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

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with multiple 
power options (K0861) and additional items and accessories (codes E0955, E1007, E1012, E1028, E2311, 
E2313, E2361, E2377, E2601, E2620, K0040, and K0108). 
 
You asked the Plan to pre-approve a group 3 standard power wheelchair and additional items and accessories. 
You say that the enrollee is requesting a power wheelchair that was approved by Medicare. You also say that 
the enrollee has multiple sclerosis, and the clinical documentation does justify their need for it. The Plan denied 
your request. The Plan says the enrollee does not have a medical need for multiple power options available 
with a K0861 group 3 power wheelchair. An expandable controller, harness and electronics are not medically 
needed. The Plan also says that power elevating leg rests are not medically needed. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair (PWC) with multiple 
power options (such as code K0861) is covered if the criteria listed in the Medicare rules section of this letter 
are met. Medicare rules also say that if the PWC base is not covered, then related accessories will be denied. 
 
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 standard power wheelchair 
and additional items and accessories. Our reviewer says that the enrollee does not meet the criteria for 
coverage. Our physician reviewer found the enrollee has 5 out of 5 strength in their upper extremities and is 
independent in toilet transfer. Our reviewer also found that the enrollee does 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 standard power wheelchair and additional items and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 standard power 
wheelchair with multiple power options (K0861) and additional items and accessories (codes E0955, E1007, 
E1012, E1028, E2311, E2313, E2361, E2377, E2601, E2620, K0040, and K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 and supplies. 
 
You asked the Plan to pre-approve the Dexcom G7 and supplies. You say that these items are a medical 
necessity. The Plan denied your request. The Plan says the clinical information provided does not show you 
meet criteria for the Dexcom G7 system and standard supply allowance for this device. 
 
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 Dexcom G7 and supplies. Our 
reviewer says that these items are not medically necessary. Our physician reviewer found CGM coverage 
criteria require insulin or low blood glucose sugar. You are not on any medications for diabetes mellitus so you 
would not qualify for the CGM per plan criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Dexcom G7 and supplies have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Dexcom G7 and supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device from an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a pneumatic compression device from an OON provider. You say that the 
prescribed type of compression pump, the Medi Genius, is only available through the requested OON provider. 
You say that this specific device has a dual wave, 10 chamber system which has a peristaltic treatment mode. 
You say that this has been prescribed due to the sensitivity of the enrollee's skin and the need of exact 
compression of specific areas of the limbs. The Plan denied your request. The Plan says there are network 
providers within a reasonable distance from the enrollee's location that can provide medically necessary 
equipment/items. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 pneumatic compression device from 
an OON provider. Our reviewer says that the criteria for OON coverage have not been met. Our physician 
reviewer found the Plan is offering adequate care to meet the enrollees medical needs through in-network 
providers. There is not a unique aspect about the enrollee's condition that that would make it medically 
necessary to see the requested OON provider. The Plan has shown that they have in-network providers who 
would meet the Standards 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 a pneumatic compression device from an OON provider have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device from an out-
of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair with single power 
option (K0856) and additional items and accessories (codes E2311, E2313, E2377, E0953, E0955, E1002, 
E1012, E1028, E2361, and E2607). 
 
You asked the Plan to pre-approve a Group 3 standard power wheelchair and additional items and accessories. 
You say that the services are found to be both medically necessary and covered, under Medicare guidelines. 
The Plan denied your request. The Plan says the enrollee does not have medical need for single power option 
included with a K0856 group 3 power wheelchair. The Plan also says that the electronic connection, harness, 
and expandable controller are not medically needed as there is no need to control more than two power options 
through the joystick (only two power features are appealed). 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 PWC with single power option (such as 
code K0856) is covered if the criteria listed in the Medicare rules section of this letter are met. Medicare rules 
also say that if the PWC base is not covered, then related accessories will be denied. 
 
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 standard power wheelchair 
and additional items and accessories. Our reviewer says that the enrollee does not meet the criteria for 
coverage. Our physician reviewer found the enrollee has lower motor neuron disease, is not a safe ambulator, 
and previously used a power wheelchair. The enrollee has intact skin. Our reviewer also found that the enrollee 
does 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 standard power wheelchair and additional items and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 standard power 
wheelchair with single power option (K0856) and additional items and accessories (codes E2311, E2313, 
E2377, E0953, E0955, E1002, E1012, E1028, E2361, and E2607).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a skilled nursing facility visit provided on January 26, 2023. 
 
You asked the Plan to pay for a skilled nursing facility visit. You say that the enrollee is in a facility and the 
facility should have obtained the prior authorization. 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 skilled nursing facility 
visit provided on January 26, 2023.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pre-approve wheelchair transportation. 
 
You asked the Plan to pre-approve the wheelchair transportation. You say that you need the transportation for 
doctor visits and medical care as you have multiple myeloma that causes you pain. You also say that you are in 
a wheelchair twenty-four by seven. The Plan denied your request. The Plan says that your request of non-
emergency medical transportation will be covered if you have a completed Physician Certification Statement 
(PCS) form by your treating physician. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers transportation that is the most cost effective and accessible. This can include: ambulance, 
litter van, wheelchair van medical transportation services, and coordinating with para transit. The forms of 
transportation are authorized when your medical and/or physical condition does not allow you to travel by bus, 
passenger car, taxicab, or another form of public or private transportation, and depending on the service, prior 
authorization may be required. Non-emergency medical transportation (NEMT) requires the completion of a 
physician certification statement (PCS) form to determine the appropriate level of service. This form must be 
completed by your treating physician prior to the services being arranged or provided. 
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of the wheelchair transportation. have been met. Therefore, we decided that 
the Plan has to pre-approve wheelchair transportation.  
 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the knee brace and the ankle foot brace 
provided on May 18, 2023. 
 
You asked the Plan to waive the coinsurance for the knee brace and the ankle foot brace. You say that you were 
told that the items would be 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 20% 
coinsurance for prosthetic devices and related supplies. 
 
You have been asked to pay 20% coinsurance for the knee brace and the ankle foot brace. This item/service 
falls within the prosthetic devices and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the coinsurance for the knee brace and the ankle foot brace provided on May 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a gynecology office visit to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve a gynecology office visit. You say that you are requesting reconsideration of 
the denied authorization. The Plan denied your request. The Plan says this service is available with in-network 
providers. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. 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 
a gynecology office visit to be provided by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a nuclear stress test provided on June 12, 
2023. 
 
You asked the Plan to waive the copayment for a nuclear stress test. You say that you were told the incorrect 
amount for 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 $300 
copayment for in-network outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $300 copayment for a nuclear stress test. This item/service falls within the in-network outpatient diagnostic tests and therapeutic services and supplies 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 nuclear stress test provided on June 12, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral minimally invasive sacroiliac joint fusion 
(27279). 
 
You asked the Plan to pre-approve bilateral minimally invasive sacroiliac joint fusion. You say that the services 
are necessary. The Plan denied your request. The Plan says medical necessity has not been established. 
Therefore, coverage criteria 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 bilateral minimally invasive sacroiliac 
joint fusion. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found detailed documentation is not evident regarding imaging 
or radiographic evidence supporting significant sacroiliitis pathology. Multiple other plausible pain generators including at the lumbosacral spine are evident. There are limited large-scale, long-term references showing the 
safety and efficacy of the requested surgery in this clinical setting. Therefore, the requested bilateral minimally 
invasive sacroiliac joint fusion 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 bilateral minimally invasive sacroiliac joint fusion have not been met. 
Therefore, we decided that the Plan does not have to pre-approve bilateral minimally invasive sacroiliac joint 
fusion (27279).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the radiology services provided on June 26, 
2023, to June 27, 2023. 
 
You asked the Plan to waive the copayment for the radiology 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 $150 
copayment for outpatient hospital services. 
 
You have been asked to pay a $150 copayment for the radiology services. 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. Therefore, we decided that the Plan does not have to waive the copayment for the 
radiology services provided on June 26, 2023, to June 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the repair or modification of a hearing aid (V5014) provided 
on June 7, 2023. 
 
You asked the Plan to pay for the repair or modification of a hearing aid (V5014). You say that while boating, 
you lost your balance, fell into the lake and lost both of your new hearing aids. You also say that the provider 
told you a new pair would cost $500. The Plan denied your request. The Plan says they offer hearing aids as an 
additional benefit to the member. However, the repair of the hearing aid and related services is not covered. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only, not repairs and related services.  
 
 
  We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the repair or modification of a hearing aid (V5014) have not been met. Therefore, we decided that 
the Plan does not have to pay for the repair or modification of a hearing aid (V5014) provided on June 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for out-of-network outpatient mental health 
care provided on May 26, 2023. 
 
You asked the Plan to waive the coinsurance for out-of-network outpatient mental health care. You say that 
you disagree with the coinsurance. 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 30% 
coinsurance for out-of-network outpatient mental health care. 
 
You have been asked to pay 30% coinsurance for out-of-network outpatient mental health care. This 
item/service falls within the out-of-network 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 coinsurance for out-of-network outpatient mental health care provided on May 26, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assisted living visits and related services provided on July 
19, 2022, to November 22, 2022. 
 
You asked the Plan to pay for assisted living visits and related services. You say that this service is supported 
in the records. 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 assisted living visits and 
related services provided on July 19, 2022, to November 22, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 72 routine transportation trips. 
 
You asked the Plan to pre-approve the additional routine transportation trips. You say that the services are 
necessary for your medical needs. The Plan denied your request. The Plan says the requested services will 
exceed the benefit limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 72 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve an additional 72 routine transportation trips.