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

 
We decided that the Plan does not have to pre-approve addition to power seating system, center mount power 
elevating leg rest/platform, complete system (CPT code E1012) and electronic connection between wheelchair 
controller and two or more power seating system motors, including all related electronics, indicator feature, 
mechanical function selection switch, and fixed mounting hardware (E2311). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the DME is not 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 the DME. Our physician reviewer 
found the enrollee has a neurologic disorder with functional deficits. Criteria for a power wheelchair are met. 
The requested electrical accessories are not medically necessary as the enrollee does have use of the upper 
extremity and can operate and control the power options using the switches that are included in the basic 
wheelchair. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve addition to power seating system, center mount power elevating leg rest/platform, complete 
system (CPT code E1012) and electronic connection between wheelchair controller and two or more power 
seating system motors, including all related electronics, indicator feature, mechanical function selection switch, 
and fixed mounting hardware (E2311).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications.  
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the submitted records show that the 
enrollee has not tried and failed the Plan's required drugs, zoledronic acid and an oral bisphosphonate. The oral 
bisphosphonate is not recommended due to a history of gastroesophageal reflux disease; however, there is no 
indication that zoledronic acid would be contraindicated or less effective. Prolia is therefore not reasonable or 
medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and appliance 
(E0670). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested device. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and appliance (E0670).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient admission provided on July 11, 2022, through July 
14, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for inpatient admission. You say that the hospital admission of the enrollee was 
medically necessary. The Plan denied your request. The Plan says the inpatient admission was not medically 
necessary. There is no documented assessment to support the enrollee was expected to require a hospital stay 
over two midnights. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 inpatient admission. Our physician reviewer found the stress test was delayed 
and so the admission was prolonged even though the enrollee was stable without evidence of ACS or other 
acute condition. It was not expected that the enrollee would require hospitalization that would likely cross 2 
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 inpatient admission have not been met.  
 
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 pay for inpatient admission. Therefore, we decided that the Plan 
does not have to pay for inpatient admission provided on July 11, 2022, through July 14, 2022, by an out-of-
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. You say that you cannot use a manual chair to travel long 
distance. The Plan denied your request. The Plan says you are able to walk. 
 
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 your condition cannot be improved by a walker, cane, or manual wheelchair. The 
power scooter is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan 
covers equipment for use outside the home. 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 scooter.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychiatry services provided on January 24, 2022 to 
February 3, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for psychiatry services. You say that this provider was mistakenly classified as out-
of-network. The Plan denied your request. The Plan says this provider is out-of-network with the Plan and 
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. This Plan does include a Point-of-Service (POS) benefit; 
however, the POS benefit only offers coverage for out-of-network supplemental dental services. 
 
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 psychiatry services provided on January 24, 2022 
to February 3, 2022, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services 14 hours per week and skilled 
nursing care three visits per week. 
 
You asked the Plan to pre-approve home health services. You say that the requested services are medically 
necessary. The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services and HHA services may be 
covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify 
the need for home health care services.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
enrollee is not homebound. The enrollee does not have documented skilled nursing or skilled therapy needs. 
The enrollee appears to require custodial supervision due to psychiatric issues. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health aide services 14 hours per week and skilled nursing care three visits 
per week.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic eye exam (92012) provided 
on July 25, 2022. 
 
You asked the Plan to waive the copayment for the diagnostic eye exam. You say that you have never been 
billed for a follow-up visit before. 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 $35 
copayment for each Medicare covered eye exam. 
 
You have been asked to pay a $35 copayment for the diagnostic eye exam. This item/service falls within the 
vision 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 the diagnostic eye exam 
(92012) provided on July 25, 2022.
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 the enrollee cannot take care of themselves and 
needs physical therapy. The Plan denied your request. The Plan says the Medicare guidelines for SNF 
admission were not met. 
 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 that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the LifePak Nano supplement from NuSkin provided on 
August 10, 2022. 
 
You asked the Plan to pay for the LifePak Nano supplement from NuSkin. You say that you want to be 
reimbursed for your NuSkin multivitamins as an approved over-the-counter item. The Plan denied your 
request. The Plan says the service 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 LifePak Nano supplement from NuSkin this appeal does not serve a purpose that is primarily medical in 
nature. Although the Plan has a supplemental benefit for some items and services not covered by Medicare, this 
item with no medical purpose is not covered by Medicare or the Pick Your Perks reimbursement program. Therefore, we decided that the Plan does not have to pay for the LifePak Nano supplement from NuSkin 
provided on August 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve expandable controller (E2377) harness (E2313) 
electronic connection between wheelchair controller and two or more power seating system motors (E2311) 
and power seat elevation system (E2300). 
 
You asked the Plan to pre-approve the power seat elevation system and upgraded electronics. You say that the 
provided records support the necessity of the requested items. The Plan denied your request. The Plan says 
E2300 is not primarily medical in nature and the upgraded electronics are not medically necessary because the 
approved power options come with their own switches and there is not a medical need to control these power 
options through the joystick. 
 
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 power seat elevation system and 
upgraded electronics. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the provided records document that the 
enrollee has 3/5 right hand strength and is independent (with adaptations) with dressing, bathing, eating and 
grooming thus indicating he has adequate upper extremity strength and function to operate the wheelchair's 
power options with their own switches. The requested power seat elevation feature is statutorily non-covered as 
it serves no primary medical purpose.  
 
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 power seat elevation system and upgraded electronics have not been met. 
Therefore, we decided that the Plan does not have to pre-approve expandable controller (E2377) harness 
(E2313) electronic connection between wheelchair controller and two or more power seating system motors 
(E2311) and power seat elevation system (E2300).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an air ambulance transport service provided on August 8, 
2022 
 You asked the Plan to pay for the air ambulance transport service. You say that the air transportation services 
were needed for the level of care that the member needed.  The Plan denied your request. The Plan says the air 
transportation service was not medically necessary. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air ambulance transport service. Our 
reviewer says that the service was not medically necessary. Our physician reviewer found while transport to the 
emergency department/acute care hospital was medically necessary and reasonable, the use of air ambulance 
was not. The enrollee could have been safely transported via ground ambulance without an expected decline in 
their 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 air ambulance transport service have not been met. Therefore, we decided 
that the Plan does not have to pay for an air ambulance transport service provided on August 8, 2022
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient stay provided from March 25, 
2022, to March 30, 2022. 
 
You asked the Plan to waive the copayment for an inpatient stay. You say that you were transferred to this 
hospital, from another inpatient facility, and feel it should be considered the same inpatient stay. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. This is classed as a new admission, 
as it is a new facility. 
 
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 $295 
copayment each day for days 1 to 4 for inpatient hospital services. You were in the hospital for 5 days, 
resulting in a $1180 total copayment ($295 x 4 = $1180). 
 
You have been asked to pay a $1180 copayment for an inpatient stay. This item/service falls within the 
inpatient 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 copayment for an inpatient stay provided from March 25, 
2022, to March 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is medically stable and ready 
for the next level of care, which is LTACH. The Plan denied your request. The Plan says based on Medicare 
guidelines the long term acute care hospital services you are requesting do not meet the requirements for 
approval. 
 
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 the enrollee appears to be still somewhat unstable and should only require short-term 
additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for transfer. The enrollee does not require services at the LTACH that are not already available at 
the current 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the 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 the requested home ventilator is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for a home 
ventilator. 
 
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 enrollee does not meet criteria for a home ventilator. Our physician reviewer found the enrollee has 
severe chronic obstructive pulmonary disease (COPD) and was hospitalized recently with an exacerbation and 
influenza. Arterial blood gas (ABG) testing was consistent with acute on chronic hypercarbic respiratory 
failure. Of note, the enrollee had an ABG several months ago with normal PaCO2. There is no ABG done while stable to document chronic CO2 retention.  If the enrollee does have chronic CO2 retention, the enrollee 
may benefit from BiPAP with AVAPS during sleep. Medicare does not cover a home ventilator when used as 
BiPAP. 
 
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.