Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home personal care services. 
 
You asked the Plan to pre-approve home personal care services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested 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 home personal care services. Our 
reviewer says that the documentation does not support that the requested services are medically reasonable or 
necessary. Our physician reviewer found the documentation does not support 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. There are no 
complex wounds, new enteral feedings or other skilled nursing need. As you do not require skilled therapy or 
skilled nursing services, you do not meet the definition of home health aide services. Therefore, you do not 
meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home personal care services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve home personal care services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377), expandable controller 
harness (E2313) and electronic connection (E2311) for the enrollee. 
 
You asked the Plan to pre-approve these items. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the enrollee's upper limb strength and function are therefore adequate for the 
member to be able to control the power options using their own switches which are included in the allowance 
of these power options. 
 
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 these items. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. The 
documentation does not reveal that the patient requires other types of proportional input devices or non-
proportional input devices. The patient does not need to operate 3 or more powered seating actuators through 
the drive control, a separate display, other electronic devices, or an attendant control. The patient's upper 
extremity strength and function are sufficient for the patient to control any power options through their own 
individual switches. Our physician reviewer found that the enrollee's condition does not meet criteria for 
coverage of these items. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
 
 
Medicare rules for coverage of these items have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an expandable controller (E2377), expandable controller harness (E2313) and electronic 
connection (E2311) for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the two ultrasounds you had on June 18, 
2020. 
 
You asked the Plan to waive the copayments for the two ultrasounds. You say that you believe this was billed 
incorrectly. The Plan denied your request. The Plan says you were charged these copayments 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 $110 
copayment for each radiological diagnostic service.  
 
You have been asked to pay a $110 copayment for each of the two ultrasounds. The two ultrasounds fall within 
the radiological diagnostic service 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 
the two ultrasounds you had on June 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0648) provided to the enrollee on 
December 24, 2019. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says there is insufficient detail to support the billed charges. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order and proof of delivery for the supplies provided in this case. 
The proof of delivery and itemized delivery ticket cannot be verified to go with the invoice as there are 
multiple billed codes given. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral 
orthosis (L0648) provided to the enrollee on December 24, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient rehabilitation facility (IRF) admission and 
services provided to the enrollee from December 12, 2019 to December 20, 2019. 
 
You asked the Plan to pay for the IRF care. You say that these services were medically necessary. The Plan 
denied your request. The Plan says that the enrollee did not require an intensive regiment of physical therapy 
and occupational therapy in the acute inpatient rehab 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 pay for the IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
complexity of the patient's nursing, medical and rehabilitation needs did not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for confusion after a 
recent fall with elbow and tibial fractures. The enrollee's medical problems were stable. There are no identified 
problems that needed inpatient medical management. There were no complex nursing or rehabilitation needs. 
 
 
The patient did not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. The medical record supported a need for physical and 
occupational therapy but it did not support a need for an intensive rehabilitation therapy program. There is not a 
reasonable expectation that this patient would have been 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 did 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 the IRF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient rehabilitation facility (IRF) admission and services provided to the enrollee 
from December 12, 2019 to December 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive audiometry threshold evaluation & speech 
recognition; tympanometry provided on February 26, 2020. 
 
You asked the Plan to pay for the comprehensive audiometry threshold evaluation & speech recognition; 
tympanometry. The Plan denied your request. The Plan says the Plan requires utilization of network providers 
when possible and available, and requires authorization for certain services. No medical necessity for an out-of-
network provider, such as an urgent or emergency situation, has been documented.   
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a comprehensive audiometry threshold evaluation & speech 
recognition; tympanometry provided on February 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the nebulizer and administration set 
(A7005, E0570) provided November 26, 2019, to December 26, 2019. 
 
You asked the Plan to waive the coinsurance for the nebulizer and administration set. You say that you were 
never informed about potential coinsurances with the equipment you were renting. The Plan denied your 
request. The Plan says the coinsurance applied correctly in this case. 
 
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 and related supplies.  
 
You have been asked to pay a 20% coinsurance for the nebulizer and administration set. The services provided 
falls within the durable medical equipment and related supplies benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the coinsurance for the nebulizer and administration set (A7005, E0570) provided November 26, 
2019, to December 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe continuous positive airway pressure (C-PAP) device you rented from December 9, 2019, to July 9, 2020.You asked the Plan to waive the coinsurance forthe C-PAP device. You say that this provider keeps sending you the wrong items.The Plan denied your request. The Plan says you were charged this coinsurance correctly.  The Plan says that the provider is more than happy to accept returns of items not you did not order, but they have delivery proof that you have received this C-PAP machine.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 20% coinsurance for durable medical equipment. You have been asked to pay 20% coinsurance for the C-PAP device. the C-PAP device falls within the durable medical equipment 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 forthe continuous positive airway pressure (C-PAP) device you rented from December 9, 2019, to July 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dynamic knee splint. 
 
You asked the Plan to pre-approve the dynamic splint. You say that this device would be helpful to improve 
range of motion. The Plan denied your request. The Plan says coverage is allowed for mechanical stretching 
devices when you have significant stiffness (contracture) of a joint within the first 4 months following surgery. 
There must be failed improvement in the range of motion despite participating in therapy as ordered during the 
recovery period. The records provided indicate that you are not using the JAS dynamic splint in combination 
with therapy. It is not covered as a single, stand alone treatment. 
 
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 dynamic splint. Our reviewer says 
that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is insufficient evidence of that this method of splinting is safe for this patient to use 
without the supervision of a skilled therapist or that this device is more effective or as effective and safe as 
traditional supervised skilled physical therapy which is the standard of care. Additionally, the literature does 
not provide a proven standard protocol of use of this device. 
 
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 dynamic splint have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a dynamic knee splint.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound debridement provided on February 
18, 2020 and the lower extremity study on March 5, 2020. 
 
You asked the Plan to waive the copayment for the wound debridement and lower extremity study. You say 
that you are being charged for procedures that weren't performed. You say that it's against the contract to be 
charged for the remaining amount after insurance has paid. The Plan denied your request. The Plan says the 
copayments applied 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 $325 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges. Your contract with the 
Plan clearly says that you must pay a $160 copayment for each Medicare-covered radiological diagnostic 
service, not including x-rays. 
 
You have been asked to pay a total of $318.43 for the wound debridement and lower extremity study.  
 
Date of Service Service Allowed Amount Standard Copayment Member Liability 
February 18, 2020 Wound 
Debridement 
$160.81 $325 $158.43 
March 5, 2020 Lower Extremity 
Study 
$214.47 $160 $160 
TOTAL:    $318.43 
 
The wound debridement falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital 
Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The lower extremity study falls 
within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for wound debridement provided on February 18, 2020 and the lower 
extremity study on March 5, 2020.  
 
Your complaint about threatened and harassed is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary visit (99335) provided on May 13, 2020 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for domiciliary visit. You say that you provided medically necessary services in 
good faith. 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 domiciliary visit (99335) provided on May 13, 
2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device. 
 
 
 
You asked the Plan to pay for a pneumatic compression device. You say that the enrollee requires the device. 
The Plan denied your request. The Plan says the documentation failed to prove that sufficient evidence of four-
week trial of conservative therapy. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0651 is covered for the treatment of 
lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. A four-week 
trial of conservative therapy demonstrating failed response to treatment is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular home usage of conservative therapy including compression garments, exercise and 
elevation. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound study of arteries of both legs 
(93924) provided on June 25, 2020. 
 
You asked the Plan to waive the copayment for the ultrasound study of arteries of both legs. You say that you 
feel that the copayment being charged is excessive. The Plan denied your request. The Plan says the copayment 
applied correctly in this case. 
 
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 $150 
copayment for radiological diagnostic services, not including X-rays.  
 
You have been asked to pay a $150 copayment for the ultrasound study of arteries of both legs. the ultrasound 
study of arteries of both legs falls within the radiological diagnostic services, not including X-rays 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 ultrasound study of arteries of both legs 
(93924) provided on June 25, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that Prolia is medically necessary. The Plan denied your 
request. The Plan says a trial of Zoledronic acid is required before alternative medications can be considered. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia. Our reviewer says that Prolia is 
not medically necessary. Our physician reviewer found the record does not show a trial of the plan preferred 
drug or any reason why the plan preferred drug would be unsafe or ineffective for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
 
 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayments for behavioral health services you received from July 3, 
2020, and July 24, 2020. 
 
You asked the Plan to waive the copayments for the behavioral health services. You say that these copayments 
should be waived under your Plan's COVID-19 waiver program. The Plan denied your request. The Plan says 
that the copayment waiver doesn't apply here because the claims were billed with diagnosis and service codes 
that apply to non-behavioral health benefits. 
 
The Plan issued a copayment waiver effective May 1, 2020.  This waiver states that the Plan "is waiving 
Medicare Advantage member out-of-pocket costs for in-network primary care, outpatient behavioral health, 
and telehealth visits through the end of 2020."  In addition, on the Plan's website section that discusses this 
waiver program, it explicitly states that this waiver applies to the above-mentioned services "regardless of 
diagnosis."  That is why the Plan's argument here is not persuasive.  You received services that are categorized 
as health behavior assessments performed by a behavioral health provider type (a licensed clinical social 
worker.'  The Plan cannot add diagnosis restrictions to this waiver program when the Plan's own website 
explicitly states that the waiver applies regardless of diagnosis.  Therefore, we decided that the Plan has to 
waive the copayments for behavioral health services you received from July 3, 2020, and July 24, 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.