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

 
We decided that the Plan does not have to pre-approve a gel mattress. 
 
You asked the Plan to pre-approve the mattress. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is a convenience item that is considered not medical in nature. 
 
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 the mattress. Our reviewer says that the 
requested mattress is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the requested gel mattress is not medically necessary as this item is not reasonable and necessary for the 
diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. The 
documentation does not reveal evidence of pressure ulcers or extenuating reasons on a physical exam that you 
require this mattress for medical reasons. 
 
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 mattress have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a gel mattress.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve Automatic Implantable Cardioverter Defibrillator (AICD) placement.

You asked the Plan to pre-approve AICD placement. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says that the requested services are not medically necessary.

The Plan follows Medicare rules. Medicare rules say that AICD placement is covered 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 AICD placement. Our reviewer says that the documentation does support that the requested services are medically reasonable and necessary. Our physician reviewer found the enrollee has a persistent severe nonischemic cardiomyopathy with ejection fraction less than 35% and congestive heart failure while on optimal goal directed medical therapy. In this circumstance a defibrillation is reasonable, appropriate and considered standard accepted practice in the medical community. Coverage criteria are met since one covered indication includes: "Patients who have severe, non-ischemic, dilated cardiomyopathy . . . NYHA Class II or III heart failure, LVEF &#8804; 35%, and been on optimal medical therapy for at least three (3) months". Therefore, the enrollee meets criteria for the requested services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of AICD placement have been met. Therefore, we decided that the Plan has to pre-approve Automatic Implantable Cardioverter Defibrillator (AICD) placement. 

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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment (A4245, A4595, A6549, E0651, 
E0730, L0650) provided March 23, 2020. 
 
You asked the Plan to pay for the durable medical equipment. You say that the items were medically necessary. 
The Plan denied your request. The Plan says coverage criteria for these items have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code A4245, A4595, A6549, E0651, E0730, & L0650 is not supported in the medical record. 
Specifically, codes A4245, A4595 & A6549 are not covered. Per the NCD, Code E0730 is not covered for the 
enrollee's diagnosis. There was no physician order for CPT Code A4595. CPT code E0651 was billed without a 
required modifier. The lumbar sacral orthotic device (L0650) was provided within the reasonable useful 
lifetime of an existing device. Based on this information, we decided that Medicare rules for coverage of the 
durable medical equipment have not been met. Therefore, we decided that the Plan does not have to pay for 
durable medical equipment (A4245, A4595, A6549, E0651, E0730, L0650) provided March 23, 2020.
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 LTACH services are medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for 
coverage of LTACH services. 
 
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 there are no required medical services identified that are available at the LTACH, 
that are not available at the current health care setting being offered by the health plan. Consequently, the 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee 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 long term acute care hospital (LTACH) services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CPT code S5501 provided from December 3, 2019 to 
December 31, 2019. 
 
You asked the Plan to pay for CPT code S5501. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, CPT code S5501 has a status code of "I" under the 
Medicare Physicians Fee Schedule Database (MPFSDB) and is not valid for Medicare purposes. Medicare uses 
another code for reporting of, and payment for, this service. Therefore, we decided that the Plan does not have 
to pay for CPT code S5501 provided from December 3, 2019 to December 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve S1 and S2 sacroplasty for the enrollee. 
 
You asked the Plan to pre-approve S1 and S2 sacroplasty. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says Medicare coverage criteria are not 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 S1 and S2 
sacroplasty. Our reviewer says that the requested services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has a diagnosis of unspecified fracture of 
sacrum, initial encounter for closed fracture. An MRI on August 5, 2020 demonstrated a space-occupying 
lesion in the left side of the sacrum as well as in the left iliac bone. The documentation in the case file does not 
include results of testing of the lesions. The available documentation is insufficient to demonstrate that the 
requested S1 and S2 sacroplasty is medically reasonable and necessary and is expected to be safe and effective 
for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of S1 and S2 sacroplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve S1 and S2 sacroplasty for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility services provided 
October 7, 2019 to October 30, 2019. 
 
You asked the Plan to waive the copayment for the skilled nursing facility services. You say that you should 
owe nothing for the services. The Plan denied your request. The Plan says the correct copayment was applied. 
 
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 $0 
copayment for days 1-20 and a $172 per day copayment for days 21-100 for Inpatient Skilled Nursing Facility 
care.  
 
You have been asked to pay a $516 copayment ($172 per day) for days 21-23 of skilled nursing facility 
services. 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 skilled nursing facility services provided 
October 7, 2019 to October 30, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for testing services provided from February 21, 
2020 to February 24, 2020. 
 
You asked the Plan to waive the copayment for testing services. You say that you were told the charge would 
be less. The Plan denied your request. The Plan says the copayment you are being charged is correct. 
 
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 $65 
copayment for each covered diagnostic procedure or test at a network doctor's office.  
 
You have been asked to pay $38.15 for testing services, which is less than your $65 copayment. Testing 
services fall within the 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 testing services provided from February 21, 2020 to 
February 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (DME) as defined by codes 
E0745, E0651, A4245, A6549, L1851, L2397, L1851 and L2397 provided to the enrollee on March 20, 2020. 
 
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. 
The Plan says the documentation does not indicate services are necessary for treatment of the enrollees 
condition. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for the durable medical 
equipment (DME) as defined by codes E0745, E0651, A4245, A6549, L1851, L2397, L1851 and L2397 
provided to the enrollee on March 20, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided January 24, 
2020 to February 22, 2020. 
 
You asked the Plan to pay for the SNF services. You say that SNF services were medically necessary. The Plan 
denied your request. The Plan says coverage criteria was not met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 pay for the SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee did not require skilled 
nursing or therapy services on a daily basis. The enrollee did not meet severity of illness or intensity of service 
criteria for an inpatient basis in a skilled nursing facility setting. 
 
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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pay for skilled nursing facility (SNF) services provided January 24, 2020 to February 22, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 10, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent 
nor urgent and prior authorization was not obtained to provide out-of-network care. 
 
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 has network providers 
available who can provide 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 medical services provided on January 10, 2020 
by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a knee orthosis with 
suspension sleeve (L1851, L2397) provided to the enrollee on March 25, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollees condition. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis 
(L0650) and a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on March 25, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on January 21, 
2020. 
 
You asked the Plan to pay for the domiciliary or rest home visit. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a domiciliary or rest home visit provided on January 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical supplies provided from January 1, 2020 to 
January 31, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the medical supplies. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the service provided were neither emergent nor 
urgent and prior authorization was not obtained to provide out-of-network care. 
 
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 has network providers 
available who can provide 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 medical supplies provided from January 1, 
2020 to January 31, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D0274, D0180, D0220, and D0230) 
provided on January 31, 2020. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the dental services you received are not 
covered by Medicare or the Plan's supplemental dental 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 dental services received are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
services (D0274, D0180, D0220, and D0230) provided on January 31, 2020.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that IRF admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says Medicare coverage criteria are not met.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 based on the medical records, the documentation does not support that the 
enrollee is reasonably expected to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF at this time. Medicare coverage criteria are not 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 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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric services. 
 
You asked the Plan to pre-approve the inpatient services. The Plan denied your request. The Plan says the 
enrollee shows no evidence of being a danger to self or others. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient services. Our physician 
reviewer found that active treatment was not taking place. The services were not reasonably expected to 
improve the enrollees condition, or for the purpose of diagnosis. Based upon review the records provided, the 
enrollee was not shown to be a danger to himself. He had vague homicidal thoughts, but was without agitation 
or aggression, without perceptual disturbance including auditory or visual hallucinations. Therefore, the 
requested services are not considered medically reasonable or necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the inpatient services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve inpatient psychiatric services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Humira. 
 
You asked the Plan to pre-approve Humira. You say that the enrollee has tried and failed other medications. 
The Plan denied your request. The Plan says the  drug is not covered for the enrollee's condition by the Part B 
plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Humira.  
 
Benefits for Humira may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.