Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve K1022 and L5695. We decided that the Plan does not have to pre-
approve L5964.  
 
You asked the Plan to pre-approve additional features for a prosthesis (K1022, L5695, L5964).. You say that 
this is medically necessary. The Plan says that this is not medically necessary. 
 
 We decided that the Plan has to pre-approve K1022 and L5695.  
 
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 for K1022 and L5695. Our reviewer says that the 
enrollee is a K3 level ambulator and requires a transfemoral prosthesis for mobility and accomplishing his daily 
activities. His current prosthesis no longer functions properly and requires replacement. The prosthetic socket 
no longer fits appropriately due to the patient losing weight and the knee and foot/ankle components are 
malfunctioning. The prosthetic positional rotation unit or adaptor (K1022) is required to attach the prosthetic 
knee unit to the prosthesis and the suspension sleeve (L5695) is required to ensure proper fit of the patients 
residual limb and suspension of the prosthetic socket. 
 
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 features have been met. Therefore, we decided that the Plan has to pre-
approve K1022 and L5695.  
 
We also decided that the Plan does not have to pre-approve L5964. 
 
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 for L5964. Our reviewer says that while the 
documentation indicates that the covering system (L5964) is required to protect the patients prosthesis from 
the environment, there is insufficient documentation indicating how this is the case and why is it necessary for 
the patients function or work. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L5964 have not been met. Therefore, we decided that the Plan does not have to 
pre-approve L5964. 
 
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 ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found provided records document that the 
enrollee has chronic respiratory failure consequent to chronic obstructive pulmonary disease. The home 
ventilator is being requested for use in average volume assured pressure support (AVAPS) mode with auto-
titration (AE) which could be provided by a bilevel positive airway pressure (BiPAP) device with AVAPS and 
a back-up rate. As stated in the Local Coverage Determination (L33800): Claims for ventilators used to provide CPAP or bi-level CPAP therapy for conditions described in this RAD policy will be denied as not 
reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a rest home visit (99336) provided on August 24, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the rest home visit. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and prior authorization was not obtained. 
 
  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 a rest home visit (99336) provided on August 24, 
2022, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided on March 1, 2022, to 
March 11, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient hospital services. You say that these services were medically 
necessary. The Plan denied your request. The Plan says prior authorization must be obtained for services 
provided out-of-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 outpatient hospital services provided on March 1, 
2022, to March 11, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment (DME) 
provided on July 13, 2022. 
 
You asked the Plan to waive the coinsurance for DME. You say that you disagree with the coinsurance. The 
Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 10% 
coinsurance for Durable medical equipment (DME).  
 
You have been asked to pay a 10% coinsurance for DME. The total allowed amount for the DME is $4,962. 
You are being asked to pay $496.20 ($4,962 x 10%= 496.20). 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 coinsurance 
for durable medical equipment (DME) provided on July 13, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance ride provided on May 07, 
2022. 
 
You asked the Plan to waive the copayment for an ambulance ride. You say that you should not have to pay 
this copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $250 
copayment for ambulance services. 
 
You have been asked to pay a $250 copayment for an ambulance ride. This item/service 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 an ambulance ride 
provided on May 07, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Xgeva. 
 
You asked the Plan to pre-approve Xgeva. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Xgeva. Our reviewer says that the 
services are medically necessary. Our physician reviewer found in this case, the record indicates that the 
enrollee has a diagnosis of prostate cancer with bone metastases. The enrollee has a albumin corrected calcium 
of 8.7 which is considered normocalcemia. The Food and Drug Administration has stated that the requested 
drug is indicated for the enrollee's condition. The elements of the coverage criteria are satisfied. The requested 
service is recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Xgeva have been met. Therefore, we decided that the Plan has to pre-approve 
Xgeva.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ophthalmology office visits to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the ophthalmology office visits. You say that you would like to see the 
OON provider because they provide you the best care for your eyes. The Plan denied your request. The Plan 
says the requested provider is an OON provider and there are multiple in-network providers that can met the 
enrollee's medical needs. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the ophthalmology office visits to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
June 20, 2022 to June 23, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that the services should be 
covered as you disagree with the denial. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
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 $325 
copayment per day for days 1-6 of Inpatient hospital care.  
 
 
  You have been asked to pay a $650 copayment for 2 days of inpatient hospital care. This item/service falls 
within the Inpatient hospital care benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
an inpatient hospital stay provided from June 20, 2022 to June 23, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Part B drugs on January 19, 2022, to June 
15, 2022. 
 
You asked the Plan to waive the coinsurance for Part B drugs. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a 20% coinsurance for Medicare Part B non-chemotherapy prescription drugs. Covered drugs include 
drugs that usually arent self-administered by the patient and are injected or infused while you are getting 
physician, hospital outpatient, or ambulatory surgical center services. The provider billed in the amount of 
$2,867.48 and the allowed amount is $1,622.96. $1,622.96 x 20% = $324.59. The provider also billed in the 
amount of $3,584.35 and the allowed amount is $2,028.70. $2,028.70 x 20% = $405.74. The provider also 
billed in the amount of $3,584.35 and the allowed amount is $1,934.10. $1,934.10 x 20% = $386.82. $386.82 x 
2 = $773.64. $324.59 + $405.74 + $773.64 = $1,503.97. Therefore, resutls in the total cost sharing amount of 
$1,503.97. The enrollee has been asked to pay a 20% coinsurance for Part B drugs. This item/service falls within the 
Medicare Part B prescription drugs benefit category. This means that the enrollee has been asked to pay the 
correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee 
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the 
coinsurance for Part B drugs on January 19, 2022, to June 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient hospital stay provided from July 24, 2022, to 
July 27, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an inpatient hospital stay. You say that you are appealing with supporting 
records to support medical necessity. The Plan denied your request. The Plan says the enrollee must receive 
care from a 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 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 an inpatient hospital stay provided from July 24, 
2022, to July 27, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on July 
11, 2022 
 
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you disagree with the 
coinsurance The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance for Medicare Part B drugs. The total allowed amount for the 
Medicare Part B drugs is $250. You are being asked to pay $50 ($250 x 20% = $50). 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 coinsurance for Medicare Part B drugs provided on July 11, 2022
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on April 29, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that it was medically necessary to treat the 
enrollee and you would like the claim reprocessed. The Plan denied your request. The Plan says the rendering 
provider is an OON provider and there was no referral from an in-network provider or an approved 
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. 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 the nursing facility care provided on April 29, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 23, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you thought the provider was an in-network 
provider. The Plan denied your request. The Plan says the rendering provider is an OON provider and there 
was no approved authorization. Also, the service rendered was 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 an office visit provided on June 23, 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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you cannot walk or stand up. You also say that you 
were diagnosed with apathy in the legs and left arm. The Plan denied your request. The Plan says your clinical 
condition does not meet Medicare criteria for acute inpatient rehabilitation admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  You have a past medical history of multiple sclerosis, lumbar disc herniation, bipolar disorder and urinary 
retention. You are living at home with lower extremity weakness. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. While you may benefit from additional multiple therapies, including 
physical and occupational therapy, the documentation does not reveal you require this therapy on an intensive 
IRF level. Medically necessary care can be provided a in a different 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested device is medically necessary. 
The Plan denied your request. The Plan says a BiPAP device with AVAPS would meet all the needs requested 
by the provider. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found a home ventilator is not 
medically necessary.  This patient has chronic hypercarbic respiratory failure related to obesity-hypoventilation 
syndrome.  The patient does not have chronic obstructive pulmonary disease (COPD), thoracic restrictive 
disease, or neuromuscular disease.  The patient was shown during a recent hospital stay to substantially improve the partial pressure of carbon dioxide (PaCO2) while on BiPAP with AVAPS, and the patient may 
benefit from this device during sleep, as an outpatient. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.