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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 
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 SNF care. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found records do not document the need for 
intravenous medications, new tube feeding, ostomy care, daily complex wound care or respiratory care. There 
is no documentation that daily skilled services are required. Although records document the enrollee is very 
limited functionally, provided records do not document she is able to meaningfully participate with daily 
inpatient skilled therapy services. The enrollee does not require the services on an inpatient basis, only in a 
skilled nursing facility setting. Records do not document that services in the home with home health care or in 
a long-term care facility on a part time basis are not appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided March 3, 2022. 
 
You asked the Plan to pay for the orthosis. You say that the claim denied for records not received, however the 
records were completed on availability within the time frame allowed. This claim met all of Medicare's DME LCD coverage criteria. The Plan denied your request. The Plan says the records do not support the billed 
service; missing documentation. 
 
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 pay for the orthosis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found provided records do not document a need to reduce pain by restricting mobility of the trunk or 
to facilitate healing following an injury to the spine or related soft tissues or to facilitate healing following a 
surgical procedure on the spine or related soft tissue or to otherwise support weak spinal muscles and/or a 
deformed spine. 
 
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 pay for the lumbar-sacral orthosis (L0650) provided March 3, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten additional physical therapy visits. 
 
 
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee is receiving repetitive exercise without documentation of 
response to the program, or evidence that unique input of a skilled therapist is medically necessary. 
 
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 additional 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 per a physical therapy progress note dated 5 23 2022, the patient 
continues to have deficits with balance, especially when walking outside of the home and on uneven surfaces 
The patient does report of a history of falls but also being noncompliant with use of a walker outside of the 
home. The physical examination showed four out of five motor strength in the lower extremities. A physical 
therapy discharge summary dated 3/10/2022 indicated that the patient was noted to have four out of five motor 
strength in the lower extremities. There is inadequate documentation provided in terms of objective outcome 
measures demonstrating that the patient continues to make progress with the skilled services of a physical 
therapist. The continued physical therapy can be considered maintenance in nature and does not require the 
skilled services of a physical therapist. Therefore, the continued physical therapy can be considered 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 the additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve ten additional physical therapy visits.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home infusion medication (J1170) and supplies (A9900) 
from the home infusion supplier. 
 
You asked the Plan to pre-approve the home infusion refill equipment. You say that this infusion equipment 
from the home infusion supplier should be covered. The Plan denied your request. The Plan says this payment 
is included in the payment that is made incident to the provider responsible for refilling the infusion pump. 
 
The Plan must follow Medicare rules. Medicare rules say that prolonged drug and biological infusions that start 
'incident to' a physician's service using an external pump should be treated as an 'incident to' service and cannot 
be billed on suppliers' claims.  
 
We looked at the file and Medicare rules. In this case, the documentation confirms you are refilling the infusion 
pump in the providers office not the home health setting. These services are covered under the incident to 
benefit and will not be covered when requested from the home infusion supplier. Based on this information, we 
decided that Medicare rules for coverage of the home infusion refill equipment have not been met. Therefore, we decided that the Plan does not have to pre-approve home infusion medication (J1170) and supplies (A9900) 
from the home infusion supplier.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the general health panel provided on January 5, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-
covered code. 
 
You have requested payment for services billed under code 80050. Medicare does not cover or pay for services 
billed under this code. Therefore, we decided that the Plan does not have to pay for the general health panel 
provided on January 5, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continue skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve continue skilled nursing facility (SNF) services. You say that the enrollee 
does not meet the goals and needs to continue in a skilled nursing facility. The Plan denied your request. The 
Plan says the enrollee 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 continue skilled nursing facility (SNF) 
services. Our reviewer says that there are no identifiable skilled nursing service needs. Our physician reviewer 
found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and 
judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does 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 continue skilled nursing facility (SNF) services have not been met. Therefore, 
we decided that the Plan does not have to pre-approve continue skilled nursing facility (SNF) services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve a skilled nursing facility (SNF) admission. You say that you feel you need 
the rehabilitation to fully function to be safe. The Plan denied your request. The Plan says based on submitted 
medical records and the Medicare Benefit Policy Manual you do not meet criteria for SNF admission. 
 
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 a skilled nursing facility (SNF) 
admission. Our reviewer says that there is no indication for daily skilled therapy. Our physician reviewer found 
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. Our reviewer also found that 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 a skilled nursing facility (SNF) admission have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six additional physical therapy visits. 
 
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan 
denied your request. The Plan says the therapy notes that there has been instruction in a home exercise 
program. 
 
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 additional 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 there are no medical notes from your treating physician provided 
documenting an order or need for additional skilled therapy services. The provided records show no 
documentation that additional home health skilled therapy services are required to effectively provide 
treatment, care, and/or services in order to improve your level of function, or to establish/perform a 
maintenance program to maintain your level of function and/or prevent deterioration. You have been instructed 
in a home exercise program. The records do not document any acute or unstable medical conditions or changes 
in function which would necessitate any further skilled therapy visits beyond what have already been approved. 
 
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 additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve six additional physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel provided on 
December 1, 2021. 
 
You asked the Plan to pay for the targeted genomic sequence analysis panel. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not a 
covered benefit.  
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The documentation shows that this the targeted genomic sequence analysis panel included testing for 51 or 
more genes. This means that the targeted genomic sequence analysis panel at issue in this appeal was requested 
solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we 
decided that the Plan does not have to pay for the targeted genomic sequence analysis panel provided on 
December 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 22, 2021. 
 
You asked the Plan to pay for 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 the PC and TC for diagnostic services are separately 
payable when furnished in different payment localities. 
 
We looked at the file and Medicare rules. The file shows that the PC and TC were not performed in different 
payment localities. Based on this information, we decided that Medicare rules for coverage of these services 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
rendered on July 22, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a nerve cryoablation procedure (0441T) provided on January 18, 2022. 
 
You asked the Plan to pay for a nerve cryoablation. You say that the services at issue were a medical necessity 
for you. The Plan denied your request. The Plan says that rules for payment have not been met because the 
services at issue are experimental/investigational. 
 
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. Specifically, the Plan has denied the services at issue as not medically necessary 
because the services are experimental/investigational. The Plan has not provided medical records for us to 
independently review the medical necessity of the services at issue. It is the Plan's responsibility to substantiate 
its denial. In this case, the denial has not been substantiated with medical documentation, so we must find in 
your favor. Therefore, we decided that the Plan has to pay for a nerve cryoablation procedure (0441T) provided 
on January 18, 2022.  
 
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 MyoPro orthosis (L8702). 
 
You asked the Plan to pre-approve a MyoPro orthosis. You say that the item at issue is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the 
item at issue is experimental/investigational. 
 
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 MyoPro orthosis. Our reviewer says 
that the item at issue is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that current clinical guidelines designate robotic therapy to be of "uncertain utility compared with dose-
matched conventional upper limb exercise therapies" with unproven benefit in the home environment. 
 
 
  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 MyoPro orthosis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a MyoPro orthosis (L8702).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional routine transportation trips. 
 
You asked the Plan to provide additional transportation. You say that you will need ongoing transportation 
services to get to your appointments. The Plan denied your request. The Plan says your benefit covers a 
maximum of 10 transportation trips. Additional trips 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 Plans coverage rules apply in this 
case. The Plan covers a maximum of 10 trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that your request exceeds the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to provide additional routine transportation trips.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pregabalin capsule. 
 
You asked the Plan to pre-approve Pregabalin. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested drug is considered self-administered. The 
Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also 
says the requested drug is not covered under Medicare Part B. 
 
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 Pregabalin capsule.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic eye exam provided on 
December 15, 2021. 
 
You asked the Plan to waive the copayment for the eye exam. You say that you thought it was a routine exam 
for glasses. 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 $40 
copayment for each eye exam.  
 
You have been asked to pay a $40 copayment for the eye exam. The eye exam falls within the Vision 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 diagnostic eye exam provided 
on December 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exam (92014) provided on March 
8, 2022. 
 
You asked the Plan to waive the copayment for the eye exam. You say that you expected to owe a $35 
copayment for a specialist office visit. The Plan denied your request. The Plan says this claim was processed 
correctly, and your copayment was assessed in accordance with your contract. 
 
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 $45 
copayment for each Medicare-covered visit for the diagnosis and treatment of diseases and injuries of the eye.  
 
You have been asked to pay a $45 copayment for the eye exam. An eye exam falls within the Medicare-
covered visit for the diagnosis and treatment of diseases and injuries of the eye 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 eye exam (92014) provided on March 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair and a bathtub wall rail. 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says these items are not a covered benefit under your 
contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature. Additionally, grab bars are not covered because they are considered self-help 
items that are not primarily medical in nature. 
 
While a shower chair and a bathtub wall rail may be appropriate for you in this case, neither the Plan nor 
Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve a 
shower chair and a bathtub wall rail.