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

 
We decided that the Plan does not have to pre-approve manual adult sized wheelchair with accessories. 
 
You asked the Plan to pre-approve DME. You say that the DME is necessary. The Plan denied your request. 
The Plan says this is not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that DME is being requested for use in a SNF or hospital. Medicare guidance says that Medicare 
does not cover wheelchairs in a nursing facility. Only custom-fit wheelchairs are covered by the enrollee's 
health plan when they are in a nursing facility. A custom-fit wheelchair must be made just for the enrollee, and 
cannot fit anyone else. The information does not show that a custom-fit wheelchair is needed for the enrollee's 
care. The information does not show that other positioning aids or a back brace have been tried and did not 
work for the enrollee. Therefore, we decided that the Plan does not have to pre-approve manual adult sized 
wheelchair with accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 standard power wheelchair. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 wheelchair. Our reviewer says that 
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found there is no 
documentation of a personal mobility deficit that impairs participation in mobility-related activities of daily 
living. There is no documentation as to whether or not the mobility deficit could be helped by the use of a 
walker, cane, or manual wheelchair. There is no documentation showing that you could safely operate a power 
mobility device. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 1 standard power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair or shower bench for the enrollee. 
 
You asked the Plan to pre-approve a shower chair or shower bench. You say that this item is necessary for the 
enrollee. The Plan denied your request. The Plan says shower chairs and benches are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair or shower bench for the 
enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab services you had on June 16, 2020. 
 
You asked the Plan to waive the copayment for the lab services. You say that you should not have to pay a 
copayment for lab services just because you didn't see a doctor on that date. The Plan denied your request. The 
Plan says you did not see a doctor on the same date as these lab services, so 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 $10 
copayment for lab services.  
 
You have been asked to pay a $10 copayment for the lab services. You did not have a PCP or specialist visit on 
the same day. 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 lab services you had on June 16, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve Magnetic Resonance Imaging (MRI) of the abdomen (74181). 
 
You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary. The Plan denied 
your request. The Plan says that coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the 
requested MRI is medically necessary. Our physician reviewer found the enrollee has a pancreatic mass and 
marked bile duct dilation, but inconclusive ultrasound and CT scans.  MRI with MRCP is medically 
appropriate and necessary for further characterization of the aforementioned findings and for treatment 
planning. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
Magnetic Resonance Imaging (MRI) of the abdomen (74181).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Oscillation & Lung Expansion Device (A9999, 
E1399). 
 
You asked the Plan to pre-approve the Oscillation & Lung Expansion Device. You say that the device is 
medically necessary. The Plan denied your request. The Plan says coverage criteria is not met. 
 
The Plan must follow Medicare rules. Medicare rules say that it is not reasonable and necessary for a 
beneficiary to use both a HFCWO (High Frequency Chest Wall Oscillation) device and a mechanical in-
exsufflation device.  
 
We looked at the file and Medicare rules. Medicare rules state that it is not medically necessary to use both a 
HFCWO and Lung Expansion device. The requested device is a combination unit that performs both functions. 
Based on this information, we decided that Medicare rules for coverage of the Oscillation & Lung Expansion 
Device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Oscillation & 
Lung Expansion Device (A9999, E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397) 
provided to the enrollee on April 27, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical 
record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the 
type and quantity of items ordered and for the frequency of use.  
 
The record shows that documentation submitted did not indicate the provider discussed the need for the billed 
supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to 
pay for a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on April 27, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept ablation procedure (22899). 
 
You asked the Plan to pre-approve the ablation procedure. You say that the procedure is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan 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 ablation procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested procedure is considered investigational in this application and is 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 ablation procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept ablation procedure (22899).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on June 29, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the billed diagnosis code is not supported in the medical records provided. Specifically, the 
provider used a right-sided diagnosis code for a left sided issue, and billed with the -LT modifier. 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 pay for the services provided on June 29, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MRI, any joint of lower extremity; without contrast 
material (CPT Code 73721). 
 
You asked the Plan to pre-approve the MRI. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI. Our physician reviewer found 
a progress note documents you report of daily pain which is increased with all activity. There is no documented 
physical examination, previous imaging studies, conservative treatments, or differential diagnosis. Without this 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve MRI, any joint of lower extremity; without contrast material (CPT Code 73721).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network specialist. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are in-network providers available to provide this service. 
 
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 
a referral to an out-of-network specialist.
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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the enrollee is with a past 
medical history of chronic obstructive pulmonary disease, chronic back pain, bladder cancer and hepatitis C 
infection who presented to the acute hospital on 10/10/2020 with cough, shortness of breath and lower 
extremity swelling related to severe mitral valve regurgitation. He was treated in the hospital with mitral valve 
repair and closure of a left atrial appendage. He also suffered cardiogenic shock due to heart failure and flail 
posterior mitral valve leaflet and respiratory failure due to pulmonary edema vs. pneumonia. These conditions 
have stabilized, he has been extubated and his volume status is reported to be excellent. He is weak and 
deconditioned and is working with physical and occupational therapy. He is walking 25 feet with contact guard 
assistance and is minimum to moderate assist for transfers and up to maximum assist for activities of daily 
living. Therapy notes indicate he has significant fatigue with activity; on 10/22/2020: "unable to ambulate to 
bathroom due to fatigue." He is reported to be medically stable for discharge. 
 
 
 
Based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation 
needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does require physical therapy and occupational therapy services but based on the medical records 
provided the enrollee does not require an intensive inpatient rehabilitation therapy program. There is concern 
that the enrollee will not be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an inpatient rehabilitation 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 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: 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 this is medically necessary. The Plan 
denied your request. The Plan says care can be provided in the current inpatient hospital. 
 
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 does not require services at the LTACH that are not already available at 
the current facility. herefore, this request for LTACH will be considered not medically necessary at this time. 
Transfer to a lower level of care may be considered at a later date. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the echocardiography, the duplex scan of 
the aorta, and the duplex scan of the extremity veins you received on May 29, 2020. 
 
You asked the Plan to waive the copayments for the echocardiography and duplex scans. You say that you 
thought these services would be covered with just 20% coinsurance. The Plan denied your request. The Plan 
says you were charged these copayments correctly. The plan says that since the Medicare-allowed amount for 
each of these three services is less than your copayment responsibility, you are only being charged the allowed 
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 $155 
copayment for each Medicare-covered radiological diagnostic service.  
 
You have been asked to pay a $155 copayment for each of the echocardiography and duplex scans. The 
echocardiography and duplex scans fall within the Medicare-covered radiological diagnostic service benefit 
category. This means that you have been asked to pay the correct amounts 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 echocardiography, the duplex scan of 
the aorta, and the duplex scan of the extremity veins you received on May 29, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transportation services (A0130, S0209) provided on January 
9, 2020. 
 
You asked the Plan to pay for the transportation services. You say that you would like reconsideration because 
you were not aware that this benefit had changed. The Plan denied your request. The Plan says this was not a 
trip home following discharge from an emergency room stay or a round-trip to a physician's office related to an 
emergency condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided 
that the Plan does not have to pay for transportation services (A0130, S0209) provided on January 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a blood pressure monitor provided on May 29, 2020. 
 
You asked the Plan to pay for the blood pressure monitor. You say that you would like reconsideration because 
this equipment is medically necessary as you experience significant variations in your blood pressure. The Plan 
denied your request. The Plan says this is a non-Medicare covered 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 pay for a blood pressure monitor provided on May 29, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided 
on June 23, 2020. 
 
You asked the Plan to pay for the comprehensive periodontal evaluation. You say that this service meets the 
criteria because it was a comprehensive oral exam. The Plan denied your request. The Plan says this service is 
not a covered benefit under your dental 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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
comprehensive periodontal evaluation (D0180) provided on June 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve advanced leg pump device from an out-of-network care 
provider. 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says there is an in-network provider that can provide the advanced pneumatic compression 
device (calibrated pressure pump) and garments (leg sleeves). 
 
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 
advanced leg pump device from an out-of-network care provider.