Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee is not receiving skilled physical therapy or skilled 
occupational therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for continued SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve SNF admission. You say that SNF admission is medically necessary. The 
Plan denied your request. The Plan says Medicare coverage criteria are not met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the 
case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to 
pre-approve SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician 
reviewer found based on the documentation provided, you do not have documented skilled nursing needs or 
skilled therapy needs. You are walking more than 100 feet. Daily skilled services are not required to establish a 
maintenance program or to prevent deterioration of your condition.  Medicare coverage criteria are not met.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) admission.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
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 the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the drug is being requested for the treatment of age related osteoporosis without current 
pathological fracture. The documentation does not support a history if an osteoporotic fracture or previous 
treatment, contraindication, or intolerance to zoledronic acid. Therefore, the enrollee does not meet criteria for 
the requested drug. 
 
 
 
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.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that SNF admission is medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria are not met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found based on the documentation provided, 
the enrollee does not have documented skilled nursing needs or skilled therapy needs. The enrollee is non-
ambulatory and unable to focus on daily activities. Daily skilled services are not required to establish a 
maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this 
point are custodial, which is not covered by Medicare. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee does not 
require close medical supervision, or have needs that can only be met at an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found 
that you are at a maximal assist level for bed rolling, sitting up, and lying down. You are at moderate assist for 
standing up, and moderate to maximal assist for propelling in a wheelchair. You do not require the intensity of 
services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative 
services and regular physician evaluation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a Group 3 power wheelchair upgraded electronics. 
 
You asked the Plan to provide the power wheelchair Electronic connection (E2311), Expandable controller 
harness (E2313), and Expandable controller (E2377). You say that the enrollee needs a Group 3 power 
wheelchair, accessories, and upgraded electronics. The Plan denied your request. The Plan says the upgraded 
electronics are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that options and accessories for wheelchairs are covered if 
the beneficiary has a wheelchair that meets Medicare coverage criteria and the option/accessory itself is 
medically necessary.  
 
The file shows that the enrollee has normal range of motion and 4/5 strength in the right upper limb. Upper 
limb strength and range of motion are adequate for the enrollee to be able to control the power options using 
their own switches which are included in the allowance of these power options. This means that Medicare rules 
for the upgraded electronics have not been met. Therefore, we decided that the Plan does not have to provide a 
Group 3 power wheelchair and upgraded electronics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Group 3 power wheelchair with single power option and attachments.You asked the Plan to pre-approvethese services. You say that this is medically necessary.The Plan denied your request. The Plan says that you do not have need for both power tilt or power recline, the request for K0856 Group 3 power wheelchair with single power option is not reasonable and 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 these services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. The documentation does reveal that you have a personal mobility deficit that impairs participation in MRADLs in the home. The documentation reveals you are not safe with a walker and due to his tremor, loss of dexterity and weakness he is unable to use a manual wheelchair. The requested Group 3 power wheelchair with single power option is not reasonable and necessary as you do not have a medical need for a special drive control (including, but not limited to, head control, sip and puff, switch control) or for single power option: power tilt or power recline. The Braden score of 20 indicates you are not at risk for development of pressure ulcer. You do not 
utilize intermittent catheterization for bladder management and does not have increasedtone or spasticity. Our physician reviewer found that your condition does not meet Medicare criteria for these 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea Group 3 power wheelchair with single power option and attachments.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital services you received 
from January 13, 2020, to January 18, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that your insurance 
should pay this in full. The Plan denied your request. The Plan says you were charged this copayment 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 $275 
copayment per day for days 1-7 for inpatient hospital care.  
 
Records show that you were in the hospital for five days.  You were charged a $275 copayment per day, for a 
total of $1375. 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 inpatient hospital services you received 
from January 13, 2020, to January 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for urgently needed services provided on 
March 9, 2020. 
 
You asked the Plan to waive the coinsurance for urgently needed services. You say that you disagree with the 
charges because this was COVID-19 related. The Plan denied your request. The Plan says the claims were 
processed correctly and you are being charged the correct 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 20% 
coinsurance for urgently needed services.  
 
You received urgently needed services on March 9, 2020. The allowed amount is $110 and 20% of that is $22.  
 
You have been asked to pay the total coinsurance amount of $22 for urgently needed services. Urgently needed 
services fall within the urgently needed services benefit category. This means that you have been asked to pay 
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
coinsurance for urgently needed services provided on March 9, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient mental health care provided on 
February 11, 2020, and February 24, 2020. 
 
You asked the Plan to waive the copayment for outpatient mental health care. You say that when you were sold 
the health plan you were not informed you would owe charges. The Plan denied your request. The Plan says the 
claims were processed correctly and you are being charged the correct 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 $30 
copayment for outpatient mental health care.  
 
You received outpatient mental health care on February 11, 2020, and February 24, 2020. Therefore, you are 
responsible to pay a $30 copayment per each visit. The total amount you owe is: $60.  
 
You have been asked to pay the total copayment amount of $60 for outpatient mental health care. Outpatient 
mental health care falls within the outpatient mental health 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 outpatient mental health care provided on February 11, 2020, and February 24, 
2020.  
 
We note your complaint that you were given false information when you signed up with the Plan. Your 
complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a treadmill. 
 
You asked the Plan to pre-approve the treadmill. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a treadmill.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a radiofrequency ablation procedure (64635,64636). 
 
You asked the Plan to pre-approve the ablation procedure. You say that the procedure is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that RF ablation is covered when 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 ablation procedure. Our reviewer 
says that the ablation procedure is not medically necessary. Our physician reviewer found the record does not 
show that the enrollee had previous nerve blocks that provided a minimum of 80% pain relief. 
 
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 ablation procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a radiofrequency ablation procedure (64635,64636).
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a mandibular partial denture (D5214). 
 
You asked the Plan to pre-approve the mandibular partial denture. You say that the dentist recommended a 
partial because your lower left jaw has teeth missing. The Plan denied your request. The Plan says that the 
records do not show that you have severely impaired masticatory function. 
 
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 
mandibular partial denture 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 mandibular partial denture. Our 
reviewer says that the criteria for coverage for a mandibular removable partial denture (D5214) have been met. 
Our physician reviewer found the enrollee is missing tooth #'s 17, 18, and 19. As a result of these missing teeth, 
tooth #'s 14 and 15 have no occlusal contacts and would extrude. Our reviewer found that placement of a 
partial denture replacing these missing teeth would give the enrollee bilateral occlusion and prevent the 
extrusion of tooth #'s 14 and 15. 
 
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 mandibular partial denture have been met. Therefore, we decided that the 
Plan has to pre-approve a mandibular partial denture (D5214).  
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy duty transport chair (E1039).

You asked the Plan to pre-approve the transport chair. You say that you would like reconsideration because this transfer chair is medically necessary. The Plan denied your request. The Plan says the record does not show that your weight is over 300lbs.

The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the transport chair have not been met. Specifically, the chair you are requesting requires that your weight is over 300lbs. The records show that you do not weigh over 300lbs. Therefore, we decided that the Plan does not have to pre-approve a heavy duty transport chair (E1039).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ketamine infusion. 
 
You asked the Plan to pre-approve Ketamine infusion. 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 Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We looked at the file and Medicare rules. Review of the file shows that this drug is covered when found to be 
medically necessary. The file does not include medical records to support medical necessity of this drug. Based 
on this information, we decided that Medicare rules for coverage of Ketamine infusion have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Ketamine infusion.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hymovis injections. 
 
You asked the Plan to pre-approve Hymovis injections. You say that Hymovis injections are medically 
necessary for this enrollee's medical condition. The Plan denied your request. The Plan says the record does not 
support the medical necessity for Hymovis injections. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Hymovis injections. Our reviewer says 
that Hymovis injections are not medically reasonable and necessary for the patient. Our physician reviewer 
found it is not clear that osteoarthritis is the predominant etiology of the member's knee pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hymovis injections have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Hymovis injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the oxygen concentrator provided on January 20, 
2020. 
 
You asked the Plan to reimburse you for the oxygen concentrator. You say that because of the altitude and 
medical issues the oxygen concentrator was medically necessary. The Plan denied your request. The Plan says 
there are no notes regarding your blood gasses. 
 
The Plan must follow Medicare rules. The rules say that for patients with arterial PO2 at or above 60 mm Hg or 
arterial O2 saturation at or above 90%, there is a rebuttable presumption of non-coverage for home oxygen.   
 
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 reimburse you for the oxygen concentrator. Our 
reviewer says that the oxygen concentrator was not medically necessary. Our physician reviewer found 
coverage criteria for the oxygen concentrator are not met. There is no documentation of hypoxemia (i.e., pulse 
oximetry or arterial blood gas) prior to the rental of the concentrator, and no evidence of a medical evaluation 
or physician order for the device. Documentation of hypoxemia is required in order for Medicare to cover 
oxygen supplementation. Therefore the oxygen concentrator rental in January is considered not 
medically necessary, and the denial is upheld. 
 
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 oxygen concentrator have not been met. Therefore, we decided that the Plan 
does not have to reimburse you for the oxygen concentrator provided on January 20, 2020.