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

 
We decided that the Plan does not have to pre-approve additional power wheelchair accessories (Omni2 control 
module for R-Net, Unitrack Fixed Mount Kit). 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says these codes cannot be approved. 
 
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 accessories. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requests for K0108, Omni2 Control Module for R-Net, and K0108, Unitrack Fixed Mount 
Kit are not medically necessary as they were included already in the approved wheelchair and accessories and 
would exceed the enrollee's need. They cannot be unbundled from the approved power wheelchair and 
accessories. The K0108 Omni2 Control Module for R-Net is already included in the approved E2377 
Expandable Controller. The code description for E2373 includes fixed mounting hardware which was already 
approved. The separate request for K0108 Fixed Mounting Kit is 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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional power wheelchair accessories (Omni2 control module for R-Net, Unitrack Fixed 
Mount Kit).
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 you can safely receive continued services at the rehab facility you are 
at. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ER visit provided. 
 
You asked the Plan to waive the copayment for the ER visit. You say that the dentist couldn't stop the bleeding 
during the extraction, so you were taken to the ER. You say that you don't feel responsible for the ER 
copayment. The Plan denied your request. The Plan says the copayment applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $75 
copayment for Medicare-covered emergency room visits. 
 
You have been asked to pay a $75 copayment for the ER visit. The ER visit falls within the "Emergency care" 
benefit category. The records show that you were treated in the ER. 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 ER visit provided.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided on May 31, 2020 
through June 22, 2020. 
 
You asked the Plan to pay for SNF care. You say that the services were medically necessary. The Plan denied 
your request. The Plan says 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 looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SNF care have not been met. Specifically, the record shows that the enrollee passed away before 
the remaining dates of service at issue. Therefore, we decided that the Plan does not have to pay for skilled 
nursing facility (SNF) care provided on May 31, 2020 through June 22, 2020.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve an axial rotation unit. We decided that the Plan does not have to 
pre-approve a flex foot system.  
 
You asked the Plan to pre-approve an axial rotation unit. You say that these items are medically necessary. The 
Plan says that these items would exceed your needs. 
 
We decided that the Plan has to pre-approve an axial rotation unit.  
 
The Plan follows Medicare rules. Medicare rules say that an axial rotation unit (L5986) is covered for 
beneficiaries whose functional level is 2 or 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 an axial rotation unit. Our reviewer says 
that based on the medical records provided, there is documentation that your functional level is a level 2, 
supporting the need for an axial rotation unit. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an axial rotation unit have been met. Therefore, we decided that the Plan has to 
pre-approve an axial rotation unit.  
 
We also decided that the Plan does not have to pre-approve a flex foot system. 
 
The Plan follows Medicare rules. Medicare rules say that a flex foot system (L5980) is only covered for 
beneficiaries whose functional level is 3 or 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 a flex foot system. Our physician 
reviewer found based on the medical records provided there is no documentation that your functional level is 
currently a level 3 or above, indicating that a flex foot system is 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 a flex foot system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a flex foot system. 
 
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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 8 additional skilled nursing home visits. 
 
You asked the Plan to pre-approve additional skilled nursing home visits. You say that you would like the plan 
to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve additional skilled nursing home visits.  
 
Our reviewer says that the documentation does not support that the requested services are medically reasonable 
or necessary. Our physician reviewer found there is no documentation that skilled nursing services are required 
to effectively provide treatment, care, and/or services in order to improve your condition, or to 
establish/perform a maintenance program to maintain your condition and/or prevent deterioration. The 
documentation supports that an unskilled caregiver would be capable of performing dressing changes to the 
right lower extremity. Therefore, you do not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional skilled nursing home visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 8 additional skilled nursing home visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide two additional one way non-emergency transportation; taxi 
(A0100) trips. 
 
You asked the Plan to provide non emergent transportation. You say that the member is reliant on the 
transportation services and has no other way to get to their appointments. The Plan denied your request. The 
Plan says the member has exhausted their benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this 
case. The Plan covers a maximum of 24 one way trips to plan approved locations per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to provide two additional one way non-emergency transportation; taxi 
(A0100) trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positioning cushion for the enrollee. 
 
You asked the Plan to pre-approve the cushion. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit, as it not considered medical in nature. 
 
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 cushion. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the requested positioning cushion is not medically necessary. The documentation does not support that 
this cushion is furnished in accordance with accepted standards of medical practice for the diagnosis or 
treatment of the enrollee's condition or to improve the function of a malformed body member or furnished in a 
setting appropriate to the enrollee's medical needs and condition. A positioning pillow is not considered 
primarily medical in nature. 
 
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 cushion have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positioning cushion for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the reclining chair (E1399). 
 
You asked the Plan to pre-approve the reclining chair. You say that you meet the Medicare criteria for benefits 
in obtaining a power lift recliner. You cannot rise from any chair without assistance. The Plan denied your 
request. The Plan says this item is not covered by Medicare. 
 
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 reclining chair (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the enrollee would 
significantly benefit from use of pneumatic compression devices. You respectfully request the Plan reconsider 
and approve these devices. The Plan denied your request. The Plan says the requested item is not a covered 
benefit under Medicare. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided 
that the Plan does not have to pre-approve a pneumatic compression device (E0676).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve electrical treatment (Spinal Cord Stimulator Implantation).
You asked the Plan to pre-approve electrical treatment (Spinal Cord Stimulator Implantation). 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 follows Medicare rules. Medicare rules say that spinal cord stimulator implantation is only covered for certain indications. 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 electrical treatment (Spinal Cord Stimulator Implantation). Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has chronic back pain due to
degenerative disk disease. The documentation shows that the enrollee has failed injections. The enrollee has not had a psychological evaluation. Therefore, the enrollee does not meet criteria for the requested services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of electrical treatment (Spinal Cord Stimulator Implantation) have not been met. Therefore, we decided that the Plan does not have to pre-approve electrical treatment (Spinal Cord Stimulator Implantation).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you would like the plan 
to reconsider their denial. The Plan denied your request. The Plan says the requested services exceed your 
benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the office visit referral. You say that you would like reconsideration because 
this provider is working on new research and has ongoing trials in which you could participate. The Plan 
denied your request. The Plan says treatment for your diagnosis can be provided by an in-network specialist. 
 
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 
the medical services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an outpatient surgery to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve an outpatient surgery. You say that you were recommended to this provided. 
The Plan denied your request. The Plan says there are in-network providers available to provide these services. 
 
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 
an outpatient surgery to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory virus panel rendered on February 22, 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 mixed respiratory virus panel, 3-5 targets (87631), 
is used when multiple influenza types (e.g., A and B) are combined with another virus, such as RSV. 
 
We looked at the file and Medicare rules. The documentation does not support that the testing was used for 
multiple influenza types. 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 respiratory virus 
panel rendered on February 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve the dental items. You say that you received your dentures in September 
2019. You say that they did not fit right and needed an adjustment. You say that after the adjustment they still 
did not fit right. You say that a plan representative advised that you should return the dentures so that you can 
get new ones elsewhere. You say that the dentist never sent back the check. You also say that you still need 
dentures. The Plan denied your request. The Plan says dentures are covered once every 5 plan years. The Plan 
says that the frequency limit has been reached. 
 
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 frequency limit of once every 5 
plan years for dentures has been reached. The record shows that the Plan paid for dentures that you received on 
July 18, 2019, thus exhausting the benefit. Therefore, we decided that the Plan does not have to pre-approve a 
complete upper denture (D5110) and a complete lower denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve the dental items. You say that the dentures were denied because of the time 
frame. You say that you cannot wait 1 year because your current denture is broken.  You also say that it is 
uncomfortable for you to eat. The Plan denied your request. The Plan says dentures are covered once every 5 
years. The Plan says that the frequency limit for these items has been reached. 
 
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 frequency limit of once every 5 
years for dentures has been reached. The record shows that the Plan paid for dentures that you received on 
October 20, 2016. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture 
(D5110) and a complete lower denture (D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
May 14, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 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 out of network physician 
services provided to the enrollee on May 14, 2020.