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

 
We decided that the Plan does not have to pre-approve a group 2 standard power wheelchair with multiple 
power options (K0841) and additional items and accessories (codes E0955, E1007, E1012, E1028, E2300, 
E2311, E2313, E2361, E2377, E2607, and E2620). 
 
You asked the Plan to pre-approve a group 2 standard power wheelchair and additional items and accessories. 
The Plan denied your request. The Plan says the enrollee does not have a qualifying diagnosis causing mobility 
limitation for which a group 3 power wheelchair is medically needed. The Plan also says as the enrollee does 
not qualify for the wheelchair base, none of the requested accessories can be covered. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 2 Multiple Power Option PWC (such as code 
K0841) is covered if all of the basic coverage criteria for a PWC are met and if the criteria listed in the 
Medicare rules section of this letter 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 2 standard power wheelchair 
and additional items and accessories. Our reviewer says that the enrollee does not meet the criteria for 
coverage. Our physician reviewer found the enrollee has fibromyalgia and rheumatoid arthritis. The enrollee is 
able to stand, and does not have skin breakdown, use an intermittent catheter or have spasm impacting 
positioning. Our reviewer also found that the enrollee does not have a qualifying diagnosis nor evidence of 
need for power seat accessories. 
 
 
 
 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 2 standard power wheelchair and additional items and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 standard power 
wheelchair with multiple power options (K0841) and additional items and accessories (codes E0955, E1007, 
E1012, E1028, E2300, E2311, E2313, E2361, E2377, E2607, and E2620).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on March 22, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
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 pay for the pneumatic compression device provided on March 22, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the heart with 
quantitative evaluation of coronary calcium.  
 
You asked the Plan to pre-approve a CT scan with quantitative evaluation of coronary calcium.. You say that 
you need this test to check if there is plaque on your heart. The Plan denied your request. The Plan says the 
coronary calcium score test 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 CT scan with quantitative evaluation 
of coronary calcium. Our reviewer says that the service is not medically necessary. Our physician reviewer 
found CT imaging of the heart without contrast material with quantitative evaluation of coronary calcium is 
considered experimental/investigational for the evaluation and management of your medical condition. 
 
 
 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 CT scan with quantitative evaluation of coronary calcium have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the 
heart with quantitative evaluation of coronary calcium.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve 8 additional acupuncture visits. 
 
You asked the Plan to pre-approve the visits. You say that you have been going to the doctors for at least two 
years to receive acupuncture treatments for injuries to your lower back in a result from a motorcycle accident.  
The Plan denied your request. The Plan says that 8 additional acupuncture visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. While your Plan offers coverage beyond the Medicare acupuncture benefit, the record shows 
this benefit has been exhausted. 
 
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 visits. Our reviewer says that 8 
additional acupuncture visits are medically necessary. Our physician reviewer found that the enrollee has 
improved over the course of therapy. Therefore, the request is 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 visits have been met. Therefore, we decided that the Plan has to pre-approve 
8 additional acupuncture visits.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six (6) additional home health services (G0299x6). 
 You asked the Plan to pre-approve home health services. You say that you disagree with the denial and request 
reconsideration. 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 services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found per chapter 7; 
the skilled nursing services were initiated to address pressure wounds. As of August 7, 2023, the wounds were 
healed. The enrollee was medically stable. The requested services were for continued observation and 
education. The enrollee's condition was stable and no adjustments to the care plan were indicated. Criteria for 
continued skilled services 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve six (6) additional home health services (G0299x6).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that it is unsafe for the enrollee to return home as they 
would be a high risk for falls. You say the enrollee was at a SNF however, after readmission to the hospital, the 
new stay has been denied. The Plan denied your request. The Plan says based on Medicare guidelines, the SNF 
services requested do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. The enrollee had cognitive and pain limitations interfering with full therapy 
participation. The enrollee's functional needs can be met at a lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine vision contact lenses. 
 
You asked the Plan to pre-approve routine vision contact lenses. You say that the item should be covered. The 
Plan denied your request. The Plan says this is not a covered item.  
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pre-approve are considered routine vision services or eyewear. Therefore, 
we decided that the Plan does not have to pre-approve routine vision contact lenses.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy duty, multiple braking system, variable wheel 
resistance walker (E0147). 
 
You asked the Plan to pre-approve a heavy duty, multiple braking system, variable wheel resistance walker. 
You say that the item is medically necessary. The Plan denied your request. The Plan says the item is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a heavy duty, multiple braking system, variable wheel 
resistance walker (E0147) is covered for beneficiaries who meet coverage criteria for a standard walker and 
who are unable to use a standard walker due to a severe neurologic disorder or other condition causing the 
restricted use of one hand. Obesity, by itself, is not a sufficient reason for an E0147 walker. If an E0147 walker 
is provided and if the additional coverage criteria are not met, it will be denied as not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a heavy duty, multiple braking system, 
variable wheel resistance walker. Our reviewer says that you do not need this item. Our physician reviewer found you do not have a neurological condition impeding use of one hand. 
 
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 heavy duty, multiple braking system, variable wheel resistance walker have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy duty, multiple braking 
system, variable wheel resistance walker (E0147).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve a bone marrow aspirate. You say that this is medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of bone marrow aspirate in the setting of 
spinal fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
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 a bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate remains experimental. More research is needed. 
 
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 bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a bone marrow aspirate (20939).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve  a Continuous Positive Airway Pressure (CPAP) device. 
 
You asked the Plan to pre-approve a CPAP device. You say that the item should be covered. The Plan denied 
your request. The Plan says that you purchased the item less than 5 years ago and therefore the item cannot be 
replaced. 
 
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. The Plan has not provided any reasoning why the CPAP cant be replaced due to 
loss. Therefore, we decided that the Plan has to pre-approve  a Continuous Positive Airway Pressure (CPAP) 
device.  
 
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 custom fabricated abutment and abutment supported 
porcelain/ceramic crown (D6057, D6058) provided on May 16, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
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 pay for custom 
fabricated abutment and abutment supported porcelain/ceramic crown (D6057, D6058) provided on May 16, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infusion services (96365, 96366, 96521, J1817) provided on 
March 6, 2023. 
 
You asked the Plan to pay for the infusion services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that services comprising an Outpatient Intravenous 
Insulin Therapy regimen are nationally non-covered. 
 
We looked at the file and Medicare rules. This service is non-covered. Based on this information, we decided 
that Medicare rules for coverage of the infusion services have not been met. Therefore, we decided that the 
Plan does not have to pay for infusion services (96365, 96366, 96521, J1817) provided on March 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anti-reflective coating (V2750) and lenses (V2783) provided 
on May 4, 2023. 
 
You asked the Plan to pay for anti-reflective coating (V2750) and lenses (V2783). You say that you had not 
considered using the insurance, but the provider said the services were covered. The Plan denied your request. 
The Plan says this service is not a covered service. 
 
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 when basic single vision, lined bifocal, lined trifocal, and lenticular 
lenses only. 
 
We looked at the file and the Plan's rules. The Plan rules say that they cover one set of lenses every calendar 
year. The Plan rules also say that this includes basic single vision, lined bifocal, lined trifocal, and lenticular 
lenses only (additional upgrades, extra charges and/or any customizations are not covered, which include 
tinting, coatings and/or special lens materials). Based on this information, we decided that the Plan's rules for 
coverage of anti-reflective coating (V2750) and lenses (V2783) have not been met. Therefore, we decided that 
the Plan does not have to pay for anti-reflective coating (V2750) and lenses (V2783) provided on May 4, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service January 21, 
2023, to February 19, 2023. You asked the Plan to pay for the billed services. You say that the NOA was submitted timely. The Plan denied 
your request. The Plan says the NOA was not received timely.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 21, 2023. The documentation presented does not show that the 
NOA was received by the Plan within 5 days of the start of care date. The NOA was not received by the Plan 
until May 22, 2023. As more than 30 days passed between the timely filing date and the NOA receipt, no 
payment can be made on this claim. Therefore, we decided that the Plan does not have to pay for the home 
health care billed for dates of service January 21, 2023, to February 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on March 30, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
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 pay for the pneumatic compression device provided on March 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on March 2, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
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 pay for the pneumatic compression device provided on March 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lenses, frames, a routine eye examination, and a vision add-
on provided on April 3, 2023. 
 
You asked the Plan to pay for lenses, frames, a routine eye examination, and a vision add-on. You say that you 
called the Plan to find out where you could go, and the Plan told you this provider. The Plan denied your 
request. The Plan says the provider is not in-network. 
 
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 when you obtain the lenses, frames, a routine eye examination, and a 
vision add-on through a Plan routine vision care provider. 
 
We looked at the file and the Plan's rules. The Plan rules also say that covered services include an annual 
routine eye examination to determine changes in your vision and/or the need for eyeglasses or contact lenses, 
eyeglass lenses and eyeglass frames when performed by a Plan routine vision care provider. The record shows 
you went to a provider that is not a Plan routine vision care provider. Based on this information, we decided 
that the Plan's rules for coverage of lenses, frames, a routine eye examination, and a vision add-on  have not 
been met. Therefore, we decided that the Plan does not have to pay for lenses, frames, a routine eye 
examination, and a vision add-on provided on April 3, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occupational therapy provided on March 03, 2023. 
 
You asked the Plan to pay for occupational therapy. You say that you were not aware authorization would be 
necessary for services covered by Medicare. 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 occupational therapy 
provided on March 03, 2023.