Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional non-emergency transportation: mini-bus, 
mountain area transports (A0120). 
 
You asked the Plan to provide additional non emergent transportation. You say that you have no other source 
of transportation to your appointments. The Plan denied your request. The Plan says you have used fifty-seven 
(57) out of sixty (60) of your supplemental routine transportation benefits; additional routine transportation is 
not covered by your Plan. 
 
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 Plan?s coverage rules apply in this 
case. The Plan covers a maximum of 60 one-way routine trips per calendar 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 provide additional non-emergency transportation: mini-bus, mountain 
area transports (A0120).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for services provided to the enrollee from January 23, 2020 to 
January 26, 2020 and billed under code 99152. 
 
You asked the Plan to pay for code 99152. You say that this claim should be paid. The Plan denied your 
request. The Plan says while a portion of this claim was paid, the documentation submitted did not indicate the 
presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness 
and physiological status; therefore, the billed service cannot be verified. Of note, an independent trained 
observer is someone other than the physician performing the services. It is noted that multiple attempts were 
made to contact the provider for additional information. Medicare criteria for code 99152 are not 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 and provide medical records that support the 
services billed. In this case, the records provided do not support the services billed under code 99152. Medicare 
rules for coverage of code 99152. Therefore, we decided that the Plan does not have to pay for services 
provided to the enrollee from January 23, 2020 to January 26, 2020 and billed under codes 99152.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 5 additional home health visits to provide skilled 
nursing services. 
 
You asked the Plan to pre-approve additional home health visits. You say that additional services are medically 
necessary. The Plan denied your request. The Plan says rules for home health care have not been met. 
 
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 additional home health visits. Our 
reviewer says that additional services are not medically necessary. Our physician reviewer found that the 
records do not show that additional 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. Your wound care is not complex. The wound is not infected and is 
healing. You and your caregiver have been educated on wound care management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional home health visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 5 additional home health visits to provide skilled nursing services.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from October 6, 2019 to 
October 8, 2019. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee was outside of the service 
area and needed medical attention. The Plan denied your request. The Plan says that the care could have been 
received as observation. 
 
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 review indicates that the record showed that at the time of inpatient admission the admitting 
physician reasonably expected that your necessary hospital care (including earlier ED and/or observation care) 
would span two midnights. 
 
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 October 6, 2019 to October 8, 2019.  
 
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: Favorable

We decided that the Plan has to pay for an upper extremity flap (15736) provided on February 11, 2020. 
 
You asked the Plan to pay for an upper extremity flap. You say that this is documented in the operative report. 
The Plan denied your request. The Plan says that this code is not supported. 
 
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 15736 is muscle, myocutaneous, or fasciocutaneous flap; upper extremity. 
 
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 an upper extremity flap. Our reviewers says 
that this code is supported in the submitted medical records. Our physician reviewer found the opprative report 
states operative report; The soft tissue was then swept away in an ulnar direction and the pronator quadratus 
muscle was seen. The muscle had a flap created by 1st dividing on its radial and distal end and then at the end 
of the procedure when I used it to cover the plate, I divided on its ulnar border, which completely freed up 
making a muscle flap of the pronator quadratus for complete plate coverage. The pronator quadratus flap was 
created and sewn in place with 4-0 Monocryl sutures to completely cover the valar plate." 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an upper extremity flap have been met. Therefore, we decided that the Plan has 
to pay for an upper extremity flap (15736) provided on February 11, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Benlysta. 
 
You asked the Plan to pre-approve Benlysta. You say that the enrollee has failed multiple therapies, but has 
been stable on Actemra injections for over a year. The Plan denied your request. The Plan says this drug is not 
covered for the enrollee's condition by Medicare Part B. 
 
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 Benlysta.  
 
Benefits for Benlysta may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Smart Drive Device for a manual wheelchair. 
 
You asked the Plan to pre-approve a Smart Drive Device. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
Review of the file shows that you are requesting a Smart Drive Device for your wheelchair. The documentation 
shows that you have a power wheelchair but are limited to using it in the home only. You are requesting this 
Smart Drive Device so that you can attach to the manual wheelchair you have to transport the wheelchair 
outside of the home. The item at issue in this appeal is for use outside of the home. Although this item may be 
helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that 
the Plan does not have to pre-approve a Smart Drive Device for a manual wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the care could be received in another setting. 
 
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 do not require the intensity of services provided at an IRF.  Specifically, the 
documentation is insufficient to show that you require fifteen hours per week of rehabilitative services and 
regular physician evaluation. 
 
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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a specialist office visit (99214) and a 
comprehensive hearing exam (92557, 92567) performed on September 16, 2020. 
 
You asked the Plan to waive the copayments for a specialist office visit and a comprehensive hearing exam. 
You say that you would like your copayments refunded because the doctor is the most condescending, rude 
person you have ever dealt with and spent no more than 3 minutes with you. The Plan denied your request. The 
Plan says the correct copayments were 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 $45 
copayment for each Medicare-covered diagnostic hearing exam and a $45 copayment for a specialist office 
visit.  
 
You have been asked to pay a $45 copayment for a specialist office visit and a $45 copayment for a 
comprehensive hearing exam. A specialist office visit falls within the "Physician/Practitioner services, 
including doctor's office visits" benefit category. A comprehensive hearing exam falls within the "Hearing 
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 copayments for a specialist office visit 
(99214) and a comprehensive hearing exam (92557, 92567) performed on September 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for denosumab injections (J0897) 
 
You asked the Plan to waive the coinsurance for denosumab injections. You say that you cannot afford this 
charge. The Plan denied your request. The Plan says this processed 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance of $772.68 for each denosumab injection. Denosumab 
injections falls within the Medicare Part B prescription drugs 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 denosumab injections (J0897).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve a power wheelchair. You say that you would like the plan to reconsider their 
denial The Plan denied your request. The Plan says the requested power wheelchair is not medically necessary. 
 
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.  
 
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 power wheelchair. Our reviewer says 
that the documentation does not support that the requested power wheelchair is medically reasonable or 
necessary. Our physician reviewer found the documentation does not support that you have a personal mobility 
deficit that impairs participation in mobility related activities of daily living in the home. The documentation 
indicates that you cannot self-propel a wheelchair due to your medical conditions but there is no objective 
physical examination of the upper and lower extremities or a detailed neuromuscular exam or evaluation of 
what wheelchair you are using and whether or not it is the appropriate fit. The documentation is not clear that 
you can safely maneuver the requested power wheelchair in your home and that the power wheelchair will 
properly fit inside the home and significantly improve mobility related activities of daily living in the home. 
Therefore, you do not meet criteria for the requested item. 
 
 
 
 
 
 
 
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 power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Theragun massage device. 
 
You asked the Plan to pre-approve the Theragun massage device. You say that you have severe neuropathy in 
both feet and both legs, past your calves. You say that you need the requested equipment in order to stimulate 
blood flow in your legs. you say that you also have arthritis in your neck. You say that it is getting difficult to 
walk and have stable mobility. You say that the stimulator would help you relax your muscles and the tension 
in your legs, in order to perform basic functions. The Plan denied your request. The Plan says the item you are 
requesting coverage for does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a Theragun massage device.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says skilled nursing care is not required in an inpatient setting. 
 
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 the admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there were no skilled nursing needs at 
the time of admission. As of 7/6/20, the enrollee did not require any skilled nursing or rehab services on daily 
basis. She was not expected to make measurable gains within a reasonable and predictable period of time or 
require skilled therapy to prevent deterioration with mobility or ADLs. The enrollee did not require skilled 
therapy to establish a safe and effective maintenance program. As a practical matter, the enrollee did not 
 
 
require any skilled services on an inpatient basis, at a SNF level of care during the period of care under review. 
 
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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
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 June 17, 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 has network providers 
available who can provide 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 June 17, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the non-emergent wheelchair van transportation. 
 
You asked the Plan to pre-approve wheelchair van transportation. You say that you feel that this should be 
approved because you don't have a van to drive the enrollee to the appointments. The Plan denied your request. 
The Plan says wheelchair van transportation is not covered by Medicare and therefore not covered by the plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pre-approve are wheelchair van transport services. Therefore, we 
decided that the Plan does not have to pre-approve the non-emergent wheelchair van transportation.
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. The Plan denied your request. The Plan says the enrollee's care is 
not complex, and does not need a team of providers. 
 
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 physician reviewer found 
that the enrollee presented to the acute hospital with a fall related to syncope and atrial fibrillation with rapid 
ventricular response. He is weak and deconditioned. He is walking 70 feet with a rolling walker with contact 
guard assistance, is at stand-by assist for transfers, and at moderate assist for activities of daily living. His 
therapy is noted to be limited by pain and fatigue. He requires two rest breaks to walk 70 feet. The complexity 
of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with 
an interdisciplinary approach to rehabilitation care. The enrollee does require physical and occupational 
therapy services, but does not require an intensive inpatient rehabilitation therapy program. There is concern 
that he will not be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an inpatient rehabilitation facility due to pain and decreased endurance. 
 
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.