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

 
We decided that the Plan does not have to pre-approve power wheelchair accessories (expandable controller, 
harness, electronic connection, waterfall arm pads) for the enrollee. 
 
 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says the upper limb strength and function are adequate for the enrollee to be able to 
control the power options using their own switches. 
 
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 accessories. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee does not need to operate 3 or more powered seating actuators through the drive 
control, a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an 
augmentative speech device or computer through the chair's drive control), or an attendant control. The 
enrollee's upper extremity strength and function indicate that he has sufficient ability to control the power 
wheelchair components through their own individual switches. The waterfall arm pads are a convenience item 
and not medically necessary per Social Security Act, Section 1862 (a)1(A) and the 42 CFR ?411.15(k), for the 
diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. 
 
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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve power wheelchair accessories (expandable controller, harness, electronic connection, 
waterfall arm pads) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested home ventilator is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the home 
ventilator. 
 
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 a home ventilator. Our reviewer says 
that the enrollee does not meet criteria for the home ventilator. Our physician reviewer found this enrollee has 
chronic hypercapnic respiratory failure related to OHS.  This is not a Medicare covered diagnosis for a home 
ventilator.  The appropriate treatment is BiPAP during sleep.  Certain BiPAP devices can provide the AVAPS-
AE mode of ventilation that has been ordered, and Medicare does not cover a ventilator when used as BiPAP.  
A home ventilator is not medically  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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
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 criteria are met and LTACH 
would be a better choice. The Plan denied your request. The Plan says there is no difference in the services 
offered by an LTACH versus staying in the current facility. 
 
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 patient is currently undergoing treatment at an ACH for CoViD-19.  The enrollee 
is not intubated/ventilated.  There is no evidence that the enrollee requires services that are not currently 
available.  As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in 
transferring the enrollee to the LTACH.  The enrollee can remain at the current ACH until such time no acute 
services are required. 
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on 
June 24, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for nursing facility care. You say that the services rendered were medically 
necessary. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent 
services rendered by an out-of-network provider. 
 
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 subsequent nursing facility care (99309) 
provided on June 24, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the stress test (93351) provided on October 1, 2019. 
 
You asked the Plan to pay for the stress test. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services were not pre-authorized or emergent. There were network 
providers available. 
 
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 service 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 stress test (93351) provided on October 1, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by the Ambulance 
Service on May 31, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that this was an emergency and could have been 
fatal or cause immediate chaos. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 31, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided by the 
Ambulance Service on May 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99358) May 13, 2020 to May 16, 2020. 
 
You asked the Plan to pay for physician services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says documentation does not support the services billed. 
 
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 99358 is not supported in the medical record. Specifically, records were not provided 
for all dates of service. Based on this information, we decided that Medicare rules for coverage of physician 
services have not been met. Therefore, we decided that the Plan does not have to pay for physician services 
(99358) May 13, 2020 to May 16, 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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the 
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical repair of a fractured 
hip. She was transferred to a skilled nursing facility and requested admission to an IRF from that facility. 
Medical problems are stable. There are no identified problems that need inpatient medical management. There 
are no complex nursing or rehabilitation needs. 
  
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. The medical record supports a need for physical and 
occupational therapy but it does not support a need for an intensive rehabilitation therapy program. There is not 
a reasonable expectation that this enrollee 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve the concentrator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee currently has a standard oxygen delivery system which is an oxygen 
concentrator and a home fill compressor system for his in-home needs and portable oxygen cylinders 
 
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet 
the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would 
benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify 
for oxygen solely based on blood gas studies obtained during sleep.   
 
To qualify for home oxygen, the patient must meet one of the following blood gas levels: 
 
 
 
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 
 
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during 
sleep for a patient who have hypoxia symptoms during sleep;  
 
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for 
patients who have hypoxia symptoms during exercise; 
 
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of 
dependent edema, pulmonary hypertension, or erythrocythemia. 
 
For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, 
there is a rebuttable presumption of non-coverage. 
 
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 concentrator. Our reviewer says that 
the requested concentrator is not medically reasonable or necessary. Our physician reviewer found you have a 
portable oxygen system consisting of refillable portable tanks. You are requesting POC for air travel. Medicare 
does not cover duplicate systems, and does not cover additional portable oxygen systems for travel outside the 
home. That is considered to be a convenience and therefore not medically necessary. There is no indication in 
the medical records that the tanks do not meet his need for mobility within the home. 
 
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 concentrator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a portable oxygen concentrator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient admission for hip surgery. 
 
You asked the Plan to pre-approve inpatient admission for hip surgery. You say that the services are necessary. 
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve inpatient admission for hip surgery. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the request for inpatient medical services is not medically necessary. The 
enrollee does not appear to have significant uncontrolled chronic conditions that pre-operatively would warrant 
an in-patient level of care. If the enrollee undergoes the procedure and intra- or post-operatively requires care 
that meets an inpatient level of services, then the Plan would approve inpatient care as an observation 
conversion. The review indicates that the items/services at issue in this case are not medically reasonable or 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient admission for hip surgery have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient admission for hip surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an all-white glass crown for tooth #7 for the enrollee. 
 
You asked the Plan to pre-approve the crown. You say that this is medically necessary. The Plan denied your 
request. The Plan says the x-rays do not show that this is medically necessary. 
 
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. The Plan covers the crown 
when the services are medically necessary and reasonable.  
 
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 crown. Our reviewer says that the 
requested crown is not medically reasonable or necessary. Our physician reviewer found the tooth had recent 
endodontic treatment and requires restoration. The pre-treatment x-ray appears to show no significant 
breakdown of the tooth prior to the root canal therapy. The post-treatment radiograph copy is of poor quality 
but it does not appear that the access for the root canal therapy would have caused any significant additional 
loss of structure. It is generally held in the profession that anterior teeth that have minimal restoration and 
endodontic treatment do not require crown restorations for strength. Posts are only needed where there is 
insufficient tooth structure available to retain a crown without the additional support, which does not appear to 
be the case here. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an all-white glass crown for tooth #7 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tumor treatment field therapy. 
 
You asked the Plan to pre-approve the requested services. You say that there is reasonable assurance that the 
benefits of the Optune device outweigh its risks. The Plan denied your request. The Plan says the enrollee has 
not use the Optune device since April 2020. 
 
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 records provided do not include a re-evaluation within the 
required time frame to show that there is evidence of adherence to therapy. Based on this information, we 
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have 
to pre-approve tumor treatment field therapy.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trelegy for the enrollee. 
 
You asked the Plan to pre-approve Trelegy. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says this drug is not covered under 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 Trelegy for the enrollee.  
 
Benefits for Trelegy 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for radiology services and an outpatient 
surgery provided by a non-participating provider on May 6, 2019, to May 7, 2019. 
 
You asked the Plan to waive the coinsurance for radiology services and an outpatient surgery. You say that you 
were told that this provider was in-network. 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 50% 
coinsurance for outpatient diagnostic tests/out-of-network/radiological services and outpatient surgery/out-of-
network.  
 
You have been asked to pay a 50% coinsurance of the allowed amount for radiology services and an outpatient 
surgery. The total allowed amount is $10,480.63. The total amount you are being asked to pay is $5,240.31 
($10,480.63 x 50% = $5,240.31). Radiology services falls within the outpatient diagnostic tests/out-of-
network/radiological services benefit category and an outpatient surgery falls within the outpatient surgery/out-
of-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 radiology services and an 
outpatient surgery provided by a non-participating provider on May 6, 2019, to May 7, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 19, 2020. 
 
You asked the Plan to pay for the laboratory 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 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, the claim was billed with an incorrect place of service 
(POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. 
Based on this information, we decided that Medicare rules for coverage of the laboratory services have not 
been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on May 
19, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a skilled nursing stay provided by a 
participating provider on February 1, 2020, to February 14, 2020. 
 
You asked the Plan to waive the copayment for a skilled nursing stay. You say that you do not understand these 
charges. 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 $0 
copayment each day for days 1-20. There is a $160 copayment for days 21-51 for skilled nursing facility (SNF) 
care/in-network.  
 
You have been asked to pay a $0 copayment each day for days 1-20. There is a $160 copayment for days 21-34 
for a skilled nursing stay. The total amount you are being asked to pay is $2,080 ($160 x 13 days = $2,080). 
These dates of services were a continuation of a skilled nursing stay. A skilled nursing stay falls within the 
skilled nursing facility (SNF) care/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 copayment 
for a skilled nursing stay provided by a participating provider on February 1, 2020, to February 14, 2020.