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

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), 
expandable controller (E2377), occupied transit (K0108), a group 3 standard power wheelchair (K0861), and 
additional items and accessories (codes E2361, E1028, E2300, E2620, E0955, E1028, E1012, E1028, E0953, 
E2607, and E1007). 
 
You asked the Plan to pre-approve an electronic connection, harness, expandable controller, and occupied 
transit. You say that when three or more power seating functions/actuators/motors are provided, one unit of 
E2311, one unit of E2377, and one unit of E2313 are allowed. You also say that the occupied transit is not an 
integral part of the base, thus a split decision should be possible. The Plan denied your request. The Plan says 
although there are three approved power options on this wheelchair (tilt, recline and elevating leg rests), there 
is not a medical need to control these power options through a special type of joystick. The Plan also says the 
occupied transit is not primarily used in the home as it is a transportation kit for the power wheelchair (PWC), 
and the transit kit does not primarily serve a medical purpose.  
 
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 an electronic connection, harness, 
expandable controller, and occupied transit. Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found the documentation 
does not support that it is medically necessary to control the requested power options through the joystick 
(drive interface). The enrollee's upper extremity strength and functional ability as evidenced by being 
independent for feeding should be sufficient to control any power options through their own switches. Our 
reviewer also found that the requested transit kit does not serve a medical purpose. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection, harness, expandable controller, and occupied transit 
have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection 
(E2311), harness (E2313), expandable controller (E2377), occupied transit (K0108), a group 3 standard power 
wheelchair (K0861), and additional items and accessories (codes E2361, E1028, E2300, E2620, E0955, E1028, 
E1012, E1028, E0953, E2607, and E1007).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on November 3, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says Medicare does not separately 
pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
November 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an endosteal implant (D6010).

You asked the Plan to pre-approve 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 Plan's 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 an endosteal implant (D6010).
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 an IRF admission is medically necessary. The Plan 
denied your request. The Plan says the IRF services requested do 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 enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a telehealth visit provided on May 19, 
2023. 
 
You asked the Plan to waive the copayment for a telehealth visit. You say that you want to appeal the amount 
being charged. 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 telehealth (additional benefits). 
 
You have been asked to pay a $20 copayment for a telehealth visit. This item/service falls within the telehealth 
(additional benefits) 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 a telehealth visit 
provided on May 19, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty at L1 
 
You asked the Plan to pre-approve kyphoplasty at L1. 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 percutaneous vertebroplasty and percutaneous 
vertebral augmentation (PVA or Kyphoplasty) procedures will be considered medically reasonable and 
necessary for certain indications. 
 
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 kyphoplasty at L1. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found detailed documentation is not 
evident regarding a diagnosis of osteoporosis and/or undergoing treatment for osteoporosis. There is no 
indication of a progression of the body height loss or a severe impact on daily activities. Moreover, there is 
magnetic resonance imaging (MRI) corroboration of retropulsion and other plausible causes of pain. Therefore, 
the enrollee does not meet the 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 kyphoplasty at L1 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve kyphoplasty at L1
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the elbow orthosis (L3761) provided April 19, 2023. 
 You asked the Plan to pay for the orthosis. You say that you have attached all the supporting documentation. 
Please reprocess the claim. 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 physician order or relevant medical records which support medical 
necessity for the supplies provided in this case. Specifically, the written order was writing one day prior to the 
face-to-face encounter that was unrelated to the right elbow and the orthotic. There is no documentation a face-
to-face encounter took place between this enrollee and the ordering Out-of-Network provider as it pertains to 
and illness or injury to her right elbow. The medical records submitted indicate that the enrollee was seen by 
the primary care provider on March 2, 2023, for an upper respiratory infection.  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 elbow orthosis (L3761) provided April 19, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that the requested medication is medically necessary for 
the enrollee's treatment for lung cancer. The Plan denied your request. The Plan says the enrollee does meet the 
requirements for the requested drug to be approved. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
 
  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 Keytruda. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested use of Keytruda (along with carboplatin and doxetacel) is not FDA-approved for 
the enrollee's diagnosis in this scenario with stage IIB squamous cell lung cancer.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and laboratory service provided on August 03, 
2022. 
 
You asked the Plan to pay for the office visit and laboratory service. 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 and 
laboratory service provided on August 03, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the abdominal ultrasound provided on May 
22, 2023. 
 
You asked the Plan to waive the copayment for the abdominal ultrasound. You say that you do not know why 
the Plan did not pay for this service. 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 $75 
copayment for in-network diagnostic tests, including ultrasounds. 
 
You have been asked to pay a $75 copayment for the abdominal ultrasound. This item/service falls within the 
in-network diagnostic tests, including ultrasounds 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. However, since the allowed amount is less than the standard 
copayment, you only owe $74.31. Therefore, we decided that the Plan does not have to waive the copayment 
for the abdominal ultrasound provided on May 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the catheter removal and replacement services provided on 
March 27, 2023. 
 
You asked the Plan to pay for the catheter removal and replacement services. 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 catheter removal and 
replacement services provided on March 27, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an EKG provided on April 13, 2023. 
 
You asked the Plan to waive the copayment for an EKG. 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 $40 
copayment for outpatient diagnostic tests/for specialtyphysician for other Medicare-coveredoutpatient 
diagnostic tests. 
 
You have been asked to pay a $40 copayment for an EKG. This item/service falls within the outpatient 
diagnostic tests/for specialtyphysician for other Medicare-coveredoutpatient diagnostic tests 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. However, you are only 
being asked to pay $14.31 which is less than the required amount. Therefore, we decided that the Plan does not 
have to waive the copayment for an EKG provided on April 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre Mis 2 reader. 
 
You asked the Plan to pre-approve the FreeStyle Libre Mis 2 reader. You say that the enrollee is on Ozempic 
and Metformin. You also say that AlC level is 7.3 today, down from 11.2  The Plan denied your request. The 
Plan says a CGM is not covered under Medicare if the enrollee is not on insulin or does not have 
documentation of recurrent problematic hypoglycemia.  
 
The Plan follows 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 FreeStyle Libre Mis 2 reader. Our 
reviewer says that the FreeStyle Libre Mis 2 reader is not medically necessary. Our physician reviewer found 
the documentation submitted does not support 3 plus administrations of insulin per day, or insulin pump or 
frequent adjustment to insulin regimen. The record also does not include sufficient documentation to confirm 
problematic hypoglycemia. The medical record includes documentation of diabetes care, however it does not 
support coverage criteria has 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 the FreeStyle Libre Mis 2 reader have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a FreeStyle Libre Mis 2 reader.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77002 billed for date of service April 21, 
2023.  
 
You asked the Plan to pay for procedure code 77002. You say that the documentation supports the procedure 
that has been performed. You also say that you would like this to be reviewed and reconsidered for payment. 
The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 77002 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 77002 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 77002 billed for date of service April 21, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission to an LTACH is medically 
necessary. You would like reconsideration based on the records submitted. The Plan denied your request. The 
Plan says the enrollee does not meet all the requirements for admission to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Transfer to the LTACH is not medically necessary as the enrollee 
is not yet stable for transfer and as it would not be clinically advantageous at this time.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic mammogram provided on 
May 17, 2023. 
 
You asked the Plan to waive the copayment for the diagnostic mammogram. You say that you do not know 
why this was not fully 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 a $75 
copayment for in-network diagnostic mammograms provided at an outpatient hospital. 
 
You have been asked to pay a $75 copayment for the diagnostic mammogram. This item/service falls within 
the in-network diagnostic mammograms provided at an outpatient hospital 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 records show a diagnostic 
mammogram was provided, and the copayment was applied correctly. Therefore, we decided that the Plan does 
not have to waive the copayment for the diagnostic mammogram provided on May 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 7, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory services. You say that the provider is working to obtain network 
status with the Plan. The Plan denied your request. The Plan says these services are not covered when provided 
OON. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on April 7, 2023, 
by an out-of-network (OON) provider.