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

We decided that the Plan has to pre-approve a home ventilator for the enrollee. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says that there is a lack of medical necessity. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that 
the requested ventilator is medically reasonable and necessary. Our physician reviewer found the enrollee has 
ALS, a progressive neuromuscular disease that causes respiratory muscle weakness and hypoventilatory 
respiratory failure. The enrollee's pulmonary function has fallen dramatically over the past year, and FVC by 
home spirometry is severely reduced at less than 40% predicted. The enrollee would likely benefit from both 
nocturnal ventilation and "sip and puff" ventilation by mouthpiece during the day. A ventilator is needed for the 
sip and puff capability and is most appropriate for this enrollee's condition. The home ventilator is medically 
necessary, and the denial should be reversed. 
 
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 ventilator have been met. Therefore, we decided that the Plan has to pre-
approve a home ventilator for the enrollee.  
 
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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy (S9500 and S9501) provided on May 21, 2020, through May 27, 2020.
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT codes S9500 and S9501 have status indicators of I which means that are not valid for Medicare purposes.
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 codes S9500 and S9501 are not supported in the record. Specifically per the Physician Fee Schedule, CPT codes S9500 and S9501 have a status indicator of I This means that these codes are not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy (S9500 and S9501) provided on May 21, 2020, through May 27, 2020.
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 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 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 the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for acute respiratory failure, COVID 19 pneumonia and congestive heart failure. Medical conditions 
are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or 
rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
documents a need for physical and occupational therapy, it does not document a need for an intensive 
rehabilitation program. 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. 
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvethe RevoFit system adjustable socket.You asked the Planto pre-approvethe socket. You say that this is medically necessary to adjust the socket to prevent movement.The Plandenied your request. The Plansaysthis item 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 the socket. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the RevoFitadjustable socket does not have FDA approval and therefore cannot be considered safe and effective or the standard of care for this 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 socket have not been met.Therefore, we decided that the Plandoes not haveto pre-approvethe RevoFit system adjustable socket.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the lipid testing provided to you on October 21, 2020. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says that the benefit limit was 
exceeded. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan contract says that blood testing for cardiovascular disease is covered 
once every 5 years. The Plan has not submitted documentation showing that this was provided and paid by the 
Plan within the past 5 years. Without supporting documentation, the Plan's denial cannot be substantiated. 
Therefore, we decided that the Plan has to pay for the lipid testing provided to you on October 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says genetic screening testing is not a Medicare benefit for the diagnosis listed on the claim.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.

The file shows that a Cx Bladder test was provided to facilitate early detection of bladder cancer. There are insufficient records to show that the test was ordered due to signs and symptoms in this enrollee. The records do not show that the results of the testing would be used to determine a specific treatment strategy. The testing was requested for screening purposes. Medicare does not cover this test for screening purposes.Therefore, we decided that the Plan does not have to pay for the lab services provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on August 24, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-
network provider on August 24, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve the Mirena IUD.
You asked the Plan to pre-approve the IUD. You say that this is medically necessary. The Plan denied your
request. The Plan says that this may be approved for use in the Medicare beneficiary who presents with
endometrial hyperplasia without atypia.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically necessary.
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 IUD. Our reviewer says that the
requested services are considered medically reasonable and necessary in this case. Our physician reviewer
found you are using the levonorgestrel IUD for the treatment of heavy menstrual bleeding for which it is FDA
approved. It will also treat dysmenorrhea and is a medically safe, effective, and reasonable option. The
indication is not contraception. Therefore, the LNG-IUD is medically reasonable and 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 IUD have been met. Therefore, we decided that the Plan has to pre-approve
the Mirena IUD.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergent ambulance transport and mileage (A0425 and A0428) to a physician's office provided on September 20, 2020.
You asked the Plan to pay for non-emergent ambulance transport and mileage. You say that the service should be covered. The Plan denied your request. The Plan says ambulance transport to or from an outpatient office is not a Medicare covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. The services you have asked the Plan to pay for are ambulance transport services to a doctor's office. This is not a covered service. Therefore, we decided that the Plan does not have to pay for non-emergent ambulance transport and mileage (A0425 and A0428) to a physician's office provided on September 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a 
participating provider on June 18, 2020. 
 
You asked the Plan to waive the coinsurance for a walker. You say that you did not need this walker. You say 
that the hospital told you to take it because they would just have to throw it out. The Plan denied your request. 
The Plan says the correct coinsurance has been 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 20% 
coinsurance for durable medical equipment/in-network.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for a walker. The total allowed amount 
is $85.96. The total amount you are being asked to pay is $17.19 ($85.96 x 20% = $17.19). A walker falls 
within the durable medical equipment/in-network 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 durable medical equipment provided by a participating provider on June 18, 2020.  
 
We note your complaint about telling the hospital you didn?t need the walker. Your complaint is a grievance 
that must be answered by the health plan. Medicare does not permit us to make a decision about these types of 
complaints.
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 the IRF admission is medically necessary. The Plan
denied your request. The Plan says your needs can be met at a different level of care.
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 based on the medical records provided the complexity of your nursing, medical and
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to
rehabilitation care. You may require skilled physical therapy and occupational therapy but based on the
medical records provided you will not 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled services by an RN for management and
evaluation of the plan of care (G0162) and direct skilled nursing services of an LPN in the home health or
hospice setting (G0300).
You asked the Plan to pre-approve the skilled services by an RN and direct skilled nursing services of an LPN.
You say that you could use some assistance with care. The Plan denied your request. The Plan says the records
do not show that you require skilled nursing care or therapy. The Plan also says these services are not
medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 skilled services by an RN and direct
skilled nursing services of an LPN. Our reviewer says that skilled nursing services are not medically reasonable
and necessary. Our physician reviewer found there is no documentation that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve your condition, or to
establish/perform a maintenance program to maintain your condition and/or prevent deterioration. Our reviewer
also found that your medical conditions were last reported as stable; a cream was ordered for a rash but no
other medication changes were documented, and there was no report of any need for closer monitoring or any
report of medication compliance concerns.
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 skilled services by a RN and direct skilled nursing services of an LPN have
not been met. Therefore, we decided that the Plan does not have to pre-approve skilled services by an RN for
management and evaluation of the plan of care (G0162) and direct skilled nursing services of an LPN in the
home health or hospice setting (G0300).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a 
participating provider on September 9, 2020. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you do not agree with this. 
You say that this was not a hospital. The Plan denied your request. The Plan says the correct copayment has 
been 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 $270 
copayment for outpatient surgery/in-network/outpatient hospital.  
 
You have been asked to pay a $270 copayment for an outpatient surgery. This provider has an off campus-
outpatient hospital location that is part of a hospital; therefore, the correct copayment has been applied. An 
outpatient surgery falls within the outpatient surgery/in-network/outpatient hospital benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for an outpatient surgery provided by a participating provider 
on September 9, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on
September 20, 2020.
You asked the Plan to waive the copayment for the emergency room visit. You say that the copayment should
be dismissed because the emergency room visit was within the global period from your spinal surgery. The
Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
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 $90
copayment for each emergency room visit.
You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls
within the "Emergency Care" benefit category. Please note, there is no provision in the contract which
indicates a copayment would be waived if performed during a global surgery period.
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 emergency room visit provided on September 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient hospital observation stay 
provided from September 13, 2020, to September 16, 2020. 
 
You asked the Plan to waive the copayment for the outpatient hospital observation stay. You say that you are 
being billed the observation copayment along with a hospital stay when you were admitted a few days later for 
the same diagnosis. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing amount. 
 
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 $225 
copayment for outpatient hospital observation services.  
 
You have been asked to pay a $225 copayment for the outpatient hospital observation stay. The outpatient 
hospital observation stay falls within the "Outpatient Hospital Observation" 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 outpatient hospital observation stay provided from September 13, 
2020, to September 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on July 31, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-
network provider on July 31, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Accu-Chek Aviva Plus test strips. 
 
You asked the Plan to pre-approve Accu-Chek Aviva Plus test strips. You say that the enrollee needs to check 
his blood sugar daily. The Plan denied your request. The Plan says there is no reason given to justify a non-
preferred brand. 
 
The Plan must follow Medicare rules. Medicare rules say that and charge lower cost-sharing for the preferred 
brands or may limit the DME to only those preferred brands and manufacturers, as long as the conditions listed 
above are met. 
 
We looked at the file and Medicare rules. There is no reasoning given in the submitted documentation showing 
that it is medically necessary for the enrollee to use a non-preferred brand of test strips. The Plan has indicated 
that they will approve a preferred meter and strips. Based on this information, we decided that Medicare rules 
for coverage of Accu-Chek Aviva Plus test strips have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Accu-Chek Aviva Plus test strips.