Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional ten speech therapy sessions for the enrollee.
You asked the Plan to pre-approve the sessions. You say that this is medically necessary. The Plan denied your request. The Plan says the documentation does not support that the unique and sophisticated skills of a speech therapist are required to continue to treat the enrollee.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 sessions. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition. The enrollee has had extensive therapy for this condition and the documentation submitted does not indicate she requires the unique skills of a professional therapist to safely and effectively provide treatment. The services do not need to safely and effectively be performed only by a therapist, or under the supervision of a therapist. The enrollee is compliant and versed in a home exercise program. The requested services are not part of a maintenance program and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration.
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 sessions have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional ten speech therapy sessions for the enrollee.
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 necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 were medically stable with debility from respiratory illness with no evidence of 
need for supervision by a physical, medicine and rehabilitation (PMR) Physician or needs acute rehab nursing 
care. You may benefit from further physical therapy (PT) and occupational therapy (OT) but do not require an 
intensive therapy program. IRF admission is not medically necessary based on your lack of medical 
complexity. You will not tolerate therapies 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: 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. The Plan denied your request. The Plan says is 
receiving appropriate acute care, and does not require transfer. 
 
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 physician 
reviewer found that you were admitted to the current acute care hospital with acute mental status changes and 
shortness of breath, diagnosed as pneumonia and COPD exacerbation. You were treated with antibiotics, 
breathing treatments, steroids, and BiPAP. Recently, you have improved some, but are still requiring higher 
oxygen supplementation, BiPAP at bedtime and as-needed, continuation of steroid taper, and physical therapy. 
Based on the recent documentation, you appear to require additional acute care services as your breathing 
continues to improve and therapy is initiated. However, this appears not likely to require more than 24 days. 
You do not appear to require services at the LTACH that are not already available at the current facility. 
Therefore, this request for LTACH services will be considered 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 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 pre-approve enteral nutrition formula and tube feeding supplies. 
 
You asked the Plan to pre-approve enteral nutrition formula and tube feeding supplies. You say that the 
services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 
coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that enteral nutrition is covered for a beneficiary who has 
(a) permanent non-function or disease of the structures that normally permit food to reach the small bowel or 
(b) disease of the small bowel which impairs digestion and absorption of an oral diet, either of which requires 
tube feedings to provide sufficient nutrients to maintain weight and strength commensurate with the 
beneficiary's overall health status. 
 
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 enteral nutrition formula and tube 
feeding supplies. Our reviewer says that the services are not medically necessary. Our physician reviewer 
found you had a feeding tube placed because of malnutrition and poor oral intake due to loss of appetite. There 
is a history of gastritis and reflux disease but there is no disease or non-function that interferes with the 
structures that that deliver nutrition to the small bowel and there is no malabsorptive condition. You do not 
meet the coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of enteral nutrition formula and tube feeding supplies have not been met. 
Therefore, we decided that the Plan does not have to pre-approve enteral nutrition formula and tube feeding 
supplies.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve excimer laser treatments for psoriasis.

You asked the Plan to pre-approve the excimer laser treatments. You say that this is necessary and should be
covered. The Plan denied your request. The Plan says that you do not meet criteria for this treatment.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically necessary.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the excimer laser treatments. Our
reviewer says that the requested services are considered medically reasonable and necessary in this case. Our
physician reviewer found skin excimer laser treatment of psoriatic lesions is a standard of care. This patient has
failed first-line treatments and the current body surface area involved is less than 10%.

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 excimer laser treatments have been met. Therefore, we decided that the Plan
has to pre-approve excimer laser treatments for psoriasis.

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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits to be provided by an
out of network provider.
You asked the Plan to pre-approve additional physical therapy visits. You say that the enrollee has been getting
approved for physical therapy with this provider. You say that continued physical therapy is a medically
necessary service. The Plan denied your request. The Plan says the therapy needed is available in- network.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
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. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
additional physical therapy visits by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MyoCycle Home FES bike (E1399).
You asked the Plan to pre-approve MyoCycle Home FES bike. You say that the physician has prescribed the
MyoCycle and has also provided a letter to support a determination of medical necessity. The Plan denied your
request. The Plan says the nature of the device is not primarily medical in nature and therefore not covered.
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 MyoCycle Home FES bike (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested physician's services.
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says that
the Plan will only cover services with non-contracted providers if the service is for an emergency and if it is
medically necessary to go out of network.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
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. We found no exception that would require the
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the
requested physician's services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Purewick External Urine Catheter system (E1399). 
 
You asked the Plan to pre-approve Purewick External Urine Catheter system. You say that you are on a fixed 
income and the supplies are expensive. You respectfully request reconsideration to cover the expense of night 
time coverage. The Plan denied your request. The Plan says this item is not covered under 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 Purewick External Urine Catheter system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Purewick External Urine Catheter system (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the over-bed table (E0274). 
 
You asked the Plan to pre-approve the over-bed table. You say that the enrollee needs his over bed table to eat. 
He is bed bound, unable to get up or walk and unable to move his left side. The Plan denied your request. The 
Plan says this item is a convenience item and is not covered under Medicare or the plan. 
 
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 the over-bed table (E0274).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wig, any type (A9282). 
 
You asked the Plan to pre-approve a wig. You say that your condition is very distressing emotionally and in 
order to appear somewhat yourself you have started to use a wig prosthesis. Please reconsider your appeal. The 
Plan denied your request. The Plan says this item is not a covered benefit under Medicare or the Plan. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pre-approve a wig, any type 
(A9282).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Monitoring feature/device, stand-alone or integrated, any
type, includes all accessories, components and electronics (A9279) provided April 9, 2020.
You asked the Plan to pay for the monitoring device. You say that you believe this should be paid and the
records should support the necessity of the service. The Plan denied your request. The Plan says this item is not
covered under 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 monitoring device have not been met. Therefore, we decided that the Plan does not have to pay
for Monitoring feature/device, stand-alone or integrated, any type, includes all accessories, components and
electronics (A9279) provided April 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower commode chair (E1399).
You asked the Plan to pre-approve a shower commode chair. You say that the enrollee needs this chair for
mobilization as it is the most adequate. The Plan denied your request. The Plan says this item is not a covered
benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are
not primarily medical in nature.
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this
item. Therefore, we decided that the Plan does not have to pre-approve a shower commode chair (E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two extractions to be provided by an oral surgeon.
You asked the Plan to pre-approve the extractions. You say that your teeth hurt, and you are in a lot of pain.
The Plan denied your request. The Plan says dental services performed by an oral surgeon are not covered. The
Plan also says that dental services are only covered when they are performed by a participating general dentist.
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.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
covered when they are received by anyone other than a participating general dentist. Therefore, we decided that
the Plan does not have to pre-approve two extractions to be provided by an oral surgeon.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the occupational therapy re-evaluation
and the self-care management training provided on February 13, 2020.
You asked the Plan to reduce the copayments for the occupational therapy re-evaluation and the self-care
management training. You say that you should only be responsible for one copayment and should not be
responsible for an additional amount. The Plan denied your request. The Plan says you have been charged the
correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35
copayment per Medicare-covered visit of physical therapy, occupational therapy, and speech language therapy
services.
You have been asked to pay a $35 copayment for the occupational therapy re-evaluation and a $35 copayment
for the self-care management training. The occupational therapy re-evaluation and the self-care management
training fall within the "Outpatient rehabilitation services" benefit category. The medical record shows you
received the two services on the same date of service.
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 reduce the copayments for the occupational therapy re-evaluation and the self-care
management training provided on February 13, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services and an emergency
room visit provided by participating providers on May 4, 2020 to May 12, 2020.
You asked the Plan to waive the copayment for ambulance services and an emergency room visit. You say that
you do not agree with these charges. The Plan denied your request. The Plan says the correct copayments 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 $250
copayment for ambulance services/network and a $90 copayment for emergency care.
You have been asked to pay a $250 copayment for ambulance services and a $90 copayment for an emergency
room visit. The total amount you are being asked to pay is $930 ($750 ambulance ($250 x 3 trips = $750) +
180 emergency room ($90 x 2 visits = $180) = $930). Ambulance services falls within the ambulance
services/network benefit category and an emergency room visit falls within the emergency care 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 ambulance services and an emergency room
visit provided by participating providers on May 4, 2020 to May 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered on November 6, 2019.
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 procedure codes 99153 and 36000 are 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 99153 is moderate sedation services by other qualified
health care professional not performing a procedure, each additional 15 minutes (List separately in addition to
code for primary service). The definition of code 36000 is introduction of needle or intracatheter, vein.
The rules say that payment for codes with a status indicator of B is always bundled into payment for other
services not specified.
We find that CPT codes 99153 and 36000 are not supported in the medical record. Specifically, code 99153 is
an add-on code that was not billed with a primary procedure code. Code 36000 has a status indicator of B and
is not separately payable. Based on this information, we decided that Medicare rules for coverage of these
services have not been met. Therefore, we decided that the Plan does not have to pay for the services rendered
on November 6, 2019.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from September 4, 2019 to 
November 1, 2019. 
 
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 claims were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that home health claims must be billed with a valid HIPPS 
code. 
 
We looked at the file and Medicare rules. The file shows that the claims were not billed with the required 
HIPPS code. Based on this information, we decided that Medicare rules for coverage of these services have not 
been met. Therefore, we decided that the Plan does not have to pay for the home health services rendered from 
September 4, 2019 to November 1, 2019.