Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the over-the-counter (OTC) COVID-19 test (K1034) 
provided on June 26, 2023. 
 
You asked the Plan to pay for the OTC COVID-19 test. You say that you would like the clam to be processed 
towards payment. The Plan denied your request. The Plan says OTC COVID-19 tests, K1034, are not covered 
by Medicare after May 11, 2023. 
 The Plan must follow Medicare rules. Medicare rules say that the demonstration that allowed Medicare to offer 
coverage for COVID-19 over-the-counter tests at no cost ended on May 11, 2023. The rules also say that 
Medicare does not pay for OTC items, including self-administered COVID-19 tests and the OTC COVID-19 
test is an OTC item. Therefore, we decided that the Plan does not have to pay for the over-the-counter (OTC) 
COVID-19 test (K1034) provided on June 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve the injection. You say that the enrollee received 75% pain relief from their 
first injection. The Plan denied your request. The Plan says an epidural steroid injection 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 pre-approve the injection. Our reviewer says that an 
epidural steroid injection is not medically necessary. Our physician reviewer found that there is no 
documentation of at least 50% sustained improvement in pain relief or improvement in function measured from 
baseline using SAME scale for at least three months, and the requested epidural will be performed with the 
same approach, level, and medication. Therefore, the enrollee does not meet the LCD coverage criteria. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an epidural steroid injection.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided on July 13, 2023. 
 
You asked the Plan to pay for the self-administered drugs. You say that you were given drugs while being in 
the hospital which should be covered. The Plan denied your request. The Plan says that self-administered drugs 
does not fall under Medicare Part B coverage. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided on July 13, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from October 16, 2022, to 
November 11, 2022.  
 
You asked the Plan to pay for home health services. You say that you have submitted the face-to-face 
documentation so the claim can be paid. 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 pay for home health services. Our reviewer says that 
the services are not medically reasonable and necessary. Our physician reviewer found that the records include 
a physician's visit note dated July 11, 2022, requesting home health services, this note does not specify what 
services (nursing or therapy services) the enrollee needed or why. Provided records do not document any acute 
or unstable medical conditions or changes in medication or treatment which would necessitate skilled nursing 
visits. Records do not document the need for intravenous medications, new tube feeding or ostomy care or 
complex wound care. Also, the provided records include no physician signed plan 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pay for the home health services provided from October 16, 2022, to November 11, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the over-the-counter (OTC) COVID-19 test (K1034) 
provided on June 30, 2023. 
 
You asked the Plan to pay for the OTC COVID-19 test. You say that you would like the clam to be processed 
towards payment. The Plan denied your request. The Plan says OTC COVID-19 tests, K1034, are not covered 
by Medicare after May 11, 2023. 
 The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items, including self-
administered COVID-19 tests and the OTC COVID-19 test is an OTC item. Therefore, we decided that the 
Plan does not have to pay for the over-the-counter (OTC) COVID-19 test (K1034) provided on June 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections. 
 
You asked the Plan to pre-approve epidural steroid injections. You say that this is medically necessary. The 
Plan denied your request. The Plan says this does not meet the LCD criteria for coverage. 
 
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 epidural steroid injections. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found there is no history, 
physical examination, and/or concordant radiological image-based diagnostic testing supporting lumbar 
radiculopathy, radicular pain and/or neurogenic claudication due to disc herniation, osteophyte or osteophyte 
complexes, severe degenerative disc disease, producing foraminal or central spinal stenosis, or post-
laminectomy syndrome. The review has determined that the enrollee does not meet the LCD criteria for 
coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural steroid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve epidural steroid injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services provided on August 18, 2023, to, 
August 25, 2023. 
 
You asked the Plan to pay for the acupuncture services. You say that you were advised that you had an out of 
network benefit that pays 50% and are not sure why the claim was denied. You say that you suffer from low 
back pain which is why you found an acupuncturist that might help since there is not a lot of in network options 
to choose from. The Plan denied your request. The Plan says the acupuncture services were provided by an 
unqualified provider. 
 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.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the provider is not and was not supervised by a 
physician, physician assistant, or nurse practitioner/clinical nurse specialist. Therefore, we decided that the Plan 
does not have to pay for the acupuncture services provided on August 18, 2023, to, August 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for out of network dental services provided on 
June 14, 2023. 
 
You asked the Plan to waive the coinsurance for out of network dental services. You say that this should be 
covered. 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 70% 
coinsurance for comprehensive dental services.  
 
You have been asked to pay 70% coinsurance for out of network dental services. This item/service falls within 
the comprehensive dental services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for 
out of network dental services provided on June 14, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for pain management assessment and pain 
management treatment provided on May 30, 2023. 
 
You asked the Plan to waive the copayment for pain management assessment and pain management treatment. 
You say that you disagree with the copayment. 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 $25 
copayment for outpatient diagnostic tests/pain management assessment and a $75 copayment for outpatient 
diagnostic tests/pain management treatment.  
 You have been asked to pay a $25 copayment for pain management assessment and a $75 copayment for pain 
management treatment. The total amount you are being asked to pay $100 ($75 x $25 = $100). This 
item/service falls within the outpatient diagnostic tests/pain management assessment and outpatient diagnostic 
tests/pain management treatment 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 copayment for 
pain management assessment and pain management treatment provided on May 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM)
sensor.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the criteria for coverage are not met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage
have been met.

We looked at the file and Medicare rules. The previous determination stated that our physician reviewer found
that the services were medically necessary; however, this review did not follow the Medicare criteria for
coverage. Despite the physician review, the records clearly show that the enrollee does not treat with insulin or
have a history of hypoglycemic events. Based on this information, we decided that Medicare rules for coverage
of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a
Dexcom G6 continuous glucose monitor (CGM) sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services provided on August 8, 2023. 
 
You asked the Plan to pay for the acupuncture services. The Plan denied your request. The Plan says 
acupuncture is covered for the treatment of low back pain only, when furnished by a provider who meets 
provider requirements. 
 
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.   
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, you received treatment for vertigo and dizziness. 
However, acupuncture is only covered for chronic low back pain. Furthermore, the provider is not and was not 
supervised by a physician, physician assistant, or nurse practitioner/clinical nurse specialist. Therefore, we 
decided that the Plan does not have to pay for the acupuncture services provided on August 8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. 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 compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.   
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crown - porcelain fused to noble metal tooth 2 
and tooth 4 (D6752), and a pontic - porcelain/ceramic for tooth 3 (D6245). 
 
You asked the Plan to pre-approve retainer crown and a pontic. You say that your dentist asked for a bridge to 
replace your missing teeth. The Plan denied your request. The Plan says to approve a bridge, you must be 
missing only one upper front tooth or only two lower front teeth. The two lower front teeth must be next to 
each other. You also cannot be missing any of your back teeth. Our dentist looked at the x-rays your dentist 
sent us and said you are missing other teeth. 
 
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. The Plan covers retainer 
crown and a pontic when the services are medically necessary and reasonable.  
 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 retainer crown and a pontic. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found bridges will only be 
covered if no other teeth are missing in the same arch other than 3rd molars. As there are missing posterior 
teeth in the arch, and a single maxillary anterior tooth is not being replaced, the Plan criteria for fixed 
bridgework has not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of retainer crown and a pontic have not been met. Therefore, we decided that the 
Plan does not have to pre-approve retainer crown - porcelain fused to noble metal tooth 2 and tooth 4 (D6752), 
and a pontic - porcelain/ceramic for tooth 3 (D6245).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen concentrator (E1390), an oxygen tent (E0455), 
and a battery pack and cartridge (E1356) provided on April 4, 2023, to May 4, 2023. 
 
You asked the Plan to pay for the oxygen concentrator (E1390), an oxygen tent (E0455), and a battery pack and 
cartridge (E1356). You say that the prescription was made by your physician. You say that the portable oxygen 
concentrator and extra battery will allow you to leave your home and still get the oxygen you need. The Plan 
denied your request. The Plan says the purchased oxygen equipment is not a covered benefit. 
 
The Plan follows Medicare rules. Medicare rules state that purchased oxygen equipment is statutorily non-
covered. 
 
In this case, the oxygen equipment at issue was purchased and not rented. Neither Medicare nor the Plan covers 
purchased oxygen equipment. Therefore, we decided that the Plan does not have to pay for the oxygen 
concentrator (E1390), an oxygen tent (E0455), and a battery pack and cartridge (E1356) provided on April 4, 
2023, to May 4, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided.  
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided.  Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652).
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 needs this care to regain independence. 
The Plan denied your request. The Plan says the enrollee's condition does not meet the criteria for an IRF 
admission.  
 
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 enrollees 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine eye exam rendered on January 25, 2023.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the claim was processed correctly.

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 one routine eye exam every 12 months.

We looked at the file and the Plan's rules. The previous determination stated that the Plan did not sufficiently
support that this was a routine eye exam; however, the documentation clearly shows that the exam was billed
with a diagnosis for a diagnosis of bilateral myopia (nearsightedness). This is a diagnosis for routine vision
care. The file also shows that you previously received a routine eye exam on July 20, 2022, for which the Plan
approved and paid. The routine eye exam on January 25, 2023, was provided less than 12 months from your
previously covered routine eye exam. Based on this information, we decided that the Plan's rules for coverage
of these services have not been met. Therefore, we decided that the Plan does not have to pay for the routine
eye exam rendered on January 25, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on June 24, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you 
refused an ambulance ride to avoid charges and but are receiving charges anyways. You also say that you did 
not use the ambulance for transport to the hospital and the payment of ambulance services should not be 
denied. The Plan denied your request. The Plan says these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 24, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on June 24, 2023.