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

 
We decided that the Plan does not have to pay for the seat lift chair and mechanism received on May 10, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed are met. The rules say that Medicare will pay for durable medical equipment that is mainly used to serve 
a medical purpose. 
 
 
 
 
 
 
 
 
 
 
 
We looked at the file and Medicare rules. The services at issue are a recliner with seat lift mechanism. The 
recliner chair is not covered, as the item does not serve a purpose that is primarily medical in nature. The 
documentation in the file does not support that the criteria for coverage of the seat lift mechanism are met. 
Therefore, we decided that the Plan does not have to pay for the seat lift chair and mechanism received on May 
10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism. 
 
You asked the Plan to pre-approve the mechanism. You say that this is medically necessary, because you have 
had two joints replaced. The Plan denied your request. The Plan says there is no documentation of a current 
diagnosis of severe arthritis or severe neuromuscular disease. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed above are met. 
 
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 mechanism. Our reviewer says that 
the requested mechanism is not medically reasonable or necessary. Our physician reviewer found the 
documentation does not reveal objective evidence of severe arthritis of the hip. The documentation does not 
reveal neuromuscular disease. The documentation does not support that a seat lift is likely to effect 
improvement in your condition or arrest or retard deterioration in your condition. The records do not indicate 
that you are completely incapable of standing from a chair in the home on a physical exam. The records do 
indicate that you can ambulate. 
 
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 mechanism have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a seat lift mechanism.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Duplixent. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
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 Duplixent.  
 
Benefits for these services 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered by the out of network 
(OON) provider on February 3, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
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 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 laboratory services rendered by the out of network (OON) provider on February 3, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hernia repair procedure provided on July 5, 2019. 
 
You asked the Plan to pay for the hernia repair procedure (49568-59). You say that the Plan should pay this 
claim. The Plan denied your request. The Plan says an add-on code is eligible for payment only if it is reported 
with an appropriate primary procedure performed by the same practitioner. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural 
service. Specifically, the claim cannot be paid as billed as it is missing a procedural code accepted with 49568. 
Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier 
have not been met. Therefore, we decided that the Plan does not have to pay for the hernia repair procedure 
provided on July 5, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
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 services can be safely received in other settings, for example: a skilled nursing 
facility, home with home health and home physical therapy, or home with outpatient therapy. 
 
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 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 not require an intensive rehab program. Care at the skilled nursing facility level appears to be more 
appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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) for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on March 10, 2020. 
 
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says that 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 psychotherapy services provided on March 10, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for outpatient services provided on February 1, 2020 through March 9, 
2020. 
 
You asked the Plan to pay for the outpatient services. You say that you would like reconsideration because you 
have submitted all of the necessary information. The Plan denied your request. The Plan says that the receipts 
sent are not itemized or properly coded. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient services have been met. Specifically, the record includes sufficient information to 
determine whether payment is due and the amount of payment. Therefore, we decided that the Plan has to pay 
for outpatient services provided on February 1, 2020 through March 9, 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: 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 services are medically necessary. The Plan 
denied your request. The Plan says the services are 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 medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital on September 23, 2020 for decompressive surgery and discectomy. On September 27, 2020 her back 
pain was controlled and she was ambulating 600 feet with modified independence with a two wheeled walker. 
The documentation does not support that the complexity of the enrollee's nursing, medical and rehabilitation 
needs require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee is medically stable and the documentation does not support that he has complex medical issues that 
require acute rehab nursing care, or monitoring by an inpatient PMR physician three times per week. While the 
enrollee is reasonably expected to benefit from continued PT and OT, the documentation does not support that 
there is need for an intensive therapy program. 
 
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: 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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
thoracic wedge fracture and right ischium fracture after a fall. You were discharged home with home health 
and therapy services on September 2020. You remain in the home now. Medical problems are stable. There are 
no acute inpatient medical needs. There are no complex nursing or rehabilitation needs. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and 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 you 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 Plan does not have to pre-approve CardioMEMS device (CPT Code C2624 and CPT Code 
33289). 
 
You asked the Plan to pre-approve the device. You say that the device is necessary. The Plan denied your 
request. The Plan says the device is not necessary. 
 
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 device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this circumstance therapy change based on data obtained from a CardioMEMs device has 
been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy.  
Moreover, concerns have been raised about potential bias in this trial calling into question the results. 
Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and 
not recommended in current guidelines for the treatment of heart failure.  Medicare coverage criteria are not 
met, in my opinion, since the device should still be considered experimental or investigational. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve CardioMEMS device (CPT Code C2624 and CPT Code 33289).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on April 6, 2020 by an out-of-
network provider. 
 
You asked the Plan to pay for the medical services. You say that you were not aware the facility was not 
contracted. The Plan denied your request. The Plan says you do not have out-of-network benefits. 
 
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 medical services provided on April 6, 2020 by 
an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement services provided on May 29, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the debridement services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
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 debridement services provided on May 29, 
2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve alveoloplasty in conjunction with extractions - four or 
more teeth or tooth spaces, per quadrant (D7310 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that you are requesting review of denial of 
services. The Plan denied your request. The Plan says the services are not a covered benefit under the plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Medicare guidance says alveoloplasty is a dental services exclusion of Medicare. 
Therefore, we decided that the Plan does not have to pre-approve alveoloplasty in conjunction with extractions 
- four or more teeth or tooth spaces, per quadrant (D7310 x 2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve housekeeping services. 
 
You asked the Plan to pre-approve the housekeeping services. You say that even pushing a vacuum is hard for 
you due to your medical state. The Plan denied your request. The Plan says this service is not covered by 
Medicare or the Plan. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the housekeeping services have not been met. The health plan contract says services not covered 
by Medicare under any condition: Homemaker services include basic household assistance, including light 
housekeeping or light meal preparation. Therefore, we decided that the Plan does not have to pre-approve 
housekeeping services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walker. 
 
You asked the Plan to pre-approve the walker. You say that this is medically necessary. The Plan denied your 
request. The Plan says a physician order or supporting medical information was not provided. 
 
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 walker. Our reviewer says that the 
requested walker is not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no objective evidence from the treating physician that you have a mobility deficit that impairs 
participation in MRADLs. The documentation does not reveal an objective treating medical practitioner gait 
evaluation indicating that you can safely use the requested walker or that the deficit can be sufficiently resolved 
with a walker. 
 
 
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 walker have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a walker.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services provided from July 13, 2018 to July 16, 
2018. 
 
You asked the Plan to pay for hospital services. You say that you were not able to submit this claim timely. The 
Plan denied your request. The Plan says claims must be submitted within a year of the services. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for hospital services was not filed until March 9, 2020. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for hospital services provided from July 13, 2018 to July 16, 2018.