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

 
We decided that the Plan does not have to pre-approve custom breast prosthesis (L8035). 
 
You asked the Plan to pre-approve custom breast prosthesis. You say that the custom breast prosthesis is the 
best non-surgical option for this enrollee, as she had a left mastectomy due to breast cancer and wears a size 13 
standard breast prosthesis. You also say the standard breast prosthesis in this size is extremely heavy for the 
enrollee. The Plan denied your request. The Plan says the requested prosthesis is denied as not reasonable and 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of custom breast prosthesis have not been met. Specifically, LCD 33317 confirms that the medical 
necessity for the additional feature of the requested prosthesis has not been established and is denied as not 
reasonable and necessary. Therefore, we decided that the Plan does not have to pre-approve custom breast 
prosthesis (L8035).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 power wheelchair (K0800). 
 
You asked the Plan to pre-approve a group 1 power wheelchair. 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 follows Medicare rules. Medicare rules say that power mobility devices are covered when specific 
criteria are 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 group 1 power wheelchair. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the documentation is 
conflicting that the enrollee has a mobility limitation that significantly impairs his ability to participate in one 
or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, 
and bathing in customary locations in the home and is unable to be helped by a manual wheelchair or walker. A 
July 12, 2023, physician progress note indicates normal gait, 4/4 strength. The review of systems was negative 
for falls, joint pain, weakness, gait abnormality. The March 13, 2023, document notes that the enrollee is 
unable to safely transfer to/from a scooter or safely operate a scooter. The documentation does not support the 
need for the requested power operated vehicle. 
 
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 group 1 power wheelchair have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a group 1 power wheelchair (K0800).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a laboratory testing in a facility provided on February 17, 
2023. 
 
You asked the Plan to pay for a laboratory testing in a facility. You say that you depend on the facility staff to 
verify eligibility and to obtain authorization. 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 a laboratory testing in a 
facility provided on February 17, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that you need to take care of your health to be able to take 
care of your spouse. The Plan denied your request. The Plan says Prolia is not medically necessary, and the 
step therapy requirements have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. Also, 
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 Prolia. Our reviewer says that Prolia is 
not medically necessary. Our physician reviewer found that although the request use of Prolia is FDA-approved 
for the enrollees diagnosis, the step therapy requirements have not been met. The enrollee has not tried and 
failed the Plans required drugs abaloparatide, Calcitonin, intravenous bisphosphonate, oral bisphosphonate, 
raloxifene, romosozumab or teriparatide. Also, there is no indication that the Plan's required drugs would likely 
be less effective or likely have adverse effects for the enrollee. 
 
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 have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that the CGM is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the Medicare criteria was not met. 
 
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 CGM. Our reviewer says that the 
CGM coverage criteria was not met. Our physician reviewer found that the criteria for a CGM coverage 
includes low blood sugars or insulin use; as the enrollee is not using insulin now and we are not told of low 
blood sugars, the criteria for coverage are not met at this time; although the CGM may help the enrollee, 
coverage criteria are not met at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service March 6, 
2023, to March 25, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that these services were medically necessary and 
were ordered by an in-network provider. 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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service March 6, 2023, to March 25, 2023.
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 requires daily physician checks and 24-
hour nursing for proper medication management. Services needed may be provided safely in a lower level of 
care. The Plan denied your request. The Plan says the enrollee's records do not show the need for the intensity 
of 3 hours of daily therapies provided in the IRF setting. 
 
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 pay for continuation of inpatient care provided from 
February 23, 2023, to February 28, 2023. 
 
You asked the Plan to pay for continuation of inpatient care. You say that continuation of inpatient care was 
medically necessary. The Plan denied your request. The Plan says continuation of inpatient care is not 
medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We 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 continuation of inpatient care. Our reviewer says that the requested continuation of inpatient care is not considered medically reasonable and necessary in 
this case. Our physician reviewer found that as of February 23, 2023 continuation of inpatient care at issue in 
this case was not medically reasonable or necessary. The enrollee was hemodynamically stable, tolerating an 
oral diet and required no inpatient diagnostic studies or therapeutic interventions.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continuation of inpatient care have not been met. Therefore, we decided that the 
Plan does not have to pay for continuation of inpatient care provided from February 23, 2023, to  
February 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance applied to laboratory services provided on 
February 17, 2023. 
 
You asked the Plan to waive the coinsurance applied to the laboratory services. You say that you do not want to 
pay the laboratory, nor do you feel that the Plan should pay the laboratory, for the services provided. You say 
that the results of the laboratory testing were untimely and took three-times longer than normal. You say that 
this is unacceptable and that the delay could have caused you harm, had your doctor not moved forward with 
an antibiotic treatment prior to the lab results being provided.  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 30% coinsurance for laboratory tests provided out-of-network.  for Outpatient Laboratory Tests.  
 
You have been asked to pay a 30% coinsurance for laboratory tests provided out-of-network for the laboratory 
services. This service falls within the Outpatient Laboratory Tests 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 applied to laboratory services provided on February 17, 2023.  
 
Your complaint about the laboratorys delay in care is not a valid appeal for medical coverage. This part 
of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) and 
ground mileage (A0425) provided on June 6, 2022.  
 
You asked the Plan to pay for the services. You say that this is transport to and from for a dialysis appointment. 
You also say that Medicare covers this service.  The Plan denied your request. The Plan says the Plan's policy 
covers non-emergency ambulance transportation when it is the only way to safely, and adequately transport a 
member, or if other means of transporting a member are unsafe due to a medical condition. The Plan also says 
that this claim does not meet these requirements.  
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 services. Our physician reviewer found 
transportation via ambulance to and from the enrollees hemodialysis appointment was not medically 
necessary. The enrollee did not require the expertise of trained personnel or the equipment available only on an ambulance in order to effectuate a safe transport.  Transportation could have been provided by other means 
(stretcher van, wheelchair van, private car, taxi) without endangering the enrollees condition. A prudent 
layperson would not believe that immediate medical attention was required for someone who was attending a 
scheduled appointment. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the non-emergency ambulance transportation (A0428) and ground mileage (A0425) provided 
on June 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0013M) provided on January 5, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0013M) provided on January 5, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services (87801, 87798, 87481) provided on February 13, 
2023. 
 
You asked the Plan to pay for laboratory services. You say that these services were medically necessary and are 
supported in the medical record. The Plan denied your request. The Plan says that these services were not billed 
appropriately. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not cited the rule used to make their decision and we 
were unable to find this information in a determination which applies to the state where these services were 
provided. In addition, the services at issue were each reported with the -59 modifier, indicating that they were 
provided as separate and distinct services. It does not appear that the Plan has performed a review to determine 
whether the reported modifiers were appropriate or not. The Plan has not fully substantiated their denial in this 
case. Therefore, we decided that the Plan has to pay for laboratory services (87801, 87798, 87481) provided on 
February 13, 2023.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for collection of venous blood by venipuncture provided on 
March 06, 2023. 
 
You asked the Plan to pay for collection of venous blood by venipuncture. You say that the services should be 
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 collection of venous 
blood by venipuncture provided on March 06, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided on 
March 24, 2023. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that you left and did not 
receive services. 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 $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for the emergency room visit. This item/service falls within the 
emergency 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. The record shows this claim was approved and you are responsible for the cost share amount. Therefore, 
we decided that the Plan does not have to waive the copayment for the emergency room visit provided on 
March 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the specialist office visit provided on March 
1, 2023. 
 
You asked the Plan to waive the deductible for the specialist office visit. You say that you should only have a 
$45 copayment for a specialist. 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. Your 
contract with the Plan says that there is an $800 deductible which applies to specialist physician/practitioner 
services. Your contract with the Plan also says that you must pay 40% coinsurance after meeting the deductible 
for out-of-network specialist office visits. 
 
 The item or service you asked the Plan to waive the deductible for falls within the physician/practitioner 
services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is an $800 deductible which applies to specialist physician/practitioner services. This cost sharing is a 
contractual obligation that had not been met at the time the specialist office visit was received on March 1, 
2023. Therefore, we decided that the Plan does not have to waive the deductible for the specialist office visit 
provided on March 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 08, 2022. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration of the denied 
claim. 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 an office visit provided 
on April 08, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 21, 2023. 
 
You asked the Plan to pay for an office visit. You say that the services should be 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 an office visit provided 
on February 21, 2023.