Persius/hicric huggingface dataset:
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 would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested admission 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 you required maximum assistance times two to sit up, stand up, and to shuffle 2 feet. 
You required minimal assistance to sit. The documentation does not support that you require an an acute 
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not 
support that you require an intensive rehabilitation therapy program. Your care needs can be met at a lower 
level of 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered pressure reducing air mattress identified with 
code E0277. 
 
You asked the Plan to pre-approve a powered pressure reducing air mattress. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not medically 
necessary. The Plan follows Medicare rules. Medicare rules say that group 2 support surfaces are 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 a powered pressure reducing air 
mattress. Our reviewer says that the documentation does not support that the requested powered pressure 
reducing air mattress is medically reasonable or necessary. Our physician reviewer found the documentation 
does not support that the enrollee has multiple stage II pressure ulcers located on the trunk or pelvis which have 
failed to improve over the past month. The enrollee does not have large or multiple stage III or IV pressure 
ulcer(s) on the trunk or pelvis or a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis 
within the past sixty days. Therefore, the enrollee does not meet criteria for the requested item. 
 
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 powered pressure reducing air mattress have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a powered pressure reducing air mattress identified with 
code E0277.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Accu-Chek Aviva Plus test strips. 
 
You asked the Plan to pre-approve the test strips. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not the preferred brand. 
 
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 test strips. Our reviewer says that 
the requested test strips are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the plan preferred products include one touch verio and onetouch ultra.  The documentation 
does not outline a rationale or discussion why the preferred brand is not utilized. Without the support of the 
documentation, medical necessity cannot be determined. 
 
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 test strips have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Accu-Chek Aviva Plus test strips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neurology services provided on June 3, 2020. 
 
You asked the Plan to pay for the neurology 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. 
 
The Plan must follow Medicare rules. 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 
CPT codes 92540, 92546, 92547, 92537, 97750, 92550, 92588, and 92585 were provided to the enrollee on 
June 3, 2020. Based on this information, we decided that Medicare rules for coverage of the neurology services 
have not been met. Therefore, we decided that the Plan does not have to pay for the neurology services 
provided on June 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wrist hand orthosis (L3916), ankle foot orthosis (L1971) and 
a plastic foot (L3170) provided on August 7, 2020. 
 
You asked the Plan to pay for the orthoses. You say that you would like reconsideration because this equipment 
was medically necessary. The Plan denied your request. The Plan says the medical records do not show that the 
physician discussed the need for these orthoses. 
 
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 orthoses. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is insufficient evidence of an objective physical examination of the wrist including 
detailed findings of strength, range of motion, instability or other finding indicating that the wrist hand orthosis 
is medically necessary.  There is no objective detailed neuromuscular and gait physical examination of the 
member indicating the member is ambulatory and has weakness or deformity of the foot and ankle and needs 
stabilization for medical reasons. 
 
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 orthoses have not been met. Therefore, we decided that the Plan does not 
have to pay for wrist hand orthosis (L3916), ankle foot orthosis (L1971) and a plastic foot (L3170) provided on 
August 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve liquid food. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no order for enteral supplement on file. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found a review of the documentation does not include medical records. There is no provider history, physical, 
or documentation of medical decision-making to support the requested supplement. Without the support of the 
documentation, medical necessity cannot be determined. 
 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve liquid food.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency care provided on August 13, 
2020. 
 
You asked the Plan to waive the copayment for the emergency care. You say that you should not have to pay 
the copayment because your prescription caused the medical emergency. 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 $120 
copayment for Emergency Care.  
 
You have been asked to pay a $120 copayment for the emergency care. The emergency care falls within the 
Emergency Care benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency care 
provided on August 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you an additional amount for hearing aids provided on 
August 17, 2020. 
 
You asked the Plan to reimburse you an additional amount for hearing aids. The Plan denied your request. The 
Plan says the hearing aid benefit was applied correctly to the claim. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan?s coverage rules apply in this case.  
 
We looked at the file and the Plan's rules. The file shows that the hearing aid benefit was applied correctly to 
the claim. Therefore, we decided that the Plan does not have to reimburse you an additional amount for hearing 
aids provided on August 17, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis 5mg tablet. 
 
You asked the Plan to pre-approve the tablet. You say that this is medically necessary. The Plan denied your 
request. The Plan says Medicare says Part B programs can only provide limited benefits for prescription drugs. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eliquis 5mg tablet.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the preventive procedure provided. 
 
You asked the Plan to pay for the preventive procedure. You say that the dental practice should have to inform 
the enrollees of the charge for personal protective equipment before treatment. The Plan denied your request. 
The Plan says this service is not covered. The Plan also says you did not contact the Plan prior to the date of 
service to verify benefits. 
 
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. The Plan is unable to allow additional payment for this service because 
participating providers are receiving a separate monthly stipend for unspecified preventive procedure. The Plan 
also says it is the provider's discretion on whether they bill you for charges beyond the stipend amount. 
Therefore, we decided that the Plan does not have to pay for the preventive procedure provided.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the osseous surgery (D4261) provided. 
 
You asked the Plan to pay for the osseous surgery. You say that your dentist noticed a problem with a tooth, 
and advised you to be seen by a specialist. The Plan denied your request. The Plan says that periodontally 
involved teeth that would qualify for surgical pocket reduction benefits and osseous grafts must be documented 
to have at least 5mm pocket depths. The Plan also says that if pocket depths are under 5mm, the procedure is 
not a contract benefit. 
 
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 osseous 
surgery 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 pay for the osseous surgery. Our reviewer says that 
this service was medically reasonable and necessary. Our physician reviewer found the documentation 
indicates that an area of external resorption on the buccal aspect of tooth #22, 2-3mm apical to the gingival 
margin was present. Our reviewer found that to gain access to properly place a restoration to the area, osseous 
surgery was performed. Our reviewer also found that this service was medically reasonable and necessary to 
save the tooth. 
 
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 osseous surgery have been met. Therefore, we decided that the Plan has to 
pay for the osseous surgery (D4261) provided. 

 
 
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no clinical advantage to the inpatient rehabilitation facility over the acute care 
hospital. 
 
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 enrollee does not require the intensity of services provided at an IRF.  
Specifically, the enrollee is not shown to be able to perform fifteen hours per week of rehabilitative services 
with regular physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR). 
 
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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an automatic blood pressure monitor. 
 
You asked the Plan to pre-approve this item. You say that a blood pressure monitor is medically necessary. The 
Plan denied your request. The Plan says you do not meet criteria for coverage of this item. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only 
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require 
ABPM to confirm a diagnosis of hypertension.  
 
 
 
 
 
 
 
 
 
The records do not show that this monitor is requested in the setting of home dialysis services, or that this 
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home 
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. 
Therefore, we decided that the Plan does not have to pre-approve an automatic blood pressure monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive dental exam received on August 5, 2020. 
 
You asked the Plan to pay for the comprehensive dental exam. You say that you disagree with the plan's denial. 
The Plan denied your request. The Plan says the services received exceed your benefit limit. 
 
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. 
 
Review of the file shows that you received a comprehensive dental exam on August 5, 2020. You previously 
received a comprehensive dental exam on January 5, 2020. This service is only covered once every three years. 
Three years had not passed since your previous comprehensive dental exam. Therefore, we decided that the 
Plan does not have to pay for the comprehensive dental exam received on August 5, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided from July 3, 
2019, to August 2, 2019. 
 
You asked the Plan to pay for the SNF services. You say that the services which the enrollee required and 
received during the dates of service in this case are coverable under the Medicare Act. The Plan denied your 
request. The Plan says that the enrollee's stay did not meet the inpatient criteria. The Plan also says that the 
enrollee's care could have been provided without an inpatient stay. 
 
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 pay for the SNF services. Our reviewer says that the 
enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found that the enrollee did not 
have daily skilled nursing needs that required the specialized skill, knowledge and judgment of a skilled 
professional nurse. The reviewer found that the enrollee did not have daily skilled nursing needs that required 
the specialized skill, knowledge and judgment of a skilled professional therapist. The reviewer found that the 
enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. The 
reviewer also found that the enrollee did not meet the severity of illness or intensity of service criteria for an 
inpatient basis in a SNF 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 the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pay for skilled nursing facility (SNF) services provided from July 3, 2019, to August 2, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the physical therapy visits provided from
August 5, 2020, to September 11, 2020.
You asked the Plan to waive the copayments for the physical therapy visits. You say that you were told that the
physical therapy visits would be covered. The Plan denied your request. The Plan says you have been charged
the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40
copayment for in-network Medicare-covered therapy services in all places of service.
You have been asked to pay a $40 copayment for each of the physical therapy visits. ($40 x 9 visits = $360).
The physical therapy visits fall within the "Outpatient rehabilitation 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 copayments for the physical therapy visits provided from August 5, 2020, to
September 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a segmented pneumatic compression device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. 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 the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation does not support the existence of lymphedema of the chest, trunk, or abdomen on an 
objective physical exam. There are no unique characteristics that would indicate the segmented pump over a 
standard pump. There is no documentation of a four week trial and failure of a standard pump. 
 
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 a segmented pneumatic compression device.