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

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport provided on July 10,  2022. 
 
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport. You say that 
the transport was medically necessary due to patient being 94 years old with a wrist fracture and hip pain. The 
Plan denied your request. The Plan says his claim does not meet the medical criteria for the ambulance 
transport. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance service, basic life support, 
non-emergency transport. Our reviewer says that the ambulance transport was not medically necessary.  
 Our physician reviewer found the transportation via ambulance to the enrollee's living facility was not 
medically necessary.  The enrollee was not bedbound, as evidenced by the ability to stand pivot transfer and 
stand. The enrollee did not require the expertise of trained personnel or the equipment available only on an 
ambulance in order to effectuate a safe transport.  Transportation could have been provided by other means 
(stretcher van, wheelchair van, car taxi) without endangering the enrollee's condition. 
 
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 ambulance service, basic life support, non-emergency transport have not 
been met. Therefore, we decided that the Plan does not have to pay for the ambulance service, basic life 
support, non-emergency transport provided on July 10,  2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an in-network exception for Koya Dayspring Active 
Compression Garment system (K1024 and K1033) to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the services. You say that the system is medically necessary. The Plan 
denied your request. The Plan says there is insufficient evidence in the medical literature to demonstrate that 
the Koya Dayspring Active Compression Garment System is an effective treatment modality for the diagnosis 
of lymphedema, providing lasting relief, as compared to other treatment modalities. The Plan states the device 
has Bluetooth technology and a companion application that exceeds your medical need. The Plan states the 
services are therefore not reasonable or medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided documentation does not sufficiently describe a prior trial of standard treatment for 
lymphedema including pneumatic compression or basic compression stockings to justify this request. It was not 
clearly described in the current literature via high quality studies that Koya Dayspring Active Compression 
Garment System is an effective treatment modality for the diagnosis of lymphedema, providing lasting relief, 
as compared to other treatment modalities. Therefore, this request for such will be considered not medically 
necessary at this time. Furthermore, the requested provided is out-of-network with the Plan. 
 
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 an in-network exception for Koya Dayspring Active Compression Garment system (K1024 
and K1033) to be provided by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided on July 6, 2021, through July 19, 2021, billed with diagnosis code A41.9.

You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that primary diagnosis code A41.9 is supported by the records. The Plan denied your request. The Plan says the documentation submitted does not support primary diagnosis of A41.9.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.

In this case, you billed the inpatient services provided with primary diagnosis code A41.9 - (Sepsis, unspecified organism). 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 inpatient hospital services at the DRG originally billed. Our reviewer says that the documentation does not support the primary diagnosis code A41.9 - (Sepsis, unspecified organism). Our physician reviewer found the member presented with failure to thrive and a history of extensive ear and mastoid disease. There was initial concern that the member had mastoiditis/sepsis, but advanced imaging showed no evidence of acute mastoid disease. The member was, however, found to have progressive temporomandibular joint dysfunction (TMJ) disease and autoimmune thyroiditis. A diagnosis of sepsis is not supported, and it appears that thyroiditis was not billed/coded.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided on July 6, 2021, through July 19, 2021, billed with diagnosis code A41.9.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage. 
 
You asked the Plan to pre-approve additional mileage. You say that the enrollee's oncology/hematology office 
is 63 miles away, and there is no specialist in the enrollee's area that accepts their insurance. The Plan denied 
your request. The Plan says this service is a non-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 routine transportation when a one-way trip does not exceed 50 miles. 
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, this request exceeds 
the mileage limit by 13 miles. Therefore, we decided that the Plan does not have to pre-approve additional 
mileage.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are only covered under 
certain medical indications.  
 
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 requested services. Our physician 
reviewer found that the enrollee has chronic low back pain.  She had RFA of the medial branches at L4-L5 and L5-S1 on December 6, 2022. She had 100% pain relief. 
However, her pain has returned after 4 months. The coverage criteria requires 6 months of at least 50% pain 
relief and this has not been achieved. Therefore, the require is deemed not medically 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the low vision consult and care to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the low vision consult and care. You say that the service should be covered. 
The Plan denied your request. The Plan says there are in-network providers that can perform this service. 
 
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 low vision consult and care 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 pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee will benefit from LTACH 
services to receive the care needed. The Plan denied your request. The Plan says the enrollee is receiving 
appropriate inpatient acute care and is currently unstable for transfer to an LTACH. 
 
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. Our 
physician reviewer found there is no documentation provided indicating medical necessity for admission to a 
LTACH. 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 they are currently 
receiving 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 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.
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 a home ventilator is medically necessary for 
this patient. The Plan denied your request. The Plan says the patient's condition can be managed with bi-level 
positive airway pressure (BiPAP) with average volume-assured pressure support (AVAPS). 
 
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 a home ventilator is not medically necessary. Our physician reviewer found the record indicates that the 
enrollee has chronic respiratory failure from chronic obstructive pulmonary disease. The provided primary 
source documentation does not contain sufficient detailed information in the medical record to justify the 
treatment selected. The enrollee could be treated with a BiPAP machine with AVAPS capability.  The plan has 
indicated coverage for such a device is available upon request. 
 
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.
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 are requesting reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says you do not meet the medical necessity criteria 
for an IRF 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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided 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 Dexcom G7 receiver and sensor. 
 
You asked the Plan to pre-approve the Dexcom G7. You say that the requested Dexcom G7 is medically 
necessary. The Plan denied your request. The Plan says that only the preferred brand products listed in the EOC 
are covered. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for diabetic test strips or monitors. Therefore, we decided that the Plan does not have to pre-approve a Dexcom 
G7 receiver and sensor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a personal emergency response system. 
 
You asked the Plan to pre-approve a personal emergency response system. You say that your medical team 
advised you would benefit greatly from a medical alert system, a shower chair, and physical therapy. You say 
that the medical alert system was denied. You also say that you would appreciate assistance in having your 
insurance help with the cost of these services. The Plan denied your request. The Plan says the requested device 
is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a personal emergency response system.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit, shingles vaccine, and 
administration provided on March 23, 2022. 
 
You asked the Plan to pay for the outpatient office visit, shingles vaccine, and administration. You say that 
your primary care physician (PCP) offered to give you the shingles vaccination, you asked the PCP if you 
would be charged for the shingle vaccination, and the PCP expressed verbally at the time that no, it is a covered 
charge, and the office can administer the vaccination. You also say that you would have never gotten the shot if 
you knew you would have been charged in the sum of $529.38. The Plan denied your request. The Plan says 
their first decision to deny coverage and/or payment for the service was right. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the outpatient office 
visit, shingles vaccine, and administration. The Plan follows the same rules.  
 
 Records do not show that you have been injured or directly exposed to any illness related to the outpatient 
office visit, shingles vaccine, and administration. Therefore, we decided that the Plan does not have to pay for 
the outpatient office visit, shingles vaccine, and administration provided on March 23, 2022.  
 
Benefits for the shingles vaccine 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision item or service (V2799) and bifocal lens (V2200) 
provided on December 15, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the vision item or service and bifocal lens. You say that you had cataract surgery, 
needed glasses, and paid for them. You also say that you would like to be reimbursed as the Plan has done in 
the past. The Plan denied your request. The Plan says because the provider is OON with the Plan and because 
there is no coverage when services are rendered by a non-par provider, the Plan will maintain its initial 
determination to not pay for the submitted claim. 
 
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 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 vision item or service (V2799) and bifocal lens 
(V2200) provided on December 15, 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 an IRF admission is medically necessary. The Plan 
denied your request. The Plan says the IRF services requested do not meet the requirements for approval. 
 
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 member continues to have a need for skilled therapy with ongoing safety 
concerns and a potential for functional improvement; however, the documentation doesnt support that the 
member meets the criteria for admission to an acute inpatient rehabilitation facility. There is no indication that 
the member would require skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours a 
week, under the supervision of a physician with at least 3 visits weekly to regain or maintain functional status. 
The member can receive further services 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: 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 services are necessary for the enrollee to 
maximize function and independence. The Plan denied your request. The Plan says the enrollee does not meet 
the Medicare criteria for admission to an inpatient rehabilitation facility. 
 
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 require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided 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 inpatient rehabilitation facility (IRF) admission and services.