Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has been waiting since she was 
discharged from the hospital on July 18, 2022. The Plan denied your request. The Plan says the enrollee's 
current level of function does not support that an intensive, complex, multidisciplinary approach to daily 
therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for stroke and was discharged home on July 18, 2022. There is ongoing weakness. The enrollee's 
medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for colonoscopy and moderate sedation services provided to the enrollee 
on June 1, 2021. 
 
You asked the Plan to pay for the services. You say that the cost of the services should have been covered. The 
Plan denied your request. The Plan says that these codes are not covered by Medicare in this setting. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan has not forwarded enough information to substantiate their denial. The 
plan has not specified exactly which services have been paid, and which services are still at issue in this case. 
The plan did not provide any medical records to confirm what type of colonoscopy was rendered. Therefore, 
we decided that the Plan has to pay for colonoscopy and moderate sedation services provided to the enrollee on 
June 1, 2021.  
 
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 power operated vehicle, group 1 standard, patient 
weight capacity up to and including 300 pounds (K0800). 
 
You asked the Plan to pre-approve a power operated vehicle, group 1 standard. You say that you have always 
been impaired by multiple surgeries on your legs and back. You cannot walk without intense pain and would 
like to have some mobility. The Plan denied your request. The Plan says your request is not a covered benefit 
because your records show you do not have an intent to use the power scooter in your home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a power operated vehicle, group 1 standard, patient weight capacity up to and including 
300 pounds (K0800).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 5, 2021 billed with 
codes 81406, 81405, 81404, 81403, 81402, 81401, 81400, 81321, 81275, 81270, 81235, 81210, 81201, 81314, 
81311, 81310, 81293, 81276, 81272, 81121, 81120. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says this claim was not billed in 
accordance with Medicare billing regulations. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
February 5, 2021 billed with codes 81406, 81405, 81404, 81403, 81402, 81401, 81400, 81321, 81275, 81270, 
81235, 81210, 81201, 81314, 81311, 81310, 81293, 81276, 81272, 81121, 81120.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
reader (K0554) and sensor (K0553). 
 
You asked the Plan to pre-approve a Freestyle Libre CGM and related supplies. You say that the requested 
items are a medical necessity for you. The Plan denied your request. The Plan says rules for payment for CGMs 
and related supplies have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre CGM and related supplies have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre continuous glucose monitor (CGM) reader (K0554) and sensor (K0553).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. You say that the scooter would give you the autonomy to 
go around in the community. The Plan denied your request. The Plan says your power wheelchair is in good 
working condition. 
 
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. 
 
The file shows that you have a power mobility device. Your current device serves the same purpose as the 
requested power scooter. Requested scooter is for use outside of the home. Although this item may be helpful, 
neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan 
does not have to pre-approve a power scooter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on February 15, 2022. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says this testing is a statutorily excluded 
service based on the services rendered. 
 
The Plan must follow Medicare rules. Medicare rules say that panels of tests that include the FANCC gene are 
non-covered. 
 
We looked at the file and Medicare rules. Review of the file shows that the next generation sequence testing 
panel included testing for the FANCC gene. This means this entire panel is not covered. Based on this 
information, we decided that Medicare rules for coverage of the genetic testing services have not been met. 
Therefore, we decided that the Plan does not have to pay for the genetic testing services provided on February 
15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve voice-controlled window blinds. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
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 voice-controlled window blinds.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Budesonide inhalation suspension. 
 
You asked the Plan to pre-approve Budesonide inhalation suspension. You say that the requested drug is 
medically necessary for treatment of the enrollee's eosinophilic esophagitis. The Plan denied your request. The 
Plan says the requested drug is not being administered via nebulizer for the treatment of obstructive pulmonary 
disease. The Plan says that the requested drug in this circumstance is not covered under part B. The Plan says 
that this Medicare Advantage Plan does not cover outpatient prescription drugs. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Budesonide inhalation 
suspension.  Benefits for Budesonide inhalation suspension 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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the unlisted molecular pathology procedure (81479) provided on 
December 20, 2021, by an out-of-network provider. 
 
You asked the Plan to pay for the unlisted molecular pathology procedure. You say that these services were 
authorized by an in-network physician. The Plan denied your request. The Plan says that the services were 
provided out-of-network. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the unlisted molecular pathology procedure by a contract provider. The file does 
not show that the plan provided notice that the unlisted molecular pathology procedure would not be covered. 
Under Medicare rules, this means the unlisted molecular pathology procedure is considered approved by the 
plan. Therefore, we decided that the Plan has to pay for the unlisted molecular pathology procedure (81479) 
provided on December 20, 2021, by an out-of-network provider.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance on February 25, 2022. 
 
You asked the Plan to waive the copayment for ambulance. You say that you were told that you would not have 
to pay for it. The Plan denied your request. The Plan says the cost-sharing 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 a $225 
copayment for each Medicare-covered service or one-way trip by ground transportation. Worldwide 
Ambulance Coverage. Covered ambulance services include fixed wing, rotary wing, and ground ambulance 
services, to the nearest appropriate facility that can provide care if they are furnished to a member whose 
medical condition is such that other means of transportation could endanger the persons health or if authorized 
by the plan. 
 
 
 
 You have been asked to pay a $225 copayment for ambulance. Ambulance 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 on February 25, 
2022.
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 requested admission to an IRF is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
   
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 seven days after an amputation for gangrene, the enrollee was functioning at a home 
care level. By his own performance the enrollee does not require intensive rehabilitation or require frequent 
physiatry oversight. 
 
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 bi-level positive airway pressure (BiPAP) device 
(E0470). 
 
You asked the Plan to pre-approve a BiPAP device. You say that the requested item is a medical necessity for 
you. The Plan denied your request. The Plan says rules for coverage for a BiPAP device have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that continued coverage of a PAP device beyond the 
first three months of therapy requires documentation of clinical benefit, demonstrated by in-person clinical re-
evaluation by the treating practitioner with documentation that symptoms of obstructive sleep apnea are 
improved and objective evidence of adherence to therapy. Adherence to therapy is defined as use of PAP 
greater than or equal to 4 hours per night on 70 percent of nights during a consecutive thirty (30) day period 
anytime during the first three (3) months of initial usage. 
 
We looked at the file and Medicare rules. The available medical records do not document a use of the requested device greater than or equal to 4 hours per night on 70 percent of nights during a consecutive 30-day period 
anytime during the first 3 months of initial usage. Based on this information, we decided that Medicare rules 
for coverage of a BiPAP device have not been met. Therefore, we decided that the Plan does not have to pre-
approve a bi-level positive airway pressure (BiPAP) device (E0470).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy visits from December 06, 2021, to April 11, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient mental health. You say that you would like to see this provider 
allowed to be paid for his services, even though he is out-of-network. The Plan denied your request. The Plan 
says the services were provided out-of-network and were not approved in advanced. 
 
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 had network providers 
available who could have provided the psychotherapy visits at issue in this appeal. The Plan did not pre-
approve the psychotherapy visits at issue. We found no exception that would require the Plan to pay for these 
psychotherapy visits. Therefore, we decided that the Plan does not have to pay for psychotherapy visits from 
December 06, 2021, to April 11, 2022, by an out-of-network (OON) provider.
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 requested admission to an IRF is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have intensive or complex rehabilitation needs. Intensive 
rehabilitation is not medically necessary following a hip fracture repair. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continued skilled nursing facility (SNF) admission and 
services from July 3, 2022, forward. 
 
You asked the Plan to pre-approve continued SNF care. You say that you are unable to move on your own or 
transfer from chair to chair and still requires therapy. The Plan denied your request. The Plan says based on 
Medicare guidelines, your request for approval of continued admission in a SNF does not meet the 
requirements for approval.  
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve continued SNF care. Our reviewer says 
that continued SNF care is not medically reasonable and necessary from July 3, 2022, forward. Our physician 
reviewer found that you do not have daily skilled nursing needs that require the specialized skill, knowledge, 
and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled 
nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a continued skilled nursing facility (SNF) admission and services from July 3, 
2022, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the recreation center membership purchased on December 
14, 2021. 
 
You asked the Plan to pay for the recreation center membership. You say that you do not understand how the 
enrollee's maximum amount was exhausted because the membership runs from January 12, 2022, to January 
11, 2023. The Plan denied your request. The Plan says the annual maximum benefit limit has been reached. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a combined 
total of up to $240 per year for membership in health club/fitness classes, health education, nutritional benefits, 
weight management programs, in-home safety assessments, and home/bathroom safety devices. 
 The Plans rules for coverage of gym benefits have not been met because the record shows that your Wellness 
Your Way benefit was exhausted on January 12, 2021. Since the enrollee purchased another membership for 
January 12, 2022, to January 11, 2023, during the 2021 benefit year, the payment would apply toward the 
enrollees 2021 benefits. Therefore, we decided that the Plan does not have to pay for the recreation center 
membership purchased on December 14, 2021.