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

 
We decided that the Plan does not have to pre-approve Glucerna shakes. 
 
You asked the Plan to pre-approve Glucerna shakes. You say that the enrollee needs a lower carbohydrate 
formula due to her diabetes. The Plan denied your request. The Plan says oral nutritional supplementation is not 
covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve Glucerna shakes.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oncology analysis of minimal residual disease (MRD) 
(Signatera test). 
 
You asked the Plan to pre-approve Signatera test. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says this is not medically necessary. 
 The Plan follows Medicare rules. Medicare rules state that molecular pathology procedures may be covered 
under certain circumstances. 
 
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 Signatera test. Our reviewer says that 
the enrollee does not meet criteria for the Signatera test. Our physician reviewer found Medicare covers 
Signatera testing for adjuvant and recurrence monitoring in patients with stage IIb or higher breast cancer. The 
coverage applies across all subtypes of the disease, including hormone receptor positive, HER2-positive, and 
triple negative breast cancers. However, the enrollee has stage IA invasive lobular breast cancer and thus does 
not fall within the criteria requirements. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Signatera test have not been met. Therefore, we decided that the Plan does not 
have to pre-approve oncology analysis of minimal residual disease (MRD) (Signatera test).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing. 
 
You asked the Plan to pre-approve the requested testing. You say that the test could provide information for 
next lines of therapy. The Plan denied your request. The Plan says the enrollee previously had testing. 
 The Plan must follow Medicare rules. Medicare rules say that next generation sequencing is only covered under 
certain medical indications. 
 
The file shows that FoundationOne genetic testing was requested. We looked at the file and Medicare rules. 
NGS testing is covered when the enrollee has not been previously tested with the same test using NGS for the 
same cancer genetic content. The records show that the enrollee received FoundationOne testing in 2021.  
Based on this information, we decided that Medicare rules for coverage of the requested testing have not been 
met. Therefore, we decided that the Plan does not have to pre-approve genetic testing.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital evaluation and management (EM) services 
provided on June 30, 2022, billed with code 99223. 
 
You asked the Plan to pay for the EM service provided. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says the level of care is not supported. 
 
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 99223 is Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. 
 
We asked our physician 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 EM service provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that the history of present illness was not 
comprehensive (i.e., alleviating/exacerbating factors, home treatments tried, response to home/ED 
treatments). No surgical history, family history or medication list is documented. As such, the history is not 
comprehensive, and the billing of CPT 99223 is not supported. 
 
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 EM service provided have not been met. Therefore, we decided that the Plan 
does not have to pay for inpatient hospital evaluation and management (EM) services provided on June 30, 
2022, billed with code 99223.
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 are not sure why your request 
was denied. You also say that you have chronic back pain, are unable to stand up for long, you have a bad 
knee, had a stroke, get dizzy spells due to traumatic brain injury, and have fallen several times. The Plan denied 
your request. The Plan says the requested power operated vehicle does not meet the criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that if a group 2 POV, such as code K0806, is 
provided it will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a 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).
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 cannot go home because you are not up to your 
full ability as you were before you got ill. 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided on March 2, 2023, by 
an OON provider.  You asked the Plan to pay for the psychotherapy services. You say that the service was medically necessary. 
The Plan denied your request. The Plan says the service was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the psychotherapy services provided on March 2, 
2023, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device. 
 
You asked the Plan to pre-approve the requested services. You say that measurements show persistent 
lymphedema.  The Plan denied your request. The Plan says a trial of conservative therapy has not been 
completed. 
 
The Plan must follow Medicare rules. Medicare rules say that pneumatic compression devices are only covered 
under certain medical indications. 
 
We looked at the file and Medicare rules. The records provided do not document conservative therapy that 
consists of regular, and complaint attempts over a four-week period. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a pneumatic compression device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is medically ready for 
discharge to a LTACH. You say that it would be medically and ethically inappropriate to discharge the enrollee 
to a lower level of care where their needs cannot be met. The Plan denied your request. The Plan says an 
LTACH admission is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the documentation does not support the transfer to a LTACH, and the enrollee is 
receiving the appropriate care in the current acute care setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home delivered meals including preparation per 
meal. 
 
You asked the Plan to pre-approve the home delivery meals. You say that your chart is incorrect, and your 
principal hospital diagnosis was congestive heart failure (CHF). The Plan denied your request. The Plan says 
you do not meet the coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that home delivered meals not covered.  However, 
the Plan offers a home-delivered meal benefit that exceeds Medicare coverage. For that reason, the Plans 
coverage rules apply in this case.  
 
 
 Though the Plan offers a home-delivered meals benefit in excess of Medicare coverage, the home delivered 
meals including preparation per meal does not meet criteria. Specifically, CHF was not the primary diagnosis at 
discharge. Also, you were discharged to a skilled nursing facility. Therefore, we decided that the Plan does not 
have to pre-approve the home delivered meals including preparation per meal.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair (K0001). 
 
You asked the Plan to pre-approve a manual wheelchair. You say that the item is medically necessary. The 
Plan denied your request. The Plan says the enrollee has completed several weeks of physical therapy where 
she underwent training and evaluation in use of a cane and is now able to ambulate household distances with 
use of a cane. 
 
The Plan must follow Medicare rules. Medicare rules say that for a manual wheelchair to be covered, the 
enrollees mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or 
walker. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a manual wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-
approve a manual wheelchair (K0001).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pre-approval for a standard hemi-wheelchair (K0002) 
and additional items and accessories (codes E0951 x2, E0971 x2, E2601, E2611, E2201, and E0961 x2). 
 
You asked the Plan to pre-approve pre-approval for a standard hemi-wheelchair and additional items and 
accessories. You say that you need a wheelchair for shopping in large stores because you have fallen in the past 
and have needed assistance getting up. You also say that you need a wheelchair so you can go to parks. The 
Plan denied your request. The Plan says the requested wheelchair cannot be considered reasonable and 
necessary. The Plan also says the clinical information indicates the wheelchair is for use outside the home, 
which is not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve pre-approval for a standard hemi-wheelchair (K0002) and additional items and accessories 
(codes E0951 x2, E0971 x2, E2601, E2611, E2201, and E0961 x2).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Wegovy. 
 
You asked the Plan to pre-approve the medication. You say that the requested medication is medically 
necessary. The Plan denied your request. The Plan says the medication is not covered as a medical benefit 
under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Wegovy.  
 
Benefits for the medication 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit (99285) provided on May 3, 
2021. 
 
You asked the Plan to pay for the emergency department visit. You say that the claim was submitted well 
within the payer limits. The Plan denied your request. The Plan says this claim was processed correctly due to 
the claim not being filed until October 24, 2022, without good cause. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
 
 The record shows that a claim for the emergency department visit was not filed until October 24, 2022. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for the emergency department visit (99285) provided 
on May 3, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mental health visit provided on March 11, 2023, by an 
OON provider.  You asked the Plan to pay for a mental health visit. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says this service was not authorized. 
 
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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a mental health visit provided on March 11, 2023, 
by an OON provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve True Metrix glucose test strips. 
 
You asked the Plan to pre-approve the True Metrix glucose test strips. You say that the enrollee tried and failed 
OneTouch Verio test strips and has type 2 diabetes. The Plan denied your request. The Plan says that the 
prescriber is requesting a non-preferred test strip due to a need for data management software, and conditions 
for coverage are not met. 
 
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 hasn't given us a valid denial reason for this claim. The 
Plan's 2023 Evidence of Coverage states for all people who have diabetes (insulin and non-insulin users). 
Covered services include supplies to monitor your blood glucose: Blood glucose monitor, blood glucose test 
strips, lancet devices and lancets, and glucose-control solutions for checking accuracy of test monitors. You 
can find this information on page 53 of the Plans 2023 Evidence of Coverage. Therefore, we decided that the 
Plan has to pre-approve True Metrix glucose test strips.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the OTC vitamins provided on July 12, 2022, to February 12, 
2023. 
 
You asked the Plan to pay for the OTC vitamins. You say that you have sent in receipts to the health plan to 
prove the cost of your vitamin supplements. The Plan denied your request. The Plan says the service is not a 
covered benefit. 
 
Medicare generally does not cover OTC items. However, the Plan offers an OTC benefit that exceeds Medicare 
coverage. For that reason, the Plans coverage rules apply in this case. 
 
Thought the Plan offers an OTC benefit in excess of Medicare coverage, the OTC vitamins are not covered. 
Specifically, the record shows you utilized your monthly $50 allowance each month from July 2022 through 
May 2023. This means that the additional OTC vitamins exceed your benefit allowance. Therefore, we decided 
that the Plan does not have to pay for the OTC vitamins provided on July 12, 2022, to February 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the glucose strips (A4253) provided on February 13, 2023. 
 
You asked the Plan to pay for the glucose strips. You say that the item is medically necessary. The Plan denied 
your request. The Plan says this is not the preferred brand. 
 
The Plan follows Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the Durable Medical Equipment 
(DME) to only those preferred brands and manufacturers 
 
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 glucose strips. Our reviewer says that the 
enrollee does not need this item. Our physician reviewer found there is no reason given whey the preferred 
glucose strips would not suffice instead of the requested brand. 
 
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 glucose strips have not been met. Therefore, we decided that the Plan does 
not have to pay for the glucose strips (A4253) provided on February 13, 2023.