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

 
We decided that the Plan does not have to pre-approve a commode chair (E0163). 
 
You asked the Plan to pre-approve the commode. You say that the commode is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that commodes are covered when the beneficiary is 
confined to a single room or one level of the home environment and there is no toilet on that level.  
 
We looked at the file and Medicare rules. No records were provided to show the enrollee could not access 
standard toilet facilities. Based on this information, we decided that Medicare rules for coverage of the 
commode have not been met. Therefore, we decided that the Plan does not have to pre-approve a commode 
chair (E0163).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on January 15, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says with 
limited exceptions, while the enrollee is a member of our plan, the enrollee must use network providers to get 
medical care and services. The only exceptions are emergencies, urgently needed services when the network is 
not available, out-of-area dialysis services, and cases in which our plan authorizes use of out-of-network 
providers. 
 
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 
physician?s services. 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 physician's services provided on January 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oral surgery services (21210, 21085, 21079, 21248). 
 
You asked the Plan to pre-approve oral surgery services. You say that this should be considered a medical 
service. The Plan denied your request. The Plan says this is a non-covered dental service. 
 
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 
among those covered under this benefit. Medical records have not been submitted to support that the requested 
services are medical in nature rather than dental. Therefore, we decided that the Plan does not have to pre-
approve oral surgery services (21210, 21085, 21079, 21248).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical extractions to be provided by an oral surgeon. 
 
You asked the Plan to pre-approve the extractions. You say that all of your teeth are infected, and you are in 
excruciating pain. The Plan denied your request. The Plan says your contract with the Plan only provides 
coverage for dental services when they are performed by a participating general dentist. The Plan also says that 
dental services performed by an oral surgeon are not covered. 
 
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 provided by anyone other than a participating general dentist. Therefore, we decided 
that the Plan does not have to pre-approve surgical extractions to be provided by an oral surgeon.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray services with CPT code 71045 provided on June 6, 
2020. 
 
You asked the Plan to pay for CPT code 71045. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that  for Medicare to consider coverage and payment 
for any item or service, the  information submitted by the supplier or provider must confirm that Medicare  
coverage criteria have been met. 
 
We looked at the file and Medicare rules. In this case, there were no medical records provided confirming that 
two separate x-rays were provided on June 6, 2020. The file shows that the Plan paid for one x-ray (71045) 
provided on June 6, 2020. Therefore, we decided that the Plan does not have to pay for the x-ray services with 
CPT code 71045 provided on June 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC). 
 
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 the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a Group 3 PWC is covered when specific criteria 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of right 
cerebrovascular accident, right hemiplegia, and mobility limitations. The records do not indicate that she is at 
high risk for development of a pressure ulcer, utilizes intermittent catheterization for bladder management or 
requires a power seating system to manage increased tone or spasticity. She does not meet the criteria for 
coverage of the requested Group 3 PWC and the services are not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Group 3 power wheelchair (PWC).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services rendered from August 5, 2020 to 
September 2, 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 the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. The provider submitted 
claims for procedure codes 97035 (ultrasound therapy). These services are not covered when performed by a 
chiropractor. Therefore, we decided that the Plan does not have to pay for the chiropractic services rendered 
from August 5, 2020 to September 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need therapy. 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 submitted records show that 
you were admitted to the hospital on December 9, 2020 after a fall with hip and elbow fractures. You 
underwent hip surgery on December 11, 2020. You need maximum assistance with lower body dressing and 
toilet transfers. You are able to sit up and stand up with assistance. You do not require the intensity of services 
in an IRF. You are not shown to be able to perform 15 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy services with CPT codes 99601, 
S9363 and S9810 provided on July 16, 2020. 
 
You asked the Plan to pay for CPT codes 99601, S9363 and S9810. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, CPT codes 99601, S9363 and S9810 have a status code 
of "I" under the Medicare Physicians Fee Schedule Database (MPFSDB) and are not valid for Medicare 
purposes. Medicare uses other codes for reporting of, and payment for, these services. Therefore, we decided 
that the Plan does not have to pay for the home infusion therapy services with CPT codes 99601, S9363 and 
S9810 provided on July 16, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transportation services provided on June 8, 
2020. 
 
You asked the Plan to pay for the ambulance services. You say that no authorization could be obtained. The 
Plan denied your request. The Plan says prior authorization is required for non-emergency transport. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that prior authorization is required for non-emergency transportation. 
 
We looked at the file and the rules. The Plan did not pre-approve the ambulance 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 ambulance transportation services provided on June 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be 
provided at a lower level of care. 
 
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. The 
enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to 
require, or to be able to tolerate, fifteen hours per week of rehabilitative services with regular physician 
evaluation. The enrollees care needs can be met at a lower level of care. Our physician reviewer found that the 
enrollee's condition does 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 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 for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Computed Tomography (CT) of the 
abdomen (74170) provided July 8, 2020. 
 
You asked the Plan to waive the copayment for the CT scan. You say that the copayment should be waived. 
The Plan denied your request. The Plan says the correct copayment was 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 $115 
copayment for diagnostic radiology.  
 
You have been asked to pay a $115 copayment for the CT scan. The CT scan falls within the diagnostic 
radiology 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 Computed Tomography 
(CT) of the abdomen (74170) provided July 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that all of the enrollee's medically necessary care, including 
physician and occupational therapies, can be provided at a lower level of acuity, such as a skilled nursing 
facility. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. The patient 
is improving but will require additional short term acute care services which can safely be administered at the 
current facility. The patient does not require services at the LTACH that are not already available at the current 
facility. Our physician reviewer found that the enrollee's condition does 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 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for glaucoma diagnostic testing provided to the enrollee on 
August 10, 2020. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says testing determined to be investigational is not covered. 
 
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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there are no established definitive indications for VEP, either for early detection or during follow-up of 
glaucoma. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for glaucoma diagnostic testing provided to the enrollee on August 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from LTACH 
care. The Plan denied your request. The Plan says there is no clinical benefit for LTACH care rather than 
continued care in a short-term facility. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is a female who was admitted to the current acute care hospital with 
small bowel obstruction receiving lysis of adhesions surgery. The course was complicated by worsening 
respiratory failure, aspiration of barium, bleeding around CVL site requiring high flow oxygen and antibiotics 
for pneumonia. She has since weaning off high flow oxygen and is improving overall. 
 
The patient is improving but will require additional short-term acute care services which can safely be 
administered at the current facility. The patient does not 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. Transfer to a lower level of care may be considered when treatment has completed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-covered chiropractic services provided from August 
4, 2020 to August 31, 2020. 
 
You asked the Plan to pay for the non-covered chiropractic services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered 
when provided by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the non-covered chiropractic services provided from August 4, 2020 to 
August 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction you received on September 2, 2020. 
 
You asked the Plan to pay for the refraction. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pay for are considered routine vision services or eyewear. Eye refractions 
are not covered by Medicare or your plan. Therefore, we decided that the Plan does not have to pay for the eye 
refraction you received on September 2, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 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 custodial care is not a covered benefit. 
 
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 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 skilled nursing facility (SNF) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy sessions to be provided by the out-of-
network provider. 
  
You asked the Plan to pre-approve the physical therapy sessions. The Plan denied your request. The Plan says 
that based on the information received from your healthcare provider it was determined that it is not medically 
necessary for you to go an out-of-network provider for physical therapy. A network gap does not exist. 
 
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 physical 
therapy sessions to be provided by the out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Queen or Full Orthopedic Bed and Frame 
 
You asked the Plan to pre-approve the orthopedic bed. You say that you require the bed for health conditions 
you are struggling with. The Plan denied your request. The Plan says while you may qualify for a hospital bed, 
at this time the plan has not received a request from a practitioner for a hospital bed. A non-hospital orthopedic 
bed is furniture and does not meet coverage criteria. 
 
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 requested 
is a non-hospital bed and 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 Queen or Full Orthopedic Bed and 
Frame