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

 
We decided that the Plan does not have to pay for physician services (CPT 99350) provided to the enrollee on 
July 19, 2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says upcoding from this physician group is well known, and contact/discussion with the group has 
yielded no corrections to their incorrect billing. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99350 is "home visit by a physician or advanced 
practitioner such as a physician assistant (PA) or nurse practitioner (NP)." 
 
We asked our coding 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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our coding reviewer found the medical 
records provided documented that and the LVN, performed this service. This procedure does not fall within the 
scope of a Licensed Vocational Nurse, therefore this service is not eligible for reimbursement. 
 
We looked at this coder'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 pay for physician services (CPT 99350) provided to the enrollee on July 19, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided by a 
participating provider on April 12, 2020 to May 1, 2020. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you shouldn't have been 
transported from the hospital to begin with. The Plan denied your request. The Plan says the correct copayment 
has been 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 $200 
copayment for ambulance services/in-network/ground ambulance.  
 
You have been asked to pay a $200 copayment for ambulance services. The total amount you are being asked 
to pay is $400 ($200 x 2 trips = $400). Ambulance services fall within the ambulance services/in-
network/ground ambulance 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 
services provided by a participating provider on April 12, 2020 to May 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2750) for tooth #'s 10 and 11. 
 
You asked the Plan to pre-approve the crowns. The Plan denied your request. The Plan says this service is 
allowed one time every 60 months. The Plan also says that you had this service less than 60 months ago. 
 
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, crowns are limited to one per tooth per 
60 months. The record shows that you received a crown (D2750) on tooth #10 on November 26, 2019, and you 
received a crown (D2750) on tooth #11 on October 16, 2019, and your crowns benefit has been exhausted for 
tooth #'s 10 and 11. Therefore, we decided that the Plan does not have to pre-approve crowns (D2750) for tooth 
#'s 10 and 11.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee currently meets the rehabilitation 
admission criteria. You say that the needs cannot be met at the current level of care. The Plan denied your 
request. The Plan says Medicare coverage criteria has not been met. 
 
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 IRF level of therapies is not required given the current level of function. Our 
reviewer says that the enrollee's rehabilitation needs can be met in a lower intensity 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hot tub. 
 
You asked the Plan to pre-approve a hot tub. 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 a covered benefit. 
 
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 hot tub.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tacrolimus capsules (J7507). 
 
You asked the Plan to pre-approve Tacrolimus capsules. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is covered under Medicare Part D. 
 
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 Tacrolimus capsules 
(J7507).  
 
Benefits for Tacrolimus capsules may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you are unable to stand up in the shower due to 
the pain in your legs from your diabetes. You stated that you are unable to stand for long periods of time and 
you need the requested shower chair. You asked the Plan to reconsider providing coverage. The Plan denied 
your request. The Plan says this item is not a covered benefit. 
 
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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from February 24, 
2020 through February 27, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The 
Plan denied your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the records do not show that the physician reasonably expected that the patient's 
hospital care would span two midnights. Urinalysis was negative for infection and the patient had signs and 
symptoms suggestive of a viral enteritis which resolved and likely caused dehydration and worsening 
confusion as a result warranting short-term monitoring and intravenous (IV) fluids under observation status. 
Awaiting a urine culture result as an inpatient was not warranted. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from February 24, 2020 through 
February 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a special upper limb orthosis for the enrollee. 
 
You asked the Plan to pre-approve the orthosis. You say that this is medically necessary. The Plan denied your 
request. The Plan says further studies are needed to establish the clinical effectiveness and long-term safety of 
this device. 
 
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 orthosis. Our reviewer says that the 
requested orthosis is not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no evidence that the Myopro is proven to be more beneficial for treatment of the enrollee's 
medical condition of hemiparesis post stroke than any available standard therapy. There is not enough evidence 
in the literature that this device will increase bimanual activities of daily living or improve enrollee's 
hemiparesis from her stroke. 
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a special upper limb orthosis for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional transportation trips.
You asked the Plan to pre-approve additional transportation trips. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the requested services are not a covered
benefit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers a maximum of 24 one-way trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we
decided that the Plan does not have to pre-approve additional transportation trips.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from May 2, 2019 through 
May 4, 2019. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The 
Plan denied your request. The Plan says that the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found patient with acute new cerebrovascular accident (CVA) and it is reasonable to expect that 
patient will need to stay at least two midnights. Appropriate evaluation was done and patient left sooner as 
symptoms improved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from May 2, 2019 through May 4, 2019.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-share for ophthalmological Medical Exam & Eval; 
Comprehensive, New Patient, 1 + Visits (92004) and ophthalmic Ultrasound, Echography, Diagnostic; Corneal 
Pachymetry, Unilateral or Bilateral (76514) provided on March 9, 2020 by an in-network provider. 
 
You asked the Plan to waive the cost-share for the services. You say that your materials show that copay 
responsibility to be $15 for a Specialist Visit not $25 and $0.00 for Diagnostic Tests and Lab Services not 
$7.61. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC 
benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that you received ophthalmological Medical Exam & Eval; Comprehensive, New 
Patient, 1 + Visits (92004) and ophthalmic Ultrasound, Echography, Diagnostic; Corneal Pachymetry, 
Unilateral or Bilateral (76514). 
 
You are asked to pay a $25 copayment for the vision exam and a $7.61 copayment for the echography. Your 
EOC states, enrollees must pay a $25 copay for Medicare-covered diagnostic eye exam and Echocardiography 
with an approved amount from $1 to $300. 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 cost-share for 
ophthalmological Medical Exam & Eval; Comprehensive, New Patient, 1 + Visits (92004) and ophthalmic 
Ultrasound, Echography, Diagnostic; Corneal Pachymetry, Unilateral or Bilateral (76514) provided on March 
9, 2020 by an in-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oral sleep apnea device (E0486) to be provided by 
the out of network (OON) provider. 
 
You asked the Plan to pre-approve this device. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested item is available with an in-network 
provider. 
 
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 item at issue in this appeal. We found no exception that would require the Plan 
to pre-approve this item. Therefore, we decided that the Plan does not have to pre-approve an oral sleep apnea 
device (E0486) to be provided by the out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a backup battery for a portable oxygen concentrator. 
 
You asked the Plan to pre-approve the battery. You say that this is needed in case of a hurricane or emergency. 
The Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
A backup battery is not a covered benefit according to Medicare. Therefore, we decided that the Plan does not 
have to pre-approve a backup battery for a portable oxygen concentrator.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve the insertion of a CardioMEMS device (C2624, 33289).
You asked the Plan to pre-approve the insertion of a CardioMEMS device. You say that this is medically necessary. The Plan denied your request. The Plan says that this is experimental.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 insertion of a CardioMEMS device. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the patient has mildly depressed ejection fraction with Class III congestive heart failure (CHF) symptoms. He was recently hospitalized for dyspnea and underwent cath which revealed a non-ischemic cardiomyopathy with CHF with preserved eection fraction (EF). He has had multiple attempts at diuretic titration but remains quite symptomatic. In addition, recent medication titration has resulted in significantly worsening renal failure due to likely over-diuresis and more ineffective cardiac output. Cardiomems is FDA approved and has randomized published data for the indications of Class III CHF and prior hospitalization for CHF, especially when symptoms are not well controlled with medical therapy. In this instance the patient's medications and diuretics have been titrated repeatedly and he has even undergone outpatient IV diuresis without long-term relief of symptoms. Better day to day assessment of the exact state of his cardiac filling pressures would be medically useful to more carefully titrate diuretics and other cardiac medications for blood pressure and fluid control while hopefully improving his renal function. Cardiomems device would allow this closer titration of his volume status (which appears very difficult to assess clinically or by non-invasive means like weights) and is indicated for use in this clinical situation. It is FDA approved for this purpose, has randomized published data to support its use, would not be considered investigational and is medically necessary in this patient per Medicare rules. 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 insertion of a CardioMEMS device have been met. Therefore, we decided that the Plan has to pre-approve the insertion of a CardioMEMS device (C2624, 33289).
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the comprehensive oral evaluation and intraoral x-rays. 
 
You asked the Plan to pre-approve the comprehensive oral evaluation and intraoral x-rays. You say that you 
need a new prosthesis. You say that the dentist assisted you in the past and you are satisfied with their service. 
The Plan denied your request. The Plan says out-of-network dental services are not covered 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, out-of-network services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
comprehensive oral evaluation and intraoral x-rays.
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 an IRF admission is necessary in order to
rehabilitation faster and return home. The Plan denied your request. The Plan says the enrollee does not meet
the criteria for IRF services. The Plan says that the enrollee's current needs can be safely managed with a lower
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. Our
physician reviewer found the records do not indicate that there are significant, or complex medical/nursing
issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and
other medication management, skin care, and daily therapy can be provided at a SNF. The enrollee is mostly
moderate to minimal assist for functional transfers and activities of daily living. A less intensive, longer
duration of therapy will allow for measurable gains to be attained within a reasonable and predicted period. An
IRF intensity is not warranted.
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.