Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 skilled nursing visits and 14 hours of home health aide 
services. 
 
You asked the Plan to pre-approve the skilled nursing and home health aide services. You say that you would 
like reconsideration based on the records submitted. The Plan denied your request. The Plan says these 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 the skilled nursing and home health 
aide services. Our reviewer says that the record does not show that you have skilled nursing needs. Our 
physician reviewer found in the absence of skilled nursing needs, home health aide services are not covered. 
 
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 skilled nursing and home health aide services have not been met. Therefore, 
we decided that the Plan does not have to pre-approve 4 skilled nursing visits and 14 hours of home health aide 
services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Optimizer Smart implantable pulse generator. 
 
You asked the Plan to pre-approve the device. You say that the device is necessary. The Plan denied your 
request. The Plan says the device is not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on the records the patient has refractory congestive heart failure. In this circumstance, 
treatment with the Optimizer System (CPT0408T) device has been demonstrated in only one trial to help 
reduce hospital readmission compared to standard medical therapy. Moreover, the trial was very small (only 
160 patients) and the results for the composite endpoint barely reached statistical difference (p=0.048). 
Therefore, the efficacy of the Optimizer System (CPT0408T) is still uncertain at this time according to leading 
authorities and not recommended in current guidelines for the treatment of heart failure. Medicare coverage 
criteria are not met since the device should still be considered experimental or investigational. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Optimizer Smart implantable pulse generator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nurse practitioner services provided on February 7, 2020. 
 
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says the 
Plan requires utilization of network providers when possible and available and requires authorization for 
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency 
situation, has been documented.   
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for nurse practitioner services provided on February 7, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the documentation does not support that the complexity of the enrollee's nursing, 
medical and rehabilitation needs requires an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. The enrollee's medical condition is generally stable and the documentation does not support 
that he has complex medical issues that require acute rehab nursing care, or monitoring by an inpatient Physical 
Medicine and Rehabilitation (PM&R) physician three (3) times per week. While the enrollee is reasonably 
expected to benefit from continued physical therapy (PT) and occupational therapy (OT), the documentation 
does not support that there is need for an intensive therapy program with therapy 3 hours per day, with frequent 
physician oversight and an interdisciplinary approach to rehabilitation care. There is a reasonable expectation 
that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lift chair. 
 
You asked the Plan to pre-approve the lift chair. You say that the lift chair is necessary. The Plan denied your 
request. The Plan says a lift chair not a covered benefit. The Plan states you do meet criteria for a lift chair 
mechanism from an in-network provider. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed above are met. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lift chair have not been met. A lift chair not a covered benefit. The Plan states you do meet 
criteria for a lift chair mechanism from an in-network provider. Therefore, we decided that the Plan does not 
have to pre-approve lift chair.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of a home service aide. 
 
You asked the Plan to pre-approve the in home services aide. You say that you would like reconsideration 
because you require help to shower. The Plan denied your request. The Plan says this service is not medically 
necessary because your assisted living facility provides it. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 in home services aide. Our reviewer 
says that the records do not show that skilled nursing or skilled therapy 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. Our physician reviewer found 
the request for home health aide services exceeds your needs and is not  reasonable and necessary for the 
treatment of your illness or injury in addition to the aide you already receive at your assisted living facility. 
 
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 in home services aide have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the continuation of a home service aide.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthoses (L1851, L1971, L2397). 
 
You asked the Plan to pay for the orthoses. You say that the items were medically necessary. The Plan denied 
your request. The Plan says the documentation did not include valid proof of delivery. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery however, the claim submitted.
The documentation was not itemized.
The record shows that the Plan made several attempts to obtain the necessary documentation without 
success. Therefore, we decided that the Plan does not have to pay for orthoses (L1851, L1971, L2397).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the complete upper and lower denture (D5110 and 
D5120). 
 
You asked the Plan to pre-approve the complete upper and lower denture (D5110 and D5120). You say that 
your grandchild put your dentures in the trash. You say that you need more dental coverage. The Plan denied 
your request. The Plan says the service exceeds the maximum count allowed in benefit plan. 
 
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, you also have a maximum benefit of 
one complete upper and lower denture every five plan years. Dentures were provided on October 18, 2018, 
which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve the complete 
upper and lower denture (D5110 and D5120).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Superion interspinous spacer.You asked the Plan to pre-approvea Superion interspinous spacer. The Plan denied your request. The Plan says this is not medically 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 a Superion interspinous spacer. Our reviewer says that the requested servicesare not considered medically reasonable and necessary in this case. Our physician reviewer found that this spacer remains experimental. More research is needed to show safety and efficacy.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 Superion interspinous spacer have not been met.Therefore, we decided that the Plan does not have to pre-approvea Superion interspinous spacer.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on June 27, 
2020, and July 24, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that these services were 
rendered without your knowledge and that you cannot afford them. The Plan denied your request. The Plan 
says these copayments were charged 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $300 copayment per one-way trip for ambulance services.  
 
The plan is currently charging $365.38 for these two ambulance transports because the allowed amount of each 
transport ($182.69) is less than the $300 per trip copayment obligation. This copayment is due regardless of the 
reason for the transport. This means that the enrollee has been asked to pay the correct amount based on the 
contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in 
the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services 
provided on June 27, 2020, and July 24, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography angiogram (CTA) scan of the 
abdomen/pelvis. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says that the services are not medically 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 services are medically necessary. Our physician reviewer found it is medically acceptable for this enrollee 
to undergo CT angiogram in order to have more extensive vascular evaluation given the severity of her bilateral 
feet cyanosis and skin breakdown. Although the medical records indicate that she has mildly decreased TBIs 
bilaterally, this finding in the setting of bilateral feet skin breakdown and cyanosis requires further 
investigation. Based on the medical records, this enrollee is at high risk of bilateral feet wound infection and 
possible loss of lower extremities. Therefore it is prudent to undergo full evaluation to determine exact etiology 
and location of her vascular disruption. 
 
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 has to 
pre-approve a computed tomography angiogram (CTA) scan of the abdomen/pelvis.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay was medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that 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 care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the patient does not require skilled nursing 
services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely 
and effectively provide medically necessary and reasonable treatment in a SNF. The patient does not have 
complex wound care or other ongoing SNF level SN need. The patient's Foley does not require a SNF 
admission and can be managed at a lower level of care. The patient's functional level does not require skilled 
therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and 
effectively provide medically necessary and reasonable treatment in a SNF. The patient was already ambulating 
200 feet and transferring at a supervision level. The patient does not require skilled nursing or skilled therapy 
services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, this patient does 
not require the necessary services on an inpatient basis, in a skilled nursing facility setting. 
 
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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe hospital discharge services rendered on November 22, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 99239 is 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 99239 is hospital discharge day management; more than 30 minutes.We find that CPTcode 99239 is not supported in the medical record. Specifically, there is no documentation of more than 30 minutes of discharge services spent on the enrollee. 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 forthe hospital discharge services rendered on November 22, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of SNF care beginning October 10, 2020. 
 
You asked the Plan to pre-approve SNF care. You say that the stay was medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that 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 care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not require skilled nursing services 
with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and 
effectively provide medically necessary and reasonable treatment in a SNF. You do not have complex wound 
care or other ongoing SNF level SN need. Your functional level does not require skilled therapy services with 
the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide 
medically necessary and reasonable treatment in a SNF. You do not require skilled nursing or skilled therapy 
services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, you do not 
require the necessary services on an inpatient basis, in a skilled nursing facility setting. 
 
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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continuation of SNF care beginning October 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for urgent care services you received. 
 
You asked the Plan to waive the copayments for the urgent care services. You say that these copayments 
should be waived because you couldn't find a wound care doctor because of COVID-19.  If you had found a 
wound care doctor, you would not have had a copayment. The Plan denied your request. The Plan says you 
were charged these copayments correctly. The Plan says that it is only waiving copayments for primary and 
specialty office visits.  Urgent care services are not eligible for this waiver. 
 
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 $25 
copayment for urgent care services.  
 
You have been asked to pay a $25 copayment for the urgent care services. This copayment applies regardless 
of why you went to the urgent care center. 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 copayments for urgent care 
services you received.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that due to the complexity of the enrollee, she 
will continue to require acute care before she will be safe enough to transition to a lower level of care. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
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 long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in 
general, LTACHs do not provide clinical services that are materially different than those of short term acute 
care hospitals. In this case, ongoing care needs include antibiotics, surveillance laboratory studies, sacral 
wound care, and therapy services. The documentation does not support that the enrollee in this case requires 
services at the LTACH that are not available at the acute care hospital where he is currently receiving care. 
There are no required medical services identified that are available at the LTACH, that are not available at the 
current health care setting being offered by the health plan. Consequently, the requested LTACH services are 
not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 
 
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 admission to a long term acute care hospital (LTACH) for the enrollee.