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

 
We decided that the Plan does not have to pre-approve a mount on the wheelchair for a speaker. 
 
You asked the Plan to pre-approve the item. You say that the item is necessary. The Plan denied your request. 
The Plan says this is a non-covered item as it is not medical in nature. 
 
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 mount on the wheelchair for a speaker.
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 prefer to admit to acute rehabilitation because 
you were independent and active before going to the hospital and wish to return to being independent as 
quickly as possible. The Plan denied your request. The Plan says admission to acute inpatient rehabilitation 
facility was denied as not meeting criteria, is not medically necessary, and a lower level of care might be 
appropriate. Skilled nursing facility level of care was offered. 
 
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 you were admitted to an acute hospital on September 6, 2022, for an elective left 
shoulder total arthroplasty for degenerative joint disease. You underwent the procedure successfully and your 
shoulder has been placed in a sling with post-op pain. You are medically stable. While you may benefit from 
continued physical and occupational therapy your rehabilitation needs can be safely provided in a lower 
intensity and alternate setting such as in a skilled nursing 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 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 group 3 power wheelchair with additional features. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is no qualifying diagnosis causing a mobility limitation for which the group 3 
power wheelchair would be medically needed. 
 
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.  
 
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 wheelchair. Our reviewer says that 
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found that there is 
no documentation to show that the patient is unable to effectively pressure relieve, as the patient is documented 
as being able to stand for non-functional periods of time but would allow for ability of pressure relief and seat 
elevator is for convenience and 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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 3 power wheelchair with additional features.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 15, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the claim was 
billed with the incorrect date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that payment for CPT code 81479 is not supported in the medical record. Specifically, the records 
show that the specimens were collected on March 13, 2020, and March 7, 2022. The services must be billed 
with the date that the specimen was collected. This means that the claim was billed with the incorrect date of 
service. Based on this information, we decided that Medicare rules for coverage of the lab services have not 
been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on March 15, 
2022.
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 need inpatient rehabilitation after suffering from 
COVD-19 so you can regain maximum function. The Plan denied your request. The Plan says admission to the 
inpatient rehabilitation facility was denied as not meeting criteria and 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 you were admitted to an acute hospital on September 13, 2022 after a fall confused.  
 You were found to have altered mental status, hallucinations, paranoia, acute kidney injury, dehydration, and 
hypokalemia. You tested positive for COVID-19 again after having pneumonia and acute respiratory failure at 
the end of August. You were also found to have an atrial flutter, pneumonia and metabolic encephalopathy. 
You are medically improving with treatment and left with debility. While you may benefit from continued 
physical and occupational therapy your rehabilitation needs can be safely provided in a lower intensity and 
alternate setting such as in a skilled nursing 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 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 power operated vehicle (POV) represented by code 
K0800. 
 
You asked the Plan to pre-approve a POV. You say that you cannot walk because of your back injury. You say 
that a cane or walker would not help because you are not stable. The Plan denied your request. The Plan says 
the documentation provided does not demonstrate that you either lacks sufficient upper extremity function to 
propel a manual wheelchair or it is unsafe to do so. The Plan say that the documentation provided does not 
demonstrate that you have a significant impairment of mobility related activities of daily living (MRADL) that 
cannot be resolved without the use of her walker. The Plan says that you have a walker that has been approved 
and is able to overcome all MRADL limitations with the use of your walker. 
 
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.  
 
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 POV. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found there is no documentation that you have 
a personal mobility deficit that impairs participation in mobility related activities of daily living such as 
toileting, feeding, grooming and bathing in customary locations within the home. You are reported to be 
ambulatory in your home with or without a walker. The power scooter is reportedly being requested for use 
outside the home. There is no documentation that your mobility deficit cannot be helped by the use of a walker, 
cane or manual wheelchair. There is no documentation that you can safely operate a power mobility device. 
 
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 POV have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a power operated vehicle (POV) represented by code K0800.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the health club membership purchased on January 1, 2022. 
 
You asked the Plan to pay for the health club membership. You say that you provided all the proof for the 
reimbursement. The Plan denied your request. The Plan says that proof of payment was not received with your 
reimbursement request for the 2022 Wellness Allowance benefit. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only when proof of payment is submitted with the request. 
 
The Plans rules for coverage of gym benefits have been met because the contract says that proof of payment is 
required to receive reimbursement from your Wellness Allowance. The records provided show a statement of 
payments made for monthly memberships for the 2021 plan year. Therefore, we decided that the Plan has to 
pay for the health club membership purchased on January 1, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from March 26, 2022, to 
March 29, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you would like this denial to be 
overturned. The Plan denied your request. The Plan says that medical necessity is not supported for an inpatient 
level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the record showed that at the time of inpatient admission the admitting physician reasonably 
expected that the enrollee's necessary hospital care (including earlier emergency department and/or observation 
care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from March 26, 2022, to March 29, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided February 9, 2022 to February 14, 
2022. 
 You asked the Plan to pay for the inpatient services. You say that DRG 064 was correctly billed. The Plan 
denied your request. The Plan says the billed DRG is not supported by the records. 
 
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 DRG 064. 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 services. Our reviewer says that the records do not support the 
billed DRG. Our physician reviewer found documentation is unclear if there was a change in mental status due 
to metabolic causes or other yet to be established pre-existing causes. Records support DRG 065.  
 
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 services provided February 9, 2022 to February 14, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says that the stay is not medically necessary based on IRF criteria. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found IRF criteria have been met and is 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute IRF admission and services.  
 
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 power wheelchair for the enrollee. 
 
You asked the Plan to pre-approve a power wheelchair. You say that the member is too weak to use a manual 
wheelchair. The Plan denied your request. The Plan says that records do not include any impairments in 
MRADLs, a standard written order, a home assessment, or rationale on how a power wheelchair will improve 
your MRADLs. 
 
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 does not show that the enrollee a mobility deficit that impairs her participation in MRADLs, that her 
condition cannot be improved by a walker, cane or manual wheelchair or that the enrollee can safely operate 
the PMD being requested. 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 a power wheelchair for the enrollee.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from December 19, 2021, to 
December 21, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you would like this denial to be 
overturned. The Plan denied your request. The Plan says that the enrollee did not meet the inpatient criteria for 
coverage. The Plan also says that the enrollee could have safely been treated in an outpatient setting and/or 
urgent care facility. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the record showed that at the time of inpatient admission the admitting physician reasonably 
expected that the enrollee's necessary hospital care (including earlier emergency department and/or observation 
care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from December 19, 2021, to December 21, 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are unable to care for yourself and have no one 
at home to care for you. You say that you need to get your strength back to baseline so you can be home alone. 
The Plan denied your request. The Plan says the records show your condition does not meet the Medicare 
requirements for coverage of this service. 
 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 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. Our reviewer also 
found that you do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled 
nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology services (88305 and 88312) provided 
on May 11, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the surgical pathology services. You say that you would like reconsideration 
because you work with participating providers and do not see the patients. The Plan denied your request. The 
Plan says these services are not covered because they were provided OON. 
 
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 surgical pathology services (88305 and 88312) 
provided on May 11, 2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance on March 08, 2022. 
 
You asked the Plan to waive the copayment for ambulance. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing you are being charged is correct. 
 
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 $245 
copayment for each one-way Medicare-covered ground ambulance trip. Covered ambulance services include 
fixed wing, rotary wing, and ground ambulance services, to the nearest appropriate facility that can provide 
care if they are furnished to a member whose medical condition is such that other means of transportation could 
endanger the persons health or if authorized by the plan. 
 
You have been asked to pay a $245 copayment for ambulance. Ambulance 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 ambulance on March 08, 2022.