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

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that your doctor said you should have the CGM. The 
Plan denied your request. The Plan says the Medicare criteria was 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 documentation indicates that the enrollee does not have diabetes.  
Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chemotherapy provided on April 17, 2023. 
 
You asked the Plan to pay for chemotherapy. You say that you are appealing the claim payment denial. 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 chemotherapy provided 
on April 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic CGM and supplies. 
 
You asked the Plan to pay for the therapeutic CGM and supplies. You say that you are appealing the claim 
payment denial. 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 which support medical necessity for the supplies provided 
in this case. Without a valid physicians order, the service cant be verified. 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 therapeutic CGM and supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3. 
 
You asked the Plan to pre-approve a Freestyle Libre 3. 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. 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 a Freestyle Libre 3. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found in this case, the record indicates 
that the enrollee has diabetes. The record provided form August 2023 documents that the enrollee is being 
treated with insulin and that the provider has ordered the requested product. The elements of the coverage 
criteria are not satisfied. The requested service is not recommended. 
 
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 Freestyle Libre 3 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Freestyle Libre 3.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that the CGM is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the Medicare criteria was not met. 
 
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 CGM. Our reviewer says that the 
CGM coverage criteria was not met. Our physician reviewer found that the coverage criteria for a CGM require 
insulin use or low blood sugars. We are not given any medical reason why the enrollee cannot use a 
glucometer. Although a CGM might motivate the enrollee to eat better and work on blood glucose control, the 
provided criteria for the CGM coverage are not met and there is no medical reason why the enrollee is 
incapable of using a glucometer provided nor is there a plausible reason given why the glucometer is suspected 
of being inaccurate 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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the remote monitoring services provided on February 26, 
2023, by an OON provider.  
 
You asked the Plan to pay for the remote monitoring services. You say that you are requesting reconsideration 
of the denied claim. The Plan denied your request. The Plan says these services are not covered when received 
by an OON provider. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that enrollees may use either network providers or out-of-network providers for certain services. The 
Plan contract also says that out-of-network physician services are not covered. 
 
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 remote monitoring services provided on 
February 26, 2023, by an OON provider.
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 related accessories.  
 
You asked the Plan to pre-approve a group 3 power wheelchair with multiple power options and related 
accessories. You say that you have neuropathy and Guillain Barre Syndrome. You also say that you are getting 
weaker and weaker and should qualify for the chair.  The Plan denied your request. The Plan says you do not 
have medical need for multiple power options included with this group 3 power wheelchair. The Plan also says 
that it is not medically necessary to control the three requested power options through the joystick.   
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 group 3 power wheelchair with 
multiple power options and related accessories. Our reviewer says that the requested items are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the request is for a replacement 
power wheelchair with a group 3 power chair. Our physician reviewer found that you have functional 
impairment and are non-ambulatory after treatment for brain cancer. You are able to transfer and do not have 
high risk for skin breakdown, use a catheter intermittently, have spasticity, or require an alternative means of 
managing power drive.  
 
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 and related accessories 
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 related accessories.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that  the enrollee is stable for transfer and 
clearly exceeds the criteria for LTACH. The Plan denied your request. The Plan says the LTACH services are 
not medically necessary, and the enrollee's needs can be met at a lower level of care such as an acute 
rehabilitation facility, skilled nursing facility, nursing facility, outpatient setting, or home care. 
 
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 the enrollee was admitted to the acute care hospital with trauma from a car accident 
including traumatic brain injury, brain bleeds, facial fractures, femur fracture, tibial fracture, splenic laceration and complicated by respiratory failure, urinary retention, anemia, and anasarca requiring ventilation support, 
trachea placement. The enrollee appears to be more stable and should only require additional short-term acute 
care services that can safely be provided at the current facility until more stable and appropriate for a lower 
level of care. The patient does not require services at the LTACH that are not already available at the current 
facility.  
 
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 long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition to lower limb prosthesis, vertical shock 
reducing pylon feature (L5988). 
 You asked the Plan to pre-approve a vertical shock reducing pylon feature. You say that you disagree with the 
denial. The Plan denied your request. The Plan says the requested prosthesis exceeds the enrollee's need. The 
notes do not show why the requested advanced pylon is needed. 
 
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 vertical shock reducing pylon feature. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee has bilateral transtibial amputation and needs new 
prostheses. She is an active K3 ambulator who works as a home health aide. The addition of a shock absorbing 
pylon is not medically necessary per L33787. The impact on gait for the more advanced pylon is variable and 
not more impactful than standard shock absorbing ankle foot systems. The medical necessity for the addition 
above standard systems has not been provided. 
 
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 vertical shock reducing pylon feature have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an addition to lower limb prosthesis, vertical shock reducing 
pylon feature (L5988).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve the drug. You say that the enrollee does not want to undergo chemotherapy 
due to their debilitation. You say that the enrollee is willing to undergo immunotherapy as the risk for further 
debilitation is decreased.  The Plan denied your request. The Plan says Keytruda is not medically necessary.  
 
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 the drug. Our reviewer says that 
Keytruda is not medically necessary. Our physician reviewer found that the requested drug Keytruda is not 
FDA-approved and is not supported by one of the major drug compendia or by clinical research. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport, and ground mileage provided on April 1, 2023. 
 
You asked the Plan to pay for the ambulance transport service and ground mileage . You say that the service 
was provided to the enrollee for medical necessity. The Plan denied your request. The Plan says based on the 
information received, it was determined that Medicare rules for coverage of the nonemergency ambulance 
transportation and ground mileage have not been met. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 the ambulance transport service and ground 
mileage . Our reviewer says that the ambulance transport services was not medically necessary.  
 Our physician reviewer found the transportation via ambulance from the emergency department to the 
enrollee's living facility was not medically necessary. The enrollee did not require the expertise of trained 
personnel or the equipment available only on an ambulance in order to effectuate a safe transport. 
Transportation could have been provided by other means (stretcher van, wheelchair van, private car, taxi) 
without endangering the enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the ambulance transport service and ground mileage  have not been met. 
Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-
emergency transport, and ground mileage provided on April 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for eyeglasses and taxes provided February 2, 2023.  
You asked the Plan to reimburse for eyeglasses and taxes. You say that you asked the provider if they accepted 
our Plan and was told yes. The Plan denied your request. The Plan says the service is not covered under the 
members contract under any normal circumstances and is not covered by Medicare 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when . 
 
We looked at the file and the Plan's rules. The Plan rules say that they cover a routine eye examination every 12 
months, through a network or out-of-network vision provider. Eyeglasses and taxes are excluded from this 
benefit. Based on this information, we decided that the Plan's rules for coverage of eyeglasses and taxes have 
not been met. Therefore, we decided that the Plan does not have to reimburse for eyeglasses and taxes provided 
February 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for over-the-counter items provided on February 8, 2023. 
 
You asked the Plan to pay for over-the-counter items. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says claims must be submitted for reimbursement within 120 days of 
the purchase/service date. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
 
  The record shows that a claim for over-the-counter items was not filed until June 14, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for over-the-counter items provided on February 8, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport, and ground mileage provided on April 12, 2023. 
 
You asked the Plan to pay for the ambulance transport service and ground mileage. You say that the service 
was provided to the enrollee for medical necessity  The Plan denied your request. The Plan says the enrollee 
did not require the expertise of trained personnel or the equipment available only in an ambulance in order to 
effectuate a safe transport. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 the ambulance transport service and ground 
mileage. Our reviewer says that the ambulance transport services were not medically necessary. Our physician 
reviewer found the transportation via ambulance from the emergency department to the enrollee's 
residence/assisted living facility was not medically necessary.  The enrollee did not require the expertise of trained personnel or the equipment available only on an ambulance 
in order to effectuate a safe transport. Transportation could have been provided by other means (stretcher van, 
wheelchair van, private car, taxi) without endangering the enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the ambulance transport service and ground mileage have not been met. 
Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-
emergency transport, and ground mileage provided on April 12, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing the denial. The Plan denied your 
request. The Plan says IRF care is not medically necessary. 
 
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 that you do not have complex nursing or rehabilitation needs. While the medical 
record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous laminotomy/laminectomy (0275T). 
 
You asked the Plan to pre-approve a percutaneous laminotomy/laminectomy. You say that the requested 
procedure is medically necessary. The Plan denied your request. The Plan says this procedure is considered 
experimental and 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 a percutaneous 
laminotomy/laminectomy. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found that this procedure is experimental, and 
more research is needed. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a percutaneous laminotomy/laminectomy have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a percutaneous laminotomy/laminectomy (0275T).