Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve breast augmentation (19325).
You asked the Plan to pre-approve breast augmentation. 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 cosmetic procedures and related services are not
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are
coverable.
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 breast augmentation. Our reviewer says
that the services are not medically necessary. Our reviewer found medical necessity has not been adequately
defined in the medical documentation provided. The request does not satisfy Medicare medically necessary
criteria.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of breast augmentation have not been met. Therefore, we decided that the Plan
does not have to pre-approve breast augmentation (19325).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from April
19, 2019 to May 1, 2019.
You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the claim is missing required information.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must
be completed for home health care services to be covered.
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that
Medicare rules for completing the claim for home health services have not been met. Specifically, a valid
HIPPS code is required for processing. Therefore, we decided that the Plan does not have to pay for the home
health services provided to the enrollee from April 19, 2019 to May 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 30, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that the doctor is entitled to the payment for the
services provided. The Plan denied your request. The Plan says services from non-participating providers are
not covered unless they are authorized before the services are provided.
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 on December 30, 2019 by an out of network
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair harness for upgrade to expandable
controller (E2313), expandable controller (E2377), and electronic connection between wheelchair controller
and two or more power seating system motors (E2311).
You asked the Plan to pre-approve a power wheelchair harness, expandable controller, and electronic
connection between wheelchair controller and two or more power seating system motors. You say that the
items are necessary. The Plan denied your request. The Plan says based on the documentation provided,
coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that power wheelchair accessories are covered when
specific criteria is met.
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 power wheelchair harness,
expandable controller, and electronic connection between wheelchair controller and two or more power seating
system motors. Our reviewer says that the items are not medically necessary. Our physician reviewer found the
documentation does not indicate that you require a proportional input device (e.g., mini, compact, or short
throw joysticks, touchpads, chin control, head control, etc.) other than a standard proportional joystick, a nonproportional
input device (e.g., sip and puff, head array, etc.). You do not need to operate 3 or more powered
seating actuators through the joystick. You do not need an expandable controller to be able to operate one or
more of the following: a separate display (i.e., for alternate control devices); other electronic devices (e.g.,
control of an augmentative speech device or computer through the chair's drive control) or an attendant control.
The documentation indicates that you have sufficient strength and functional ability to control the power
features through their own individual switches. Therefore, the requested E2311 Electronic connection, E2377
Expandable Controller and E2313 Expandable Controller Harness 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 a power wheelchair harness, expandable controller, and electronic connection
between wheelchair controller and two or more power seating system motors have not been met. Therefore, we
decided that the Plan does not have to pre-approve a power wheelchair harness for upgrade to expandable
controller (E2313), expandable controller (E2377), and electronic connection between wheelchair controller
and two or more power seating system motors (E2311).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 additional physical therapy visits.
You asked the Plan to pre-approve the 6 additional physical therapy visits. You say that the records provided
support the need for the number of visits being requested. The Plan denied your request. The Plan says the
number of visits which remain in dispute do not meet the medical necessity criteria for coverage.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
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 6 additional physical therapy visits.
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent
deterioration of the enrollee's condition. Our physician reviewer found the requested therapy is generally not
accepted as specific and effective therapy for the enrollee's condition. The enrollee has reached a level that no
longer requires the skills of a professional therapist. She has controlled lower extremity edema with
compression garments and a home CDT program. She does not need the unique skills of a professional
therapist to safely and effectively provide treatment. Services do not only need to be safely and effectively
performed by a therapist, or under the supervision of a therapist. The enrollee was trained in a home
decongestive therapy program. The requested services are not part of a maintenance program and the
specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or
deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration.
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 6 additional physical therapy visits have not been met. Therefore, we
decided that the Plan does not have to pre-approve 6 additional physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a raised toilet seat and shower chair for the enrollee.
You asked the Plan to pre-approve a raised toilet seat and shower chair. You say that these items are medically
necessary for the enrollee. The Plan denied your request. The Plan says that these items are not covered by
Medicare.
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered
because they are not primarily medical in nature. Medicare rules also say that shower chairs are not covered
because they are not primarily medical in nature.
While a raised toilet seat and 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 raised toilet seat and
shower chair for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from
December 23, 2019 to January 1, 2020.
You asked the Plan to waive the copayment for the inpatient hospital. You say that this was an emergency
situation and say this is a great hardship. 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 $225
copayment for per day, days 1-6 for each in-network Medicare covered hospital admission/stay and a $0
copayment for additional hospital days.
You have been asked to pay a $225 copayment for days 1 to 6 of the inpatient hospital. ($225 x 6 = $1,350).
The inpatient hospital falls within the "Inpatient hospital 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 inpatient hospital stay provided from December 23, 2019 to January 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair upgraded electronics, headrest
adapter, phone holder, phone charger, fabric zip cover, incontinent resistant cover, and power seat elevation
system.
You asked the Plan to pre-approve power wheelchair upgraded electronics, headrest adapter, phone holder,
phone charger, fabric zip cover, incontinent resistant cover, and power seat elevation system.. You say that you
need the power wheelchair accessories and upgraded electronics. The Plan denied your request. The Plan says
headrest adapter, phone holder, phone charger, fabric zip cover, incontinent resistant cover, and power seat
elevation systems do not serve a medical purpose. The Plan also says the upgraded electronics 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 looked at the file and Medicare rules. Power seat elevation systems are not covered by Medicare. Upper
limb strength and range of motion are adequate for you to be able to control the power options using their own
switches which are included in the allowance of these power options. The remaining accessories are not
primarily medical in nature. Based on this information, we decided that Medicare rules for coverage of power
wheelchair upgraded electronics, headrest adapter, phone holder, phone charger, fabric zip cover, incontinent
resistant cover, and power seat elevation system have not been met. Therefore, we decided that the Plan does
not have to pre-approve power wheelchair upgraded electronics, headrest adapter, phone holder, phone charger,
fabric zip cover, incontinent resistant cover, and power seat elevation system.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for laboratory services provided on August 8,
2020 and April 15, 2020.
You asked the Plan to waive the copayments for laboratory services. You say that you should not be
responsible for the charges because the labs were not completed. 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 $10
copayment for lab services.
You received laboratory services on August 8, 2020 and April 15, 2020. Therefore, you are responsible to pay
the allowed amount of $6.84 per each test. The total amount you owe is: $13.68.
You have been asked to pay the total copayment amount of $13.68 for laboratory services. Laboratory services
fall within the outpatient diagnostic tests and therapeutic services and supplies 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 laboratory services provided on August 8, 2020 and April 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy provided on February 11, 2020.
You asked the Plan to pay for the endodontic therapy. You say that you are in treatment for stage 4 squamous
cell mouth and lymph node metastasis cancer. You also say the treatment cannot be done when there is an
infection in your mouth, which is why this root canal needed to be completed. The Plan denied your request.
The Plan says your plan does not cover this procedure.
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
endodontic therapy provided on February 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the oximeter device, non-invasive (E0445).
You asked the Plan to pre-approve the oximeter device. You say that before the pandemic you were in the
process of studying sleep apnea and was pending. You urgently need the equipment since you have had pulse
arrhythmia's in 115 and lack of oxygen. The Plan denied your request. The Plan says this item is not a covered
benefit under any normal circumstances.
The Plan must follow Medicare rules. Medicare rules say that oximeters are not covered because they are
monitoring devices that provide information to the treating practitioner to assist in managing treatment.
While an oximeter device 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 the oximeter device, non-invasive
(E0445).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulators (TENS)
unit for the enrollee.
You asked the Plan to pre-approve a TENS unit. The Plan denied your request. The Plan says that this does not
meet Medicare criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that a TENS unit is covered when the above criteria
are met.
We looked at the file and Medicare rules. The file does not indicate the enrollee is participating in a clinical
study. Based on this information, we decided that Medicare rules for coverage of a TENS unit have not been
met. Therefore, we decided that the Plan does not have to pre-approve a transcutaneous electrical nerve
stimulators (TENS) unit for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network spine surgeon.
You asked the Plan to pre-approve these services. You say that you spend your winter months in Texas and the Plan providers have not helped. The Plan denied your request. The Plan says the services are available from network providers.
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 spine surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a weighted blanket.
You asked the Plan to pre-approve a weighted blanket. You say that because of anxiety you are not able to
sleep so you require a weighted anxiety relieving blanket for assistance. The Plan denied your request. The
Plan says a weighted blanket does not meet the DME definition.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve a weighted blanket.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pain management services to be provided by an out of
network (OON) provider.
You asked the Plan to pre-approve the OON services. The Plan denied your request. The Plan says there are
available and qualified pain management providers in the enrollee's 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 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 services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve pain
management services to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that an acute inpatient rehabilitation facility admission is
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for
coverage of an 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
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found that the enrollee does not require the intensity of services provided at an inpatient
rehabilitation facility. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative
services and regular physician evaluation. The enrollee's 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 an 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 a LTACH admission is medically
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for
coverage of a LTACH admission.
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 that the enrollee is currently undergoing treatment at an acute care hospital (ACH)
for multiple traumatic injuries after falling. Most notably, the enrollee sustained intracranial injuries. The
enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee remains on a
ventilator. Given the enrollee's mental status, it is unclear that the enrollee will be weaned from the ventilator
or decannulated. There is no evidence that the enrollee requires services that are not currently available. As
LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the
enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are
required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term
care needs.
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.