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

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that the ventilator is to be used for the treatment of 
COPD. The Plan denied your request. The Plan says the request for a home mechanical ventilator set in iVAPS 
mode with Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a ventilator. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of COPD, 
although pulmonary function test result details are not provided. There is no documentation of chronic CO2 
retention on ABG done while stable as an outpatient. If the enrollee does have chronic CO2 retention, she 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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve excessive skin and tissue excision of the thigh (thigh 
lift). 
 
You asked the Plan to pre-approve thigh lift surgery. You say that you currently have an infection in the area of 
affected skin. The Plan denied your request. The Plan says this surgery is cosmetic in nature and is not 
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 thigh lift surgery. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that you have had weight loss following bariatric surgery and are 
still attempting to lose weight. The record does not indicate the presence of functional impairment or intertrigo 
of the thigh that is refractory to conservative medical treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of thigh lift surgery have not been met. Therefore, we decided that the Plan does 
not have to pre-approve excessive skin and tissue excision of the thigh (thigh lift).
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 you are appealing with supporting records. The Plan 
denied your request. The Plan says the criteria for admission to the IRF setting have not been met. 
 
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 need three hours a day/five days a week of therapies with 
multidisciplinary approach in an IRF. Our physician reviewer also found that the enrollee's rehabilitation needs 
can be safely met in a lower intensity setting in a skilled nursing facility (SNF) or continued outpatient 
therapies. 
 
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 the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says 
admission to the LTACH was denied as not meeting criteria, is not medically necessary, and continued acute 
hospital stay was offered until the enrollee could discharge to a lower level of care. 
 
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 is receiving appropriate care at the present setting. 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 the LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a primary care telehealth visit provided on 
June 24, 2022. 
 
You asked the Plan to waive the copayment for a primary care telehealth visit. You say that you did not discuss 
anything with the provider and you were only calling to tell her you were leaving the practice. The Plan denied 
your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copayment for Physician/Practitioner services, including doctors office visits. 
 
You have been asked to pay a $10 copayment for a primary care telehealth visit. This item/service falls within 
the Physician/Practitioner services, including doctors office visits 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 a primary care telehealth visit provided on June 24, 2022. 
 Maximus read your letter and knows that you may have a quality of care concern. Maximus cannot address 
quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement 
Organization for further review.
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 LTACH is medically necessary and 
the LTACH is the most appropriate level of care. The Plan denied your request. The Plan says the LTACH is 
not medically necessary, and the enrollee's needs can be met in another setting such as an inpatient 
rehabilitation facility (IRF) or a skilled nursing facility (SNF). 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the 
current acute care 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 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient diagnostic test provided on June 
22, 2022. 
 
You asked the Plan to waive the copayment for outpatient diagnostic test. You say that you are requesting 
reconsideration of the cost share charges. 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 $300 
copayment for Medicare-covered diagnostic radiology services (not including X-rays).  
 
You have been asked to pay $275.09, which is less than the $300 copayment for outpatient diagnostic test. This 
item/service falls within the Medicare-covered diagnostic radiology services (not including X-rays) 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 outpatient diagnostic test provided on June 22, 
2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the SNF is medically necessary. The Plan denied 
your request. The Plan says the SNF care is not medically necessary, and the enrollee's needs can be met at the 
current long-term acute care hospital. 
 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 clinical documentation shows that the enrollee requires skilled therapy and skilled 
nursing. However, the enrollee still requires intermittent bilevel positive airway pressure (BIPAP) and pressure 
support with daily respiratory protocol which would not be present in a SNF. From a practical standpoint, daily 
skilled services in a SNF are not medically appropriate or 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for excercise therapy provided on May 23, 
2022. 
 
You asked the Plan to waive the copayment for excercise therapy. You say that you were told by the plan that 
you would have 20 visits with no copayment due. 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 outpatient rehabilitation services. 
 
You have been asked to pay a $35 copayment for excercise therapy. This item/service falls within the 
outpatient rehabilitation 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. The therapy type changed, therefore, the copayment changed. Therefore, we 
decided that the Plan does not have to waive the copayment for excercise therapy provided on May 23, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the breast ultrasound provided on March 
24, 2022. 
 
You asked the Plan to waive the copayment for the breast ultrasound. You say that you thought the ultrasound 
was part of the mammogram. 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 $96.70 
copayment for diagnostic radiology services (ultrasounds). 
 
You have been asked to pay a $96.70 copayment for the breast ultrasound. This item/service falls within the 
diagnostic radiology services (ultrasounds) 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. The allowed amount for the ultrasound is $96.70. Since this is less than the 
$100 copayment per the EOC, you are only responsible for the lesser amount. Therefore, we decided that the 
Plan does not have to waive the copayment for the breast ultrasound provided on March 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an auricular stimulator. 
 
You asked the Plan to pre-approve the requested services. You say that the goal is to alleviate the enrollee's 
current pain. The Plan denied your request. The Plan says the requested service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The device does not meet the definition of reasonable and necessary. 
Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an auricular stimulator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee has a catheter and a 
large prostate. You say that other surgeries would be inadequate. The Plan denied your request. The Plan says 
based on Medicare guidelines, the services requested do not meet the rules for approval. 
 
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 pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient care are met in this case. 
Our physician reviewer found holmium laser enucleation of the prostate (HoLEP) is usually performed as an 
outpatient/observation procedure. Our physician reviewer also found that inpatient admission is only needed if 
complications occur or if there are other significant co-morbidities. 
 
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 not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of a pacemaker. 
 
You asked the Plan to pre-approve pacemaker. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the criteria for a pacemaker. 
 
The Plan follows Medicare rules. Medicare rules state that cardiac pacemakers are only covered for certain 
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 pacemaker. Our reviewer says that the 
enrollee does not meet the Medicare criteria for a pacemaker. Our physician reviewer found electrocardiogram 
monitoring studies and exercise testing have shown no significant bradycardia or evidence of chronotropic 
incompetence. There is no documentation of symptomatic bradycardia. As such, there is insufficient 
documentation to support the medical necessity for insertion of a pacemaker in the enrollee's clinical 
management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of pacemaker have not been met. Therefore, we decided that the Plan does not 
have to pre-approve insertion of a pacemaker.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that orthotics will relieve severe pain and to provide 
proper support for both of feet. Also, that this will improve your ability to walk and to maintain proper balance. 
The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the fistula insertion provided on June 30, 
2022. 
 
You asked the Plan to waive the copayment for the fistula insertion. You say that the surgery was not needed, 
and the cost should be waived. 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 $295 
copayment for surgery services at an outpatient hospital. 
 
You have been asked to pay a $295 copayment for the fistula insertion. This item/service falls within the 
surgery services at an outpatient hospital 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 fistula insertion provided on June 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eyeglasses. 
 
  You asked the Plan to pre-approve eyeglasses. You say that you cannot see intermediate distances well at all. 
You also say it makes it hard to walk, and you have fallen twice. The Plan denied your request. The Plan says 
you last received eyewear on November 4, 2021. The Plan also says that per the EOC, there is a $100 vision 
allowance for routine eyewear every two years, so you are not eligible for eyeglasses until November 4, 2023. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers $100 toward the cost of routine contact lenses or eyewear every 2 years. 
 
We looked at the file and the Plan's rules. The Plan rules say that they cover $100 toward the cost of routine 
contact lenses or eyewear every two years. The record shows that you last received eyewear on November 4, 
2021. Therefore, you are not eligible for eyeglasses until November 4, 2023. Based on this information, we 
decided that the Plan's rules for coverage of eyeglasses have not been met. Therefore, we decided that the Plan 
does not have to pre-approve eyeglasses.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound provided on June 16, 2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that insurance did not pay any portion 
of the ultrasound. 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 $38.05 
copayment for radiological diagnostic services, not including x-rays. 
 
You have been asked to pay a $38.05 copayment for the ultrasound. This item/service falls within the 
radiological diagnostic services, not including x-rays 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. The allowed amount for the ultrasound is $38.05. Since this is less 
than the $150 copayment per the EOC, you are only responsible for the lesser amount. Therefore, we decided 
that the Plan does not have to waive the copayment for the ultrasound provided on June 16, 2022.