Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that you need guaranteed tidal volume and battery 
backup, which is not available on a bi-level positive airway pressure (BiPAP) device. The Plan denied your 
request. The Plan says the denial of authorization for this device is correct, because Medicare does not cover a 
ventilator used in this way and your needs can be met by a bi-level positive airway pressure (BiPAP) device 
with average volume assured pressure support (AVAPS) mode instead. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilators are not covered when used to provide 
continuous or bi-level positive airway pressure (CPAP or BiPAP) therapy, regardless of the underlying medical 
condition.  
 
We looked at the file and Medicare rules. A ventilator is not covered for the requested purpose. The Plan says 
that a BiPAP device with AVAPS mode could meet your needs instead.  
 Please contact the Plan for more information about your treatment options. Based on this information, we 
decided that Medicare rules for coverage of ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) and a mandibular 
partial denture (D5214). 
 
You asked the Plan to pre-approve the partial dentures. You say that you need these dentures because it is hard 
to chew food without them. The Plan denied your request. The Plan says these services exceed the maximum 
counts allowed per period. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, maxillary partial denture (D5213) and 
mandibular partial denture (D5214) are each limited to one procedure every five plan years. The record shows 
that you received a maxillary partial denture (D5213) and a mandibular partial denture (D5214) on July 16, 
2019 and your maxillary partial denture (D5213) and mandibular partial denture (D5214) benefits have been 
exhausted. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture 
(D5213) and a mandibular partial denture (D5214).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you would like reconsideration because the 
requested shower chair is medically necessary. The Plan denied your request. The Plan says this is not a 
Medicare covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility care (SNF). 
 
You asked the Plan to pre-approve SNF care. You say that the service is medically necessary. The Plan denied 
your request. The Plan says there are no medical records in order to determine medical necessity. 
 
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 skilled nursing facility care (SNF). 
have been met. The documentation submitted does not include any relevant medical records to determine 
medical necessity of the requested service. Therefore, we decided that the Plan does not have to pre-approve 
skilled nursing facility care (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs to get into the rehabilitation center 
because she needs more extensive physical therapy than what she would get at the nursing facility. The Plan 
denied your request. The Plan says authorization denied because IRF is not medically necessary, and the 
enrollee's needs can be met at a lower level of care such as a skilled nursing facility (SNF). 
 
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 medical problems are stable and there are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need 
for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program.  
 
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 waive the copayment for an x-ray and office visit provided on 
August 2, 2021. 
 
You asked the Plan to waive the copayment for the x-ray and office visit. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
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 
copayment for Outpatient diagnostic tests and therapeutic services and supplies and a $35 copayment for 
Physician/Practitioner services, including specialist doctors office visits.  
 
 
  You have been asked to pay a $20 copayment for the x-ray and a $35 copayment for the specialist office visit. 
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 x-ray and office visit provided on August 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for outpatient clinic visits provided by a 
network facility from November 30, 2021, to December 4, 2021. 
 
You asked the Plan to waive the copayments for the outpatient clinic visits. You say that you were admitted as 
an inpatient and should not be responsible for the outpatient clinic visits. The Plan denied your request. The 
Plan says you have been asked to pay 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 $35 
copayment for each specialist visit, including outpatient clinic visit.  
 
You have been asked to pay a $35 copayment for the outpatient clinic visits on each date of service. ($35 x 3 = 
$105). The outpatient clinic visits fall within the Outpatient hospital 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 copayments for outpatient clinic visits provided by a network facility from 
November 30, 2021, to December 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a Nebulizer with compressor (E0570) 
provided on October 23, 2021. 
 
You asked the Plan to waive the coinsurance for the Nebulizer with compressor. You say that the item should 
be covered as you disagree with the charges. The Plan denied your request. The Plan says the coinsurance 
applied correctly based on the item provided. 
 
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 Durable medical equipment (DME) and related supplies.  
 
 You have been asked to pay a 20% coinsurance for the Nebulizer with compressor (allowed is $5.89 x 20% = 
$1.18). Nebulizers fall within the Durable medical equipment (DME) and related supplies 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 coinsurance for a Nebulizer with compressor (E0570) provided on October 
23, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to waive the deductible for an inpatient hospital stay provided from May 23, 
2021, to May 25, 2021. 
 
You asked the Plan to waive the deductible for an inpatient hospital stay. The Plan denied your request. The 
Plan says that 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 does not say in clear and accurate 
terms how much you should expect to pay for inpatient hospital care.  
 
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a $1,484 
deductible for inpatient hospital care. The Plan contract does not clearly say how much enrollees must pay for 
inpatient hospital care. This means that the Plan did not follow Medicare rules for disclosure of cost sharing 
information. Therefore, we decided that the Plan has to waive the deductible for an inpatient hospital stay 
provided from May 23, 2021, to May 25, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on August 16, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the imaging services. You say that you would like the Plan to reconsider the 
denial and pay for the service that was rendered. The Plan denied your request. The Plan says the rendering 
provider is an out-of-network provider and there was no referral from an in-network provider or an 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 imaging services provided on August 16, 2021, by 
an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has rehabilitation needs to improve 
strength, endurance, activities of daily life, and mobility, as well as medical needs that necessitates daily 
medical oversight. The enrollee is motivated to improve and will tolerate three hours of therapy required for 
acute rehabilitation. The Plan denied your request. The Plan says authorization denied because the IRF is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care.  Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on 
Medicare guidelines. Our physician reviewer found the enrollee's medical problems are stable and there are no 
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for 
an intensive rehabilitation program.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis, 5 mg tablets. 
 
You asked the Plan to pre-approve Eliquis. You say that the patient gets this through Champ VA and no 
authorization is required. The Plan denied your request. The Plan says this drug is not covered by 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 Eliquis, 5 mg tablets.   Benefits for Eliquis 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient hospital visit provided on 
November 9, 2021. 
 
You asked the Plan to waive the copayment for the outpatient hospital visit. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
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 Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers. 
.  You have been asked to pay an $87 copayment for the outpatient hospital visit, which is less than the standard 
$250. 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 outpatient hospital visit provided on 
November 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain fused to high noble metal crown (D2750) for 
tooth # 4. 
 
You asked the Plan to pre-approve the dental service. You say that you are on disability and have other medical 
ailments. You say that you want to know what can be done as you need the crown. The Plan denied your 
request. The Plan says porcelain fused to high noble metal crown is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested porcelain fused to high 
noble metal crown is not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pre-approve a porcelain fused to high noble metal crown (D2750) for tooth # 4.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) provided on December 16, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that as per your records, office visits do not require 
authorization. The Plan denied your request. The Plan says this provider is not a network provider with the 
Plan, and the services were not referred by a network provider. The Plan also says that they have also 
determined that these services are not urgent or emergent, nor were they approved in advance. 
 
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 (99214) provided on December 16, 
2021, 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 inpatient hospital services provided from 
September 28, 2021, to October 1, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital services. You say that you were admitted on 
the September 28, 2021, and you were discharged on the October 1, 2021, so that is not even 3 days. The Plan 
denied your request. The Plan says you were 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 $275 
copayment per day for days 1-5 and $0 after day 5 for inpatient hospital care.  
 
You have been asked to pay a $275 copayment per day for 3 days, which is a total of $825 ($275 x 3 = $875). 
Inpatient hospital services fall within the inpatient hospital care benefit category. The record shows you were in the hospital for three days. 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 inpatient hospital services 
provided from September 28, 2021, to October 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for specialist office visits provided by a 
network specialist from October 28, 2021, to November 15, 2021. 
 
You asked the Plan to waive the copayments for the specialist office visits. You say that you should not have a 
copayment for follow-up care after a procedure treatment for a wound. The Plan denied your request. The Plan 
says you have been asked to pay 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 $45 
copayment for each covered visit or consultation in an outpatient location with a specialist.  
 
 You have been asked to pay a $45 copayment for the specialist office visits on each date of service. The 
specialist office visits fall within the Physician/Practitioner services, including doctors office visits benefit 
category. There is no provision in the contract which indicates copayments would be waived for a service 
performed as a follow-up to wound treatment. 
 
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 copayments for specialist office visits provided by a network specialist 
from October 28, 2021, to November 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre and supplies. 
 
You asked the Plan to pre-approve a Freestyle Libre and supplies. You say that the items 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. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 
 We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre and supplies.