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

 
We decided that the Plan does not have to pre-approve a second portable ventilator (E0465). 
 
You asked the Plan to pre-approve a second portable ventilator. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, 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 a second portable ventilator. 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 medical records provided there is no documentation that the 
second ventilator at issue in this case is medically reasonable and necessary. The prescriber argues that the 
second ventilator is needed for portability; after thorough review of the provided medical records there is no 
documentation that you are mobile in any way. The records indicate that you are bed-bound and completely 
non-responsive. There is no documentation in the records that you are getting up to a wheelchair or being 
transported. 
 
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 second portable ventilator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a second portable ventilator (E0465).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic care. 
 
You asked the Plan to pre-approve the chiropractic care. You say that you would like consideration because 
this service is medically necessary. The Plan denied your request. The Plan says the records do not show a 
diagnosis of subluxation. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
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 chiropractic care Our reviewer says 
that findings do not reveal evidence of subluxation per Medicare guidelines. Our physician reviewer found 
chiropractic treatment is heredity supported nor allowed per Medicare guidelines. 
 
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 chiropractic care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve chiropractic care.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that your care needs can be provided at a lesser level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for weakness and high blood 
pressure. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. The medical record supports a need for physical and occupational 
therapy but it does not support a need for an intensive rehabilitation therapy program. There is not a reasonable 
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria 
for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy duty, multiple braking system, variable wheel 
resistance walker. 
 
You asked the Plan to pre-approve a heavy duty, multiple braking system, variable wheel resistance walker. 
You say that the requested heavy duty, multiple braking system, variable wheel resistance walker is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested 
heavy duty, multiple braking system, variable wheel resistance walker. 
 
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 heavy duty, multiple braking system, 
variable wheel resistance walker. Our reviewer says that the enrollee does not meet criteria for the requested 
heavy duty, multiple braking system, variable wheel resistance walker. Our physician reviewer found the 
enrollee has falls outside when smoking. The enrollee has dementia from Alzheimer's Disease with unsteady 
gait and the provider is requesting a U step walker with reverse breaking system. A nurse practitioner note 
states it will help her complete activities of daily living (ADLs) and reduce fall risk. The appeal states she 
cannot perform ADLs with current walker. She has a history of falls. She is noted to be at baseline walking and 
cognitively per a 7/14/20 progress note.  
 
The documentation is not clear that the enrollee is unable to effectively complete her mobility related activities 
of daily living with her current walker therefore the requested heavy duty, multiple braking system, variable 
wheel resistance walker 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 heavy duty, multiple braking system, variable wheel resistance walker have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy duty, multiple braking 
system, variable wheel resistance walker.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve the CardioMEMS. You say that you would like reconsideration because this 
device is medically necessary. The Plan denied your request. The Plan says this device is experimental. 
 
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 CardioMEMS. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the efficacy of the CardioMEMS device is uncertain at this time according to leading 
authorities and not recommended in current guidelines for the treatment of heart failure. 
 
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 CardioMEMS have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a CardioMEMS device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 power wheelchair with accessories (K0861). 
 
You asked the Plan to pre-approve the power wheelchair and accessories. You say that the powerchair is 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 power wheelchair and accessories. 
Our reviewer says that the requested powerchair is not medically necessary. Our physician reviewer found the 
enrollee does not have significant edema or a cast/brace that requires power elevating leg rests. The 
documentation is not consistent does not indicate that the patient is at high risk for development of a pressure 
ulcer and is unable to perform a functional weight shift as the office visit notes indicate she is ambulating with 
a walker and the evaluation indicates she can transfer independently. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a group 2 power wheelchair with accessories (K0861).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nurse visits. 
 
You asked the Plan to pre-approve skilled nurse visits. You say that the services are necessary. The Plan denied 
your request. The Plan says the services are not 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 skilled nurse visits. Our physician 
reviewer found the records do not show that skilled nursing services are required to effectively provide 
treatment, care, and/or services in order to improve the patient's condition, establish/perform a maintenance 
program to maintain the patient's condition and/or prevent deterioration. The documentation does not reveal 
evidence of complex wound care, intravenous (IV) antibiotics, or other skilled nursing (SN) need therefore SN 
home health visits are 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 skilled nurse visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve skilled nurse visits.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve for 2 home health physical therapy (PT) visits (G0151) 
7 home health physical therapy (PT) visits (G0151). 
 
You asked the Plan to pre-approve for 2 home health physical therapy (PT) visits (G0151) the home health PT 
visits. You say that you respectfully appeal the denial of physical therapy services and believe that these are 
necessary for this enrollee's condition. The Plan denied your request. The Plan says the records provided does 
not show medical necessity for the requested physical therapy. 
 
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 home health PT visits. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this case, the documentation doesn't support that the member requires skilled 
nursing services or additional skilled rehab services to provide treatment that is medically necessary. The 
enrollee does not require skilled nursing or rehab services to effectively provide treatment, care, and/or services 
in order to improve the member's condition, perform a maintenance program to maintain the patient?s 
condition and/or prevent deterioration.  He is at or near his prior level of function and has been authorized an 
additional 2 visits of physical therapy.  He lives with his family and has been medically stable. 
 
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 home health PT visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve for 2 home health physical therapy (PT) visits (G0151) 7 home health 
physical therapy (PT) visits (G0151).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on June 4, 2020. 
 
You asked the Plan to pay for the bitewing x-rays. You say that your benefit handbook states that your plan 
covers 1 dental x-ray. You also say that from this, it is clear that payment for this x-ray should be allowed. The 
Plan denied your request. The Plan says this service is not covered by the Plan. The Plan also says that you did 
not elect to purchase optional supplemental dental 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. Therefore, we decided that the Plan does not have to pay for the 
bitewing x-rays (D0274) provided on June 4, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transportation provided on February 16, 2020. 
 
You asked the Plan to pay for ambulance transport. You say that the enrollee could not have been safely 
transported by any other means. The Plan denied your request. The Plan says the denial of payment for this 
service is correct, because this ambulance transportation was not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance transport. Our reviewer says that 
this ambulance transportation does not meet the Medicare criteria for payment. Our physician reviewer found 
the medical records do not provide information as to the reason for transportation to the hospital. There is no 
evidence supporting the use of ambulance services to the hospital as the enrollee had no complaints upon 
arrival and the objective findings noted are normal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ambulance transport have not been met. Therefore, we decided that the Plan 
does not have to pay for ambulance transportation provided on February 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit and deductible for 
diabetic supplies provided by a participant provider on January 14, 2020, through March 10, 2020. 
 
You asked the Plan to waive the copayment and deductible for a specialist office visit and diabetic supplies. 
You say that you do not agree with these charges. The Plan denied your request. The Plan says the correct 
copayment and deductible amounts have been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible and a $35 copayment for physician/practitioner 
services/specialist and diabetic services and supplies.  
 
The item or service you asked the Plan to waive the copayment and deductible for falls within the benefit 
category physician/practitioner services/specialist and diabetic services and supplies. The Plan has followed 
Medicare rules by clearly disclosing in the contract that there is a $750 deductible and a $35 copayment for 
physician/practitioner services/specialist. The total amount you are being asked to pay is $200.48 This cost 
sharing is a contractual obligation that had not been met at the time a specialist office visit and diabetic supplies 
was received on January 14, 2020 to March 10, 2020. Therefore, we decided that the Plan does not have to 
waive the copayment and deductible for a specialist office visit and diabetic supplies provided by a 
participating provider on January 14, 2020, through March 10, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on March 7, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 7, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on March 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on January 2, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
available in-network. 
 
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 has network providers 
available who can provide the services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider 
on January 2, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on April 
27, 2020. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that you have never had to pay 
for this type of service in the past. The Plan denied your request. The Plan says the copayment amount you are 
being charged is correct. 
 
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 $275 
copayment for one-way ambulance trip.  
 
You have been asked to pay $275 copayment for ambulance transport. Ambulance transport falls within the 
Ambulance 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 copayment for ambulance 
transportation provided on April 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a CPAP machine and accessories (G4733, 
E0652, A7039, A7038, A4604, A7035, A7030) provided June 2, 2020. 
 
You asked the Plan to waive the coinsurance for the CPAP machine and accessories. You say that the provider 
told you the items would be covered in full. The Plan denied your request. The Plan says the correct cost-
sharing was applied 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Durable Medical Equipment.  
 
You have been asked to pay a 20% coinsurance for the CPAP machine and accessories. The CPAP machine 
and accessories falls within the Durable Medical Equipment 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 coinsurance for a CPAP machine and accessories (G4733, E0652, A7039, A7038, A4604, A7035, 
A7030) provided June 2, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from March 13, 2020, 
to April 1, 2020. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you were readmitted due to 
circumstances beyond your control. The Plan denied your request. The Plan says the claims were processed 
correctly and you are being charged the correct 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 $0 
copayment per day, for days 1-20 and a $178 per day, for days 21-100 for SNF care.  
 
You had a SNF stay from March 13, 2020, to April 1, 2020. The record shows that you had a previous SNF 
stay for a total of 23 days. Therefore, you are responsible to pay $2,908.03, which is less than the total 
copayment amount.  
 
You have been asked to pay the total copayment amount of $2,908.03 for a SNF stay. A SNF stay falls within 
the SNF 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 a SNF stay provided from 
March 13, 2020, to April 1, 2020.