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

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with a single power option 
(tilt) and accessories. 
 
You asked the Plan to pre-approve the Group 3 power wheelchair. You say that you want to appeal this denial. 
The Plan denied your request. The Plan says the power tilt is not medically needed. The Plan says upgraded 
electronics are not medically necessary as there is not a medical need to control more than two power options 
though the joystick. The Plan also says the codes used for the foot plate assembly do not match the items 
requested. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with a single power 
option may be covered when certain 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 the Group 3 power wheelchair. Our 
reviewer says that the requested Group 3 power wheelchair with a single power option is not medically 
necessary. Our physician reviewer found the provided documentation does not have high risk for skin 
breakdown, require a catheter, or have significant spasticity. The reviewer found that the enrollee does not 
require power tilt or tilt and recline. Therefore, the reviewer found that the requested Group 3 power 
wheelchair with single power option is not medically reasonable or 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 Group 3 power wheelchair have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Group 3 power wheelchair with a single power option (tilt) and 
accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wheelchair and a hospital bed provided on September 25, 
2022, to October 25, 2022. 
 
You asked the Plan to pay for a wheelchair and a hospital bed. 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 a wheelchair and a 
hospital bed provided on September 25, 2022, to October 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fluid circulating cold pad with pump. 
 
You asked the Plan to pre-approve these services. You say that you need the item after shoulder surgery. The 
Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a fluid circulating cold pad with pump (E0218) will be 
denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. The item at issue is a fluid circulating cold pad with pump. This item 
is denied by Medicare as not medically necessary. Therefore, we decided that the Plan does not have to pre-
approve a fluid circulating cold pad with pump.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuous glucose monitor (CGM) and supply allowance.  
 
You asked the Plan to pre-approve the CGM and supply allowance. You say that the repeated finger sticks over 
the years has caused calluses on the enrollee's fingers. The Plan denied your request. The Plan says that the 
Medicare criteria was not met. 
 
The Plan must follow 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 and supply allowance. Our 
reviewer says that the CGM coverage criteria was met. Our physician reviewer found that the enrollee is 
having low blood sugars and is having trouble using the fingerstick meter due to cognitive decline. 
 
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 and supply allowance have been met. Therefore, we decided that the 
Plan has to pre-approve a continuous glucose monitor (CGM) and supply allowance.   
  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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital stay provided from February 24, 2023, 
to February 27, 2023, by an OON provider.  
 
You asked the Plan to pay for the inpatient hospital stay. You say that you had authorization for these services. 
The Plan denied your request. The Plan says the provider did not notify the Plan of the admission. 
 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 records show that the authorization received was not valid based on the codes billed. 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 inpatient hospital stay provided from February 24, 2023, to 
February 27, 2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient intravenous insulin therapy (OIVIT) provided on 
May 11, 2023. 
 
You asked the Plan to pay for OIVIT. You say that you have billed the services at issue correctly. The Plan 
denied your request. The Plan says rules for payment have 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 under Medicare. Based on this information, we decided 
that Medicare rules for coverage of OIVIT have not been met. Therefore, we decided that the Plan does not 
have to pay for outpatient intravenous insulin therapy (OIVIT) provided on May 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electronic brachytherapy. 
 
You asked the Plan to pre-approve electronic brachytherapy. You say that this is medically necessary. The Plan 
denied your request. The Plan says this procedure is experimental/investigational. 
 
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 electronic brachytherapy. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found electronic brachytherapy is experimental/investigational. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of electronic brachytherapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve electronic brachytherapy.
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 it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the requirements for approval. 
 
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 provided medical records do not support that the intensive inpatient rehabilitation 
therapy program is necessary and that therapy at a lower level of care such as in a skilled nursing facility is not 
appropriate for the patient.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power 
options and accessories. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair with multiple power options. You say that the 
Group 3 suspension will assist in dissipating vibration throughout the base of the chair to minimize and 
dissipate the triggers associated with tremors experienced by the enrollee's suffering with neurological 
conditions. You also say that the pressure relief and power tilt alone do not meet the enrollee's pressure relief 
needs. The Plan denied your request. The Plan says the enrollee does not have a medical need for multiple 
power options. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with multiple power 
options may be covered when certain 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 3 power wheelchair with 
multiple power options. Our reviewer says that the request for a Group 3 power wheelchair with multiple 
power options is not medically necessary. Our physician reviewer found the provided documentation indicates 
the enrollee does not have high risk for skin breakdown, use intermittent catheterization, or have spasticity 
impacting positioning. The reviewer found that the enrollee has adequate strength to manage standard power 
drives. Therefore, the reviewer found that the request for a Group 3 power wheelchair with multiple power 
options is not medically reasonable or 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 a Group 3 power wheelchair with multiple power options have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple 
power options and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a SIJI. 
 
You asked the Plan to pre-approve the SIJI. You say that the injections help with in your daily life because you 
are in pain and cannot walk without them. The Plan denied your request. The Plan says the criteria for coverage 
have not been met. 
 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 SIJI. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the request is to repeat the injections. The physical exam does not include three diagnostic 
maneuvers. Therefore, the criteria for coverage have not been 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 a SIJI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a SIJI.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox injections (J0585). 
 
You asked the Plan to pre-approve Botox injections. You say that this service is medically necessary. The Plan 
denied your request. The Plan says coverage rules are not met. 
 The Plan must follow Medicare rules. Medicare rules say that Chemodenervation using Botox injections is 
covered for approved indications. 
 
We looked at the file and Medicare rules. The request is for treatment of gastroparesis. This is not a covered 
indication under Medicare rules. Based on this information, we decided that Medicare rules for coverage of 
Botox injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox 
injections (J0585).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a folding wheeled walker (E0143) with seat attachment 
(E0156). 
 
You asked the Plan to pre-approve a walker with seat attachment. You say that the requested items are a 
necessity for your care. The Plan denied your request. The Plan says rules for coverage for durable medical 
equipment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that in the absence of program instructions, the 
reasonable useful lifetime of equipment can in no case be less than 5 years. Computation of the useful lifetime 
is based on when the equipment is delivered to the enrollee, not the age of the equipment. 
 
We looked at the file and Medicare rules. In this case, you are requesting a replacement for a walker rollator 
received by you within the past 5 years. Therefore, the requested replacement is for an item that has not outlasted its reasonable useful lifetime. Based on this information, we decided that Medicare rules for coverage 
of a walker with seat attachment have not been met. Therefore, we decided that the Plan does not have to pre-
approve a folding wheeled walker (E0143) with seat attachment (E0156).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on February 22, 2023. 
 
You asked the Plan to pay for the 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 the office visit provided 
on February 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wet wipes. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you need the items. The Plan denied 
your request. The Plan says incontinence supplies are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve wet wipes.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the advanced care planning and the initial hospital care 
evaluation provided on May 09, 2023. 
 
You asked the Plan to pay for the advanced care planning and the initial hospital care evaluation. You say that 
the services were medically necessary. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the advanced care 
planning and the initial hospital care evaluation provided on May 09, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the mental health services provided on May 
15, 2023. 
 
You asked the Plan to waive the copayment for the mental health services. 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 $20 
copayment for outpatient mental health care. 
 
You have been asked to pay a $20 copayment for the mental health services. This item/service falls within the 
outpatient mental health care benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the mental 
health services provided on May 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a radiologic examination, spine, lumbosacral and a 
radiologic examination, pelvis provided on May 15, 2023.  
 
You asked the Plan to pay for the radiologic examination, spine, lumbosacral and the radiologic examination, 
pelvis. You say that the x-rays were necessary for the doctor to help him to work on your spine. The Plan 
denied your request. The Plan says routine chiropractic services only cover manual manipulation of the spine to 
correct a subluxation. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for a radiologic examination, spine, lumbosacral and a radiologic examination, 
pelvis provided on May 15, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services coded as 93926 performed on February 
20, 2023. 
 
You asked the Plan to pay for the imaging services. You say that the imaging services should be covered as 
billed because they are supported in the documenation. The Plan denied your request. The Plan says the 
imaging services are denied because it is not appropriate to bill a left and right sided diagnosis code when a 
bilateral code is available. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must comply with the Official 
International Classification of Disease, 10th Edition, Clinical Modification (ICD-10-CM) Coding Guidelines. The rules also say when available, providers should use bilateral codes to describe bilateral conditions. If no 
bilateral code exists, then providers should assign separate codes for the left and right side. 
 
We looked at the file and Medicare rules. In this case, 93926 was billed with diagnosis codes I70.211 
(atherosclerosis of native arteries of extremities with intermittent claudication, right leg) and I70.212 
(atherosclerosis of native arteries of extremities with intermittent claudication, left leg). We confirmed there is 
a bilateral diagnosis code, I70.213 (atherosclerosis of native arteries of extremities with intermittent 
claudication, bilateral legs), which should have been reported instead. Based on this information, we decided 
that Medicare rules for coverage of the imaging services have not been met. Therefore, we decided that the 
Plan does not have to pay for the imaging services coded as 93926 performed on February 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ClariVein endovenous ablation (36473). 
 
You asked the Plan to pre-approve ClariVein endovenous ablation. 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 treatment of varicose veins of the lower extremities is 
covered when certain 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 ClariVein endovenous ablation. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the provided 
documentation did not clearly describe 3 months of conservative therapy such as exercise, elevation, weight 
loss, and compression which is required for this procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ClariVein endovenous ablation have not been met. Therefore, we decided that 
the Plan does not have to pre-approve ClariVein endovenous ablation (36473).