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

 
We decided that the Plan does not have to provide a Group 2 power wheelchair with tilt/recline, power 
elevating leg rests and upgraded electronics. 
 
You asked the Plan to provide a Group 2 multiple power option power wheelchair (K0842). You say that the 
enrollee needs a Group 2 power wheelchair with tilt/recline, power elevating leg rests and upgraded electronics. 
The Plan denied your request. The Plan says the physician note and physical therapist evaluation do not support 
medical necessity. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that the enrollee's condition can be improved by a walker and cane. The record does not show 
abnormal muscle tone or spasticity, or severe swelling in the lower extremities. The record does not show 
current or past pressure ulcers. This means that Medicare rules for coverage of a PMD have not been met. 
Therefore, we decided that the Plan does not have to provide a Group 2 power wheelchair with tilt/recline, 
power elevating leg rests and upgraded electronics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the removal of an impacted, partially bony, tooth 
(D7230). 
 
You asked the Plan to pre-approve the removal of an impacted, partial bony tooth. You say that you were 
informed that the provider was covered. You say that you were referred to this provider by member services on 
the back of your card. The Plan denied your request. The Plan says removal of an impacted tooth is not listed as 
a covered service. The Plan also says any services not listed are not covered. 
 
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. Additionally, the Evidence of Coverage clearly states that any services 
not listed are not covered. Therefore, we decided that the Plan does not have to pre-approve the removal of an 
impacted, partially bony, tooth (D7230).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve blood glucose test strips and lancets for testing 4 times a 
day. 

You asked the Plan to pre-approve a high utilization amount of blood glucose test strips and lancets. You say 
that you need to test 4 times a day. The Plan denied your request. The Plan says there is no medical 
documentation of the need to test 4 times a day. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The treating physician has stated that he does not have enough 
information in the file to justify testing 4 times a day. Based on this information, we decided that Medicare 
rules for coverage of a high utilization amount of blood glucose test strips and lancets have not been met.  
Therefore, we decided that the Plan does not have to pre-approve blood glucose test strips and lancets for 
testing 4 times a day.
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 the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary. 
 
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 records show that this patient is improving and although requires additional short 
term acute care for additional stabilization and treatment, this should take less than 25 days, and could safely be 
completed at the current facility. The patient does not require services at the LTACH that are not already 
available at the current setting. There are no services at the LTACH that the patient requires that are not already 
available and covered at the current setting. Therefore, this request for LTACH services will be considered not 
medically necessary. Transfer to a lower level of care may be considered soon. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on May 
21, 2020. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you feel you should not 
be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan 
denied your request. The Plan says you had an office visit with a specialist on the date of service at issue in this 
appeal. The Plan says that the correct copayment has applied per your contract with the Plan. 
 
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 $45 
copayment for specialist services.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a specialist 
office visit on May 21, 2020. You have been asked to pay a $42.72 copayment for the specialist office visit, 
which is less than the contracted $45 copayment amount. The specialist office visit falls within the 
Physician/Practitioner 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 specialist office visit provided on May 21, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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 pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found based on the medical records provided there is 
no documentation that the patient requires skilled nursing services, i.e., the specialized skill, knowledge and 
judgment of a skilled professional nurse is not required to safely and effectively provide medically necessary 
and reasonable treatment. This patient does not require skilled therapy services, i.e., the specialized skill, 
knowledge and judgment of a qualified therapist is not required to safely and effectively provide medically 
necessary and reasonable treatment. Daily skilled services are not required. This patient does not require the 
services on an inpatient basis, in a skilled nursing facility setting. Services in a long-term care facility on a part 
time basis or in the home with home health services appear appropriate 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a patient lift (E0630). 
 
You asked the Plan to pre-approve a patient lift. You say that the medical documentation shows this is 
medically necessary. The Plan denied your request. The Plan says that there is not documentation showing 
more than one person is needed for transfers. 
 
The Plan must follow Medicare rules. Medicare rules say that that a patient lift is covered if transfer between 
bed and a chair, wheelchair, or commode is required and, without the use of a lift, the beneficiary would be bed 
confined. 
 
We looked at the file and Medicare rules. The submitted medical records state that transfer between bed and a 
chair, wheelchair, or commode is required and, without the use of a lift, the beneficiary would be bed confined. 
Based on this information, we decided that Medicare rules for coverage of a patient lift have been met. 
Therefore, we decided that the Plan has to pre-approve a patient lift (E0630).  
 
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that you feel you will benefit from short-term 
rehabilitation for a week so you can get stronger and return home at your prior level of function. The Plan 
denied your request. The Plan says that there is no need for daily skilled therapy services to be provided by a 
skilled therapist on a daily basis and there are no daily skilled nursing needs. 
 
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 pre-approve SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from March 10, 2020 to 
March 13, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient hospital care provided 
from March 10, 2020 to March 13, 2020 was medically necessary. The Plan denied your request. The Plan says 
that the inpatient hospital care provided from March 10, 2020 to March 13, 2020 was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the enrollee presented with acute diverticulitis and required IV antibiotics and IV analgesia, and 
IVF resuscitation. Based on the documentation provided, given the enrollee's age, and need for IV antibiotics, 
IV analgesia, and presence of anemia,  hospitalization was both reasonable to think that 2 nights would be 
required at the time of admission. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from March 10, 2020 to March 13, 2020.  
 
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: Partially Favorable

We decided that the Plan has to pay for 2 units of CPT 64451. We decided that the Plan does not have to pay 
for 1 unit of CPT 64451.  
 
You asked the Plan to pay for 3 units of CPT 64451. You say that this should be paid for. The Plan says that 
the amounts of units are incorrect. 
 
We decided that the Plan has to pay for 2 units of CPT 64451.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 64451 is "injection(s) anesthetic agent(s) and/or steroid." 
 
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. Our reviewer says that the services at issue in this case 
were partially supported by the medical records and coding guidelines. Our coding reviewer found the National 
Correct Coding Initiative Policy (NCCI) states the Maximum units (MUE) that than be billed daily for CPT 
64451 is 2. 2 units of 64451, which is validated by the medical records submitted would be payable. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 2 units of CPT 64451 have been met. Therefore, we decided that the Plan has to 
pay for 2 units of CPT 64451.  
 
We also decided that the Plan does not have to pay for 1 unit of CPT 64451. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 64451 is "injection(s) anesthetic agent(s) and/or steroid." 
 
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. Our coding reviewer found that the guidelines did not 
support payment of the third unit of CPT 64451. Because the 3rd unit of 64451 exceeds the maximum daily 
allowable Medically Unlikely Edits (MUE) it does not meet criteria for reimbursement consideration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 1 unit of CPT 64451 have not been met. Therefore, we decided that the Plan 
does not have to pay for 1 unit of CPT 64451. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a SHINGRIX vaccine. 
 
You asked the Plan to pre-approve the vaccine. The Plan denied your request. The Plan says this is not covered 
under your Part B plan. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The 
Plan follows the same rules.  
 
The records do not show that you have been injured or directly exposed to any illness related to the vaccine. 
Therefore, we decided that the Plan does not have to pre-approve a SHINGRIX vaccine.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that the records show that the enrollee continues to require acute care in the 
current setting and the enrollee would not be able to tolerate aggressive skilled therapy at this time. 
 
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. The 
documentation does not support that the complexity of this enrollee's nursing, medical and rehabilitation needs 
requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
documentation does not support that the enrollee would be able to participate in a rehabilitation therapy 
program at least 3 hours a day, 5 days a week, or 15 hours over 7 consecutive days. There is not a reasonable 
expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet 
Medicare criteria for IRF 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mastectomy sleeve (L8010) for the enrollee. 
 
You asked the Plan to pre-approve the sleeve. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a mastectomy sleeve (L8010) is not covered.  
 
The requested item is statutorily not covered by Medicare or the plan. Based on this information, we decided 
that Medicare rules for coverage of the sleeve have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a mastectomy sleeve (L8010) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from June 2, 2020, through July 26, 2020. 
 
You asked the Plan to pay for SNF care. You say that the stay was medically necessary. The Plan denied your 
request. The Plan says the stay is not medically necessary. 
 
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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found based on the medical records provided there is 
no documentation that the patient requires skilled nursing services, i.e., the specialized skill, knowledge and 
judgment of a skilled professional nurse is not required to safely and effectively provide medically necessary 
and reasonable treatment for June 2, 2020, through July 26, 2020. This patient does not require skilled therapy 
services, i.e., the specialized skill, knowledge and judgment of a qualified therapist is not required to safely and 
effectively provide medically necessary and reasonable treatment. Daily skilled services are not required. This 
patient does not require the services on an inpatient basis, in a skilled nursing facility setting. Services in the 
 
long-term care facility appear custodial in this case for June 2, 2020, through July 26, 2020. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for SNF care provided from June 2, 2020, through July 26, 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. 
 
You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested admission 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 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 you underwent cystoscopy and placement of a stent. You required minimal assistance 
for safety and balance during several steps from bed to recliner using a wheeled walker. The documentation 
does not support that the complexity of your nursing, medical and rehabilitation needs requires an acute 
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your care needs can be met at a 
lower 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.