MRI of the lumbar spine.  
 
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: 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 is at high risk for falls, stroke, infection, 
and further cognitive decline if not appropriately cared for in an inpatient setting with the proper equipment for 
disease specific care.  The Plan denied your request. The Plan says an intensive rehabilitation program 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: 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 extremely ill, unable to move or walk, care for 
yourself and is in need of inpatient rehabilitation. Member. The Plan denied your request. The Plan says you do 
not meet the Medicare criteria for admission to an Inpatient Rehabilitation Facility. 
 
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 complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a standard wheelchair (K0001). 
 
You asked the Plan to pre-approve a standard wheelchair. You say that the item is medically necessary. The 
Plan denied your request. The Plan says the notes from your provider and a home assessment did not indicate 
you have a mobility that significantly impairs your activities of daily living that cannot 
be resolved with a walker or cane. 
 
The Plan follows Medicare rules. Medicare rules say that a standard wheelchair is covered when the criteria 
listed in the Medicare Rules section is met, 
 
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 standard wheelchair. Our reviewer 
says that you do not need this medical item. Our physician reviewer found the medical records provided do not 
indicate a need for a manual wheelchair to accomplish self-care tasks and mobility. 
 
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 standard wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a standard wheelchair (K0001).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Computed tomography, lower extremity (73700). 
 
You asked the Plan to pre-approve a Computed tomography. You say that the enrollee needs services for prior 
to the Robotic assisted MAKO Knee Replacement Surgery. The Plan denied your request. The Plan says 
services cannot be approved as performed solely to plan for robot assisted surgery is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a Computed tomography. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found no compelling rationale is 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
 
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 Computed tomography have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Computed tomography, lower extremity (73700).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames, the single vision lens, the anti-reflective coating, 
and the polycarbonate lens provided on January 10, 2023. 
 
You asked the Plan to pay for the frames, the single vision lens, the anti-reflective coating, and the 
polycarbonate lens. You say that you were overcharged for the services and would like to be reimbursed. The 
Plan denied your request. The Plan says the benefit has been exhausted. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services with a $200 allowance. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid the $200 allowance towards the services, 
which exhausted the benefit. Based on this information, we decided that the Plan's rules for coverage of the 
frames, the single vision lens, the anti-reflective coating, and the polycarbonate lens have not been met. 
Therefore, we decided that the Plan does not have to pay for the frames, the single vision lens, the anti-
reflective coating, and the polycarbonate lens provided on January 10, 2023.
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 you are unable to move in and out 
of bed. You also say that this affects your quality of life. The Plan denied your request. The Plan says the 
requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0265).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqvio. 
 You asked the Plan to pre-approve Leqvio. You say that the enrollee has been diagnosed with 
hypercholesterolemia and white matter disease which Leqvio is Food and Drug Administered (FDA) approved 
for treatment. The Plan denied your request. The Plan says the step therapy requirements have not been 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 Leqvio. Our reviewer says that Leqvio 
is not medically necessary. Our physician reviewer found that the requested drug is a new start for the enrollee 
who has Hypercholesterolemia and atherosclerotic disease. The provided records do not indicate that the 
enrollee has tried and failed the Plan's preferred step one alternative. Also, there is no indication that the 
enrollee has a contraindication, to, or would have an adverse effect from the Plan's preferred step one 
alternative, Therefore, the elements of coverage criteria have not been satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Leqvio have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Leqvio.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care services provided on March 10, 2022. 
 
 You asked the Plan to pay for the initial hospital care services. You say that the enrollee was not enrolled in 
hospice on the date of service. The Plan denied your request. The Plan says Original Medicare is responsible 
for payment. 
 
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 4, 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 initial hospital 
care services provided on March 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 sensor.  
You asked the Plan to pre-approve the Dexcom G6 sensor. The Plan denied your request. The Plan says it has 
been determined that you do not meet the criteria for the Dexcom G6 sensor. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the Dexcom G6 sensor. Our reviewer 
says that the Dexcom G6 sensor is not medically necessary. Our physician reviewer found although the 
Glipizide can cause low blood glucose sugar, we are not told that you are having symptomatic low blood 
glucose sugar. The coverage criteria given require insulin use or low blood glucose sugar for CGM coverage. 
This does not mean you would not benefit from the CGM use, it does mean coverage criteria are not met. 
 
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 Dexcom G6 sensor have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Dexcom G6 sensor.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on January 23, 2023, to 
January 24, 2023. 
 
You asked the Plan to pay for self-administered drugs. You say that the claim should be reprocessed. The Plan 
denied your request. The Plan says self-administered drugs do not fall under Medicare Part B 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 pay for self-administered drugs provided 
on January 23, 2023, to January 24, 2023.  
 
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on December 8, 2022. 
 
You asked the Plan to pay for the physician's services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says in-network providers were available to provide the services. 
 
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 physician's services provided on December 8, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) scan of the abdomen and 
pelvis provided on February 28, 2023. 
 
You asked the Plan to pay for the CT scan. You say that the enrollee's hospice status was revoked on February 
26, 2023. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for a computed tomography (CT) scan of the abdomen and pelvis 
provided on February 28, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a CT scan of the abdomen and pelvis provided on June 29, 
2022.  
You asked the Plan to pay for a CT scan of the abdomen and pelvis. You say that the claim should be 
reprocessed. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for a CT scan of the abdomen and pelvis provided on June 29, 
2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ultrasound exam of the abdomen provided on February 
28, 2022.  
You asked the Plan to pay for an ultrasound exam of the abdomen. You say that the enrollee revoked hospice 
on February 26, 2022. The Plan denied your request. The Plan says Original Medicare is responsible for 
payment. 
 
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 February 26, 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 an ultrasound exam 
of the abdomen provided on February 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses provided on January 24, 2023. 
 You asked the Plan to pay for the eyeglasses. You say that you have a benefit for eyewear after cataracts and a 
benefit for routine eyewear. You say you should be able to use both benefits for the eyeglasses. The Plan 
denied your request. The Plan says the benefit has been exhausted. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services with a $100 allowance. 
 
We looked at the file and the Plan's rules. Specifically, the Plan applied the $100 benefit to claim number 
13039A142700, which exhausted the benefit. This means claim 23040A185600 denied correctly. Based on this 
information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we 
decided that the Plan does not have to pay for the eyeglasses provided on January 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames, the bifocal lenses, the progressive lenses, and the 
polycarbonate lenses provided on August 4, 2022. 
 
You asked the Plan to pay for the frames, the bifocal lenses, the progressive lenses, and the polycarbonate 
lenses. You say that you were led to believe that you did not have to pay for anything else for the eyewear. The 
Plan denied your request. The Plan says the benefit has been exhausted. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services up to a $200 allowance. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid the $200 allowance towards the vision 
services which exhausted the benefit. Based on this information, we decided that the Plan's rules for coverage 
of the frames, the bifocal lenses, the progressive lenses, and the polycarbonate lenses have not been met. 
Therefore, we decided that the Plan does not have to pay for the frames, the bifocal lenses, the progressive 
lenses, and the polycarbonate lenses provided on August 4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need rehabilitation to help regain your maximum 
level of strength and functions. The Plan denied your request. The Plan says an IRF admission is not medically 
necessary, and your needs can be met in other settings.  
 
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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for diabetic supply services provided from 
July 25, 2022, to January 29, 2023 
 
You asked the Plan to waive the coinsurance for diabetic supply services. You say that you were told you had a 
$5.00 copayment for services, but you are being billed 30% coinsurance. The Plan denied your request. The 
Plan says this cost sharing was charged correctly. 
 
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 30% 
coinsurance for diabetic supplies.  
 
  You have been asked to pay $457.30, which is 30% of the allowed amounts for diabetic supply services. This 
item/service falls within the durable medical equipment (DME) and related supplies 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 coinsurance for diabetic supply services provided from July 25, 2022, to 
January 29, 2023