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

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) and the related supply 
allowance provided by an out-of-network provider on August 10, 2023. 
 
You asked the Plan to pay for the CGM and related supply allowance. You say that you have provided all the 
required documents and would like the claim processed. The Plan denied your request. The Plan says the 
documentation requirements have not been met. The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery. Specifically, there is no signed receipt of the delivery. 
The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor (CGM) and the 
related supply allowance provided by an out-of-network provider on August 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic supplies provided on July 26, 2023. 
 
You asked the Plan to pay for diabetic supplies. You say that you have provided all of the appropriate 
documents needed for payment. The Plan denied your request. The Plan says the documentation requirements 
have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery. The proof of delivery provided does not have the 
enrollees signature. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for diabetic supplies 
provided on July 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) (A4239, E2103) 
provided on July 14, 2023.  
 
You asked the Plan to pay for the CGM. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the items denied correctly as the rendering provider is not 
enrolled with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor (CGM) 
(A4239, E2103) provided on July 14, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computer-assisted surgical navigation. 
 
You asked the Plan to pre-approve computer-assisted surgical navigation. You say that computer-assisted 
surgical navigation is medically necessary. The Plan denied your request. The Plan says medical necessity for 
the denied services has not been established after clinical review and per the peer-reviewed medical 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 computer-assisted surgical navigation. 
Our reviewer says that the requested computer-assisted surgical navigation is not considered medically 
reasonable and necessary. Our physician reviewer found computer assist shoulder surgery has not been shown 
to be more effective and better than conventional open surgery. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of computer-assisted surgical navigation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve computer-assisted surgical navigation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repairs to a Group 4 power wheelchair (K0877). 
 
You asked the Plan to pre-approve repairs to a Group 4 power wheelchair. The Plan denied your request. The 
Plan says repairs for a Group 4 power wheelchair cannot be covered, because Group 4 power wheelchairs have 
added capabilities that are not needed for use in the home and cannot be covered. 
 
The Plan must follow Medicare rules. Medicare rules say that if a Group 4 power wheelchair 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 repairs to a Group 4 power wheelchair have not been met. Specifically, since the specific power 
wheelchair base is not covered, repairs to the wheelchair cannot be covered either. Therefore, we decided that 
the Plan does not have to pre-approve repairs to a Group 4 power wheelchair (K0877).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided by an out-of-network provider on August 8, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have provided all the 
required documents and would like the claim processed. The Plan denied your request. The Plan says the 
documentation requirements have not been met. The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery. Specifically, there is no signed receipt of the delivery. 
The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the supply allowance for a continuous glucose 
monitor (CGM) provided by an out-of-network provider on August 8, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intracept procedure. 
 
You asked the Plan to pre-approve intracept procedure. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says medical studies haven't proven this service is helpful 
for the treatment of your health problem. 
 
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 intracept procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no magnetic resonance imaging showing only modic changes without facet 
degenerative joint disease or stenosis. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intracept procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve intracept procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mandibular partial denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that this is urgent as you need to replace your 
broken partial lower denture. The Plan denied your request. The Plan says your benefit for the requested item 
or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service November 9, 2021. 
Therefore, we decided that the Plan does not have to pre-approve mandibular partial denture (D5214).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skin protection and positioning wheelchair seat 
cushion (E2607). 
 
You asked the Plan to pre-approve a skin protection and positioning wheelchair seat cushion (E2607). You say 
that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says durable 
medical equipment is not covered for use in a SNF. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a skin protection and positioning wheelchair seat cushion (E2607) is being requested for use 
in a SNF or hospital. Therefore, we decided that the Plan does not have to pre-approve a skin protection and 
positioning wheelchair seat cushion (E2607).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve odor eliminators, foam cleansers, and toilet liners (i.e., 
incontinence supplies).  
 
You asked the Plan to pre-approve incontinence supplies. You say that the enrollee has severe end-stage 
Alzheimer's dementia with bowel and bladder incontinence. The requested items are beneficial for easy cleanup 
and to reduce the spread of infection. The Plan denied your request. The Plan says these items 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 odor eliminators, foam cleansers, 
and toilet liners (i.e., incontinence supplies).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement graft for ridge preservation (D7953) 
and complete maxillary overdenture (D5863). 
 
You asked the Plan to pre-approve bone replacement graft for ridge preservation and complete maxillary 
overdenture. You say that you would like help obtaining better oral health and thus better digestion from which 
you suffer. The Plan denied your request. The Plan says these services are not covered under this benefit. 
 
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 pre-approve bone 
replacement graft for ridge preservation (D7953) and complete maxillary overdenture (D5863).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the mental health services to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve the mental health services. You say that you would like to see this out-of-
network provider and have it covered as in-network. The Plan denied your request. The Plan says you must 
receive your care from a network provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The Plan has network providers available who are capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) We found no exception that would require the Plan to pre-approve these items/services. 
Therefore, we decided that the Plan does not have to pre-approve the mental health services to be provided by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a freestyle lite meter. 
 
You asked the Plan to pre-approve the freestyle lite meter. You say that the items should be covered as the 
enrollee disagrees with the denial. The Plan denied your request. The Plan says the items denied correctly as 
they are not the Plan's preferred brand. 
 
  The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non-preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for the freestyle lite meter. Therefore, we decided that the Plan does not have to pre-approve a freestyle lite 
meter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on July 11, 2023. 
 
You asked the Plan to waive the copayment for the office visit. You say that this should be quoted as an urgent 
care not a primary care and would like to dispute 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 $15 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $15 copayment for the office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 office visit provided on July 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supplies for a continuous glucose monitor (CGM) (A4239) 
provided on August 17, 2023. 
 
You asked the Plan to pay for CGM supplies. You say that the items at issue were a necessity for the enrollee's 
care. 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 for blood glucose monitors and related supplies, 
the modifiers KX or KS must be added to the code(s) on every claim submitted. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of CGM supplies have not been met. Specifically, the items at issue in this case were not billed with a required modifier. Therefore, we decided that the Plan does not have to pay for supplies for a continuous 
glucose monitor (CGM) (A4239) provided on August 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block. 
 
You asked the Plan to pre-approve a genicular nerve block. You say that a genicular nerve block is medically 
necessary. The Plan denied your request. The Plan says there is little medical evidence that shows this type of 
nerve block is helpful.  
 
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 genicular nerve block. Our reviewer 
says that the requested genicular nerve block is not considered medically reasonable and necessary. Our 
physician reviewer found that a genicular nerve block is experimental for knee pain treatment. 
 
 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 genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).  
You asked the Plan to pre-approve a CGM. You say that a CGM would benefit the enrollee. The Plan denied 
your request. The Plan says the medical criteria for a CGM have not been 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 documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on August 7, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that the OIVIT services should be paid as billed 
because they are supported in the documentation. The Plan denied your request. The Plan says the OIVIT 
services are denied because they are not supported in the documentation.  
The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on August 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) and the related supply 
allowance provided by an out-of-network provider on August 11, 2023. 
 
You asked the Plan to pay for the CGM and related supply allowance. You say that you have provided all the 
required documents and would like the claim processed. The Plan denied your request. The Plan says the 
documentation requirements have not been met. The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery. Specifically, there is no signed receipt of the delivery. 
The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor (CGM) and the 
related supply allowance provided by an out-of-network provider on August 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete upper denture (D5110) and the complete lower 
denture (D5120) provided on August 1, 2023. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says the items provided in this case are not payable as 
they were not rendered by a licensed dentist. 
 
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, you do not meet criteria for coverage 
of the dental items provided in this case. Specifically, the Plans contract states that all dental items/services 
must be rendered by a licensed dentist. However, the dentures in this case were rendered by a denturist, not a 
licensed dentist. Therefore, you do not meet criteria for coverage of the dental items provided in this case. 
Therefore, we decided that the Plan does not have to pay for the complete upper denture (D5110) and the 
complete lower denture (D5120) provided on August 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a therapeutic injection provided on 
October 10, 2023. 
 
You asked the Plan to waive the coinsurance for a therapeutic injection. You say that you should not owe this 
coinsurance amount, you only had an injection. 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 20% 
coinsurance for outpatient hospital services. 
 
You have been asked to pay 20% coinsurance for a therapeutic injection. This item/service falls within the 
outpatient hospital 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. The total you owe is $301.20 ($1,520.35 x 20% = $304.07) You've been asked to pay less 
than this 20%. Therefore, we decided that the Plan does not have to waive the coinsurance for a therapeutic 
injection provided on October 10, 2023.