Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a weight loss program. 
 
You asked the Plan to pre-approve a weight loss program. You say that you want to lose weight. You say that 
you are trying to get off Mounjaro and want your diabetes under control and being overweight does not help. 
The Plan denied your request. The Plan says a weight loss program is not a covered benefit. 
 
The Plan contract says elective or voluntary enhancement procedures, services, supplies, and medications 
(including weight loss, hair growth, sexual performance, athletic performance, anti-aging, and 
mental performances) are not covered under any condition.  
 
We looked at the file and the Plans rules. The file shows that weight loss services are not covered under any 
condition. Therefore, we decided that the Plan does not have to pre-approve a weight loss program.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on July 
14, 2023, to July 18, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that that workers from the 
Social Security Office told you that Medicare Part A is the hospital and that it is free. 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 a $465 
copayment for inpatient hospital care.  
You have been asked to pay a $465 copayment for the inpatient hospital stay. This item/service falls within the 
inpatient hospital care 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. You have been asked to pay a total of $1,860 for the inpatient hospital stay ($465 
copayment x 4 days = $1,860). You have not been charged for the day you were discharged. Therefore, we 
decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on July 14, 
2023, to July 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care services provided on June 21, 2023. 
 
You asked the Plan to pay for wound care services. You say that this is supported in the records. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for wound care services 
provided on June 21, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (denosumab) injection (J0897).  
 
You asked the Plan to pre-approve Prolia injection. You say that the enrollee has previous hypersensitivity 
reaction to Fosamax. The Plan denied your request. The Plan says Prolia is not being used for a medically 
accepted reason or is being used off-label. The Plan also says that the diagnosis provided by your doctor, 
osteopenia, is not a medically accepted use for Prolia. 
 
The Plan follows Medicare rules. Medicare rules say that in order to be covered by Medicare, a drug or 
biological must be safe and effective and otherwise reasonable and 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 Prolia injection. Our reviewer says that 
the enrollee does not meet the criteria for a Prolia injection. Our physician reviewer found the provided records 
in this case do not document a diagnosis of osteoporosis or that the patient is receiving adjuvant aromatase 
inhibitor therapy for breast cancer as required by the LCD. Our physician reviewer also found that the covered 
indication is not documented as required by the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prolia (denosumab) injection (J0897).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 7 home health skilled nursing visits.  

You asked the Plan to pre-approve 7 home health skilled nursing visits. You say that you would like to request 
reconsideration of the denied home health skilled nursing visits and that the visits requested are medically 
necessary. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health skilled nursing visits. Our 
reviewer says that the services are not medically reasonable and necessary. Our physician reviewer found the 
documentation doesn't support that the member requires additional skilled nursing services to provide 
treatment that is 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 home health skilled nursing visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 7 home health skilled nursing visits.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for mepolizumab injections provided on 
January 06, 2023, to April 04, 2023. 
 
You asked the Plan to waive the coinsurance for mepolizumab injections. You say that this is too much, and no 
one told you that there would be a 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for mepolizumab injections. This item/service falls within the 
Medicare Part B prescription drugs 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. The total you owe is $2,366.36 ($592.96 + $592.96 + $587.48 + $592.96 = 
$2,366.36). Therefore, we decided that the Plan does not have to waive the coinsurance for mepolizumab 
injections provided on January 06, 2023, to April 04, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing denoted by procedure codes 80307 and G0483, 
billed for date of service March 14, 2023. 
 
You asked the Plan to pay for procedure codes 80307 and G0483. You say that you have billed the services at 
issue correctly. The Plan denied your request. The Plan says the provided records do not support the services 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 
 
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 procedure codes 80307 and G0483 
have been met. Specifically, the results of the testing at issue have not been documented in the case record. 
Based on the available documentation, the services at issue cannot be verified. Therefore, we decided that the 
Plan does not have to pay for drug testing denoted by procedure codes 80307 and G0483, billed for date of 
service March 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the inpatient hospital stay on July 8, 2023, to 
July 11, 2023.  
 
You asked the Plan to waive the cost share for the inpatient hospital stay. You say that it is your understanding 
that if you end up being readmitted for the same condition within a short period of time you are not responsible 
for the cost of that visit. 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 a $325 
copayment per day, days 1-6 for each Medicare-covered hospital admission/stay. For the stay it's 4 x $325 = 
$1,300. The out-of-pocket was met during this stay. Therefore, results in the total cost sharing $764.79. 
 
You have been asked to pay a $764.79 cost share for the inpatient hospital stay. This item/service falls within 
the inpatient hospital care 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 cost share for the inpatient 
hospital stay on July 8, 2023, to July 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve plastic side guards (K0108 x2). 
 
You asked the Plan to pre-approve plastic side guards. You say that the items are necessary. The Plan denied 
your request. The Plan says the requested items are not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.    

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve plastic side guards (K0108 x2).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left carpal tunnel release. 
 
You asked the Plan to pre-approve left carpal tunnel release. You say that there is electrodiagnostic evidence of 
a mild left median mononeuropathy at the wrist with chronic denervation. The Plan denied your request. The 
Plan says the enrollee does not meet the criteria for coverage. 
 
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 carpal tunnel release. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee presented with complaints of nocturnal numbness in the median nerve 
distribution, pain at the radial aspect of the wrist, persistent stiffness, and persistent paresthesia. However, the 
exam does not corroborate significant findings of carpal tunnel syndrome outside of paresthesia in the median 
nerve distribution. In addition, detailed documentation regarding a trial and failure of recent, reasonable, 
comprehensive, less invasive conservative care measures is not evident. Specifically, the length of time the 
enrollee tried bracing is not documented and there is no documentation of any corticosteroid injection having 
been tried and failed. 
 
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 carpal tunnel release have not been met. Therefore, we decided that the Plan 
does not have to pre-approve left carpal tunnel release.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the electronic connection. 
 
You asked the Plan to pre-approve the electronic connection. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says there is not a medical need to control the power option 
through a joystick. 
 
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 electronic connection. Our reviewer 
says that the requested electronic connection (E2311) is not considered medically reasonable and necessary in this case. Our physician reviewer found the provided records support that the enrollee has adequate strength to 
manage standard power drives. Therefore, the reviewer found that the requested electronic connection is not 
medically reasonable and 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 the electronic connection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the electronic connection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on August 17, 2023. 
 
You asked the Plan to pay for the office visit. You say that requesting reconsideration stating you have 
included a copy of the referral from the VA. The Plan denied your request. The Plan says that unauthorized, 
out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit provided 
on August 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of torus mandibularis (D7473). 
 
You asked the Plan to pre-approve D7473. You say that this dental work is medically necessary. The Plan 
denied your request. The Plan says the requested dental 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 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 pre-approve the 
removal of torus mandibularis (D7473).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service May 1, 2023. 
 
You asked the Plan to pay for procedure code 99100. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says procedure code 99100 is considered bundled 
and not separately payable.  
 
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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service May 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the group 3 standard power wheelchair (K0861), non-
covered item or service (A9270), and sales tax (S9999) provided on May 30, 2023, by an out-of-network 
(OON) provider.  
 You asked the Plan to pay for the group 3 standard power wheelchair, non-covered item or service, and sales 
tax. You say that you purchased this power wheelchair from an OON provider because there is no dealer closer 
to you. You also say that you did not think it would be eligible for reimbursement, but your doctor suggested it 
might be, and you think it should be covered. The Plan denied your request. The Plan says no prior 
authorization was submitted to the Plan prior to the purchase of the equipment. 
 
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 2023 EOC clearly states that 
DME item(s) that cost more than $1,000 require prior authorization. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the group 3 standard power wheelchair (K0861), 
non-covered item or service (A9270), and sales tax (S9999) provided on May 30, 2023, by an out-of-network 
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthetic outer surface covering (L5962). 
 
You asked the Plan to pre-approve prosthetic covering. You say that the enrollee is in need of a replacement 
prosthesis. The Plan denied your request. The Plan says there is no documentation that the enrollee's activity 
subjects the prosthesis to harsh environmental conditions or extraordinary activities that would justify the need 
for extra protection. 
 
The Plan follows Medicare rules. Medicare rules state that protective outer covering surfaces may be covered 
for lower limb prostheses when 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 prosthetic covering. Our reviewer says that the enrollee does not meet criteria for this covering. Our physician reviewer found the documentation does 
not support that the enrollee has a medical need for a specialized outer covering for the authorized prosthesis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prosthetic covering have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a prosthetic outer surface covering (L5962).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on August 02, 2023. 
 
You asked the Plan to pay for the office visit. You say that requesting reconsideration stating you are not sure 
why this is not covered under your insurance as all your other visits are covered. The Plan denied your request. 
The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit provided 
on August 02, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 standard power operated vehicle (POV) 
(K0806). 
 
You asked the Plan to pre-approve a Group 2 standard POV. You say that you need an electric wheelchair to 
better accommodate you during activities of daily living. You also say that you need the electric wheelchair to 
get around outdoors. The Plan denied your request. The Plan says the requested scooter is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that Group 2 POVs (such as code K0806) have added 
capabilities that are not needed for use in the home, and will be denied as not reasonable and necessary. The 
rules also state that for equipment to be covered, it must be appropriate and needed for use inside the home. 
 
 We looked at the file and Medicare rules. The requested POV coded K0806 is specifically not covered by 
Medicare. The item at issue in this appeal is also for use outside of the home according to your request. 
Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. 
Based on this information, we decided that Medicare rules for coverage of a Group 2 standard POV have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a Group 2 standard power operated 
vehicle (POV) (K0806).