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

 
We decided that the Plan does not have to pay for Home infusion services provided on November 17, 2021 to 
November 24, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Home infusion services. You say that you would like to request reconsideration 
for payment. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services were not urgent or emergent. 
 
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 items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for Home infusion services provided on November 
17, 2021 to November 24, 2021 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has 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 that 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 medically necessary. Our physician reviewer found with multiple recent hospital readmissions for 
these issues, it is clear that this monitoring needs to be daily as the enrollee is recovering from heart failure. 
Documentation states that the enrollee has new weakness and endurance impairments. It will require a skilled 
therapist to monitor for signs or symptoms of cardiopulmonary decompensation as this is a new issue. From a 
practical matter, the enrollee requires both daily skilled nursing services and requires skilled therapy services 
which would be best suited in an inpatient SNF. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
 
 
 
 
 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: 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 daily 
skilled services are not necessary. Our physician reviewer found you have tolerated inpatient rehab services 
and continue to improve with daily skilled nursing and/or skilled therapy services. You could benefit from 
continued services at the current level of care. You have made slow progress with therapy, there is no 
indication that transfer to a skilled nursing facility is required. You can continue to receive skilled rehab 
services at the current IRF or be stepped down to a lower level of care when appropriate. There are no services 
offered at a SNF that are not offered at an inpatient rehab facility. 
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 massage therapy visits. 
 
You asked the Plan to pre-approve the massage therapy visits. You say that based on your experience, this 
therapy has been very helpful in addition to the exercises you do. The Plan denied your request. The Plan says 
services provided by athletic trainers, massage therapists, recreation therapists, kinesio therapists, low vision 
specialists or any other profession may not be billed as therapy services. The Plan also says that Medicare does 
not consider these services reasonable and necessary, and they are therefore excluded from your plan. 
 
 
 
 
 
 
 
 The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve 8 massage therapy visits.
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 IRF services are medically necessary. The Plan 
denied your request. The Plan says 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 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'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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the upper 
extremity. 
 
You asked the Plan to pre-approve an MRI. The Plan denied your request. The Plan says you have not 
completed six weeks of provider directed treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 an MRI. Our physician reviewer found 
that you have right shoulder pain of unspecified duration. A physical exam showed normal range of motion. 
There are no red flags apparent in the supplied records to mandate immediate MRI without a trial of 6 weeks of 
physical therapy. Therefore, the requested MRI is not medically reasonable or 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 an MRI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve magnetic resonance imaging (MRI) of the upper extremity.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve replacement of a wheelchair with a power wheelchair, 
group 3 very heavy duty (K0860). 
 
You asked the Plan to pre-approve replacement of a power wheelchair. You say that the requested wheelchair 
is medically necessary. The Plan denied your request. The Plan says the power wheelchair is specifically 
requested for use outside the home, which is not a covered indication per Medicare. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 
 
 The file shows that the enrollees current power wheelchair is from February 2018. There is no documentation 
to show that the current wheelchair is worn beyond repair or that it requires replacement. The current 
wheelchair is less than five years; therefore, replacement is not covered during the reasonable useful lifetime of 
the equipment. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we 
decided that the Plan does not have to pre-approve replacement of a wheelchair with a power wheelchair, group 
3 very heavy duty (K0860).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not support the need for a skilled physical therapist to make more home 
visits at this time. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that in this case, 
the documentation doesnt support that the enrollee requires additional skilled rehab services to provide 
treatment that is medically necessary. The enrollee does not require additional skilled rehab services to 
effectively provide treatment, care, and/or services in order to improve the members condition, perform a 
maintenance program to maintain the members condition and/or prevent deterioration. The enrollee has been 
medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The 
requested home health services 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home health services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic continuous glucose monitor (K0554) and 
therapeutic CGM Supply (K0553). 
 
You asked the Plan to pre-approve the CGM monitor and supply. You say that the medical records provided 
will show proof of medical necessity. The Plan denied your request. The Plan says the records do not support 
that the enrollee meets the Medicare criteria for therapeutic CGM. 
 
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 the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the CGM monitor and supply have not been met. 
Therefore, we decided that the Plan does not have to pre-approve therapeutic continuous glucose monitor 
(K0554) and therapeutic CGM Supply (K0553).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest (71250). 
 
You asked the Plan to pre-approve a CT scan of the chest. You say that this imaging is medically reasonable 
and necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 a CT scan of the chest. Our reviewer 
says that the requested CT scan services are not medically reasonable and necessary. Our physician reviewer 
found in this case, no physical exam or other documentation is present in the records. The medical necessity of 
the requested CT of the chest has not been illustrated in the submitted records despite multiple attempts by the 
plan to obtain documentation that supports the medical necessity. 
 
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 CT scan of the chest have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a computed tomography (CT) scan of the chest (71250).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that there is no need to transfer to the LTACH at this time. 
 
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. The enrollee 
is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the 
LTACH that are not available at the acute care hospital where he is currently receiving care. There are no 
services available at the LTACH that the enrollee requires that are not available at the health care setting being 
offered by the health plan. Our physician reviewer found that the enrollee's condition does not meet Medicare 
criteria for LTACH services. 
 
 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi electric hospital bed (E0260) and transport chair, 
adult size, patient weight capacity up to and including 300 pounds E1038. 
 
You asked the Plan to pre-approve the hospital bed and transport chair. You say that please review the attached 
document with the authorization request. The Plan denied your request. The Plan says records do not support 
medical necessity of the requested items. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of a semi electric hospital bed (E0260) 
and transport chair, adult size, patient weight capacity up to and including 300 pounds E1038 have been met. 
Medical records was required to determine medical necessity of the requested items. The Plan made several 
attempts to obtain the needed records from the provider without success. Therefore, we decided that the Plan 
does not have to pre-approve a semi electric hospital bed (E0260) and transport chair, adult size, patient weight 
capacity up to and including 300 pounds E1038.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mandibular partial denture (D5214) provided on October 
28, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the mandibular partial denture. You say that you would like to appeal this 
service. The Plan denied your request. The Plan says this service was rendered by a non-contracted provider, 
and there is no evidence of a pre-authorization. 
 
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. Although your plan has a Point of 
Service (POS) benefit, authorization is still required to see any OON providers. The Plan did not pre-approve 
the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the mandibular partial denture (D5214) provided 
on October 28, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve an MRI of the upper extremity. 
 
You asked the Plan to pre-approve an MRI of the upper extremity. The Plan denied your request. The Plan says 
that the MRI does not meet the Medicare NCD coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 an MRI of the upper extremity. Our 
reviewer says that an MRI is medically necessary. Our physician reviewer found that the enrollee continues to 
have right shoulder pain despite full course of physical therapy and medication. The enrollee fulfills the 
accepted criteria for medical necessity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the upper extremity have been met. Therefore, we decided that the 
Plan has to pre-approve an MRI of the upper extremity.  
 
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 home-delivered meals (S5170 x 56). 
 
You asked the Plan to pre-approve home delivered meals. You say that the enrollee was diagnosed with a 
congestive heart failure in 2021. The Plan denied your request. The Plan says the requested services were 
denied correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home delivered meals have not been met. Specifically, the file does not indicate that the enrollee 
had a qualifying diagnosis at the time of discharge for this service. Therefore, we decided that the Plan does not 
have to pre-approve home-delivered meals (S5170 x 56).