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

 
We decided that the Plan does not have to pay for a wheelchair ramp provided on May 10, 2021. 
 
You asked the Plan to pay for a wheelchair ramp. You say that the requested item is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that stairway elevators are not covered because they 
are not primarily medical in nature.  
 
While a wheelchair ramp 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 pay for a wheelchair ramp provided on May 10, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FANCC genetic testing provided on October 31, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that the MolDX Team has determined that testing for 
the FANCC is not a Medicare benefit and is a statutorily excluded service.  
 
We looked at the file and Medicare rules. Per LCA A53628, the requested FANCC gene testing is not a 
covered benefit. Based on this information, we decided that Medicare rules for coverage of the testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the FANCC genetic testing provided on 
October 31, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity for the enrollee. 
 
You asked the Plan to pre-approve Evenity. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the enrollee does not have any stated contraindications to the preferred product. 
 
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 Evenity. Our reviewer says that Evenity 
is not medically reasonable and necessary. There is no indication that the patient has tried and failed Forteo. 
There is no indication that the Plan's required drug would likely be less effective and/or likely have adverse 
effects for the patient. Our physician reviewer found that the enrollee's condition does not meet step therapy 
criteria for Evenity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 8, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 8, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
August 27, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you were still 
charged even though the medical center was unable to assist you. The Plan denied your request. The Plan says 
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 clearly says that you must pay a $285 
copayment for each one-way ambulance trip.  
 
You have been asked to pay a $285 copayment for the ambulance transportation. The ambulance transportation 
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 transportation provided on August 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 19, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on December 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator for the enrollee. 
 
You asked the Plan to pre-approve a portable ventilator. You say that this is medically necessary. The Plan 
denied your request. The Plan says that the use of a portable ventilator (E0466) to deliver ventilatory support 
via settings that could be equally provided by a BiPAP (E0471) with AVAPS settings 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 portable ventilator. Our reviewer says 
that a portable ventilator is not medically reasonable and necessary. There is documentation that this patient has 
chronic respiratory failure consequent to chronic obstructive pulmonary disease. The requested ventilator is to 
have settings of average volume assured pressure support (AVAP-AE with target tidal volume) that could 
equally be provided by a BiPAP device with AVAPS settings. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for a portable ventilator. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapy services provided on July 7, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage of services incident to the professional 
services of a physician or non-physician practitioner (NPP) is limited to situations in which there is direct 
supervision of auxiliary personnel..  
 
We looked at the file and Medicare rules. The in-home therapy services in this case were not provided under 
the direct supervision of a physician or NPP. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the 
therapy services provided on July 7, 2021.
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 this is medically necessary. The Plan denied your 
request. The Plan says 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 based on the medical records provided the complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The patients medical conditions are reported to be stable on outpatient 
medications with no issues that require a physicians evaluation three or more times per week. The patient does 
require physical therapy and occupational therapy services, but the medical records provided do not clarify why 
the patient requires an intensive inpatient rehabilitation therapy program. The provided records do not explain 
why the intensive inpatient rehabilitation therapy program is necessary and why therapy at a lower level of care 
such as in a skilled nursing facility is not appropriate for the patient. There is concern that the patient will not 
be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
inpatient rehabilitation facility due to her "decreased activity tolerance" and "slow progress" with therapy. The 
records do not clarify that treatment at the skilled nursing facility level is not appropriate in this case.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for specialist office visit provided on January 
11, 2022. 
 
You asked the Plan to waive the deductible for specialist office visit. You say that you were told there would 
only be a $30 copayment. The Plan denied your request. The Plan says the deductible applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible which applies to out of network specialist office 
visits. 
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category 
Physician/Practitioner Services, Including Doctors Office Visits. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $750 deductible which applies to out of network specialist 
office visits. This cost sharing is a contractual obligation that had not been met at the time the specialist office 
visit was received on January 11, 2022. Therefore, we decided that the Plan does not have to waive the 
deductible for specialist office visit provided on January 11, 2022.
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 admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no evidence that the enrollee requires services that are not currently available. 
The enrollee can remain at the current facility for the time being until treatment is completed and transfer to a 
lower level of care is more appropriate. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve excision, excessive skin and subcutaneous tissue 
(includes lipectomy), abdomen (eg, abdominoplasty) (includes umbilical transposition and fascial plication) 
(15847). 
 
You asked the Plan to pre-approve these services. You say that these services are not cosmetic in nature and are 
medically necessary. The Plan denied your request. The Plan says that your request is not medically necessary 
because your records show that this procedure is being done to repair abdominal wall laxity or diastasis recti 
and is also being performed in conjunction with a hernia repair. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The record indicates 
that you have a diastasis recti and are scheduled for repair. The requested service is excluded under Medicare 
rules. Our physician reviewer found that your condition does not meet criteria for coverage of these services. 
 
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 excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg, 
abdominoplasty) (includes umbilical transposition and fascial plication) (15847).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive your copayments for a transrectal ultrasound and an ultrasonic 
guidance procedure performed on September 8, 2021. 
 
You asked the Plan to waive your copayments for an ultrasound and an ultrasonic guidance procedure. You say 
that you paid your copayment. The Plan denied your request. The Plan says you must pay a $160 copayment 
for Medicare-covered radiological diagnostic services. 
 
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 $160 
copayment for Medicare- covered radiological diagnostic services.  
 
You have been asked to pay a $160 copayment for an ultrasound and an ultrasonic guidance procedure. For 
code 76872, the Plans allowed amount was $137.19. Your copayment for this is $160; however, since this is 
higher than the Plans allowed amount, you were only asked to pay the lesser amount. For code 76942the 
Plans allowed amount was $41.79 and you were asked to pay a required copayment of $22.81. ($137.19 + 
$22.81 = $160).  Ultrasounds and ultrasonic guidance procedures fall within the Outpatient Diagnostic Tests And Therapeutic 
Services And 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 your copayments for a 
transrectal ultrasound and an ultrasonic guidance procedure performed on September 8, 2021.
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 feel that IRF care is needed. The Plan denied 
your request. The Plan says the inpatient rehabilitation services are 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 review has determined that the complexity of the patient's nursing, medical 
and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. The patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable 
expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you feel that you require intensive rehabilitation to 
recover after your surgery. The Plan denied your request. The Plan says you are medically stable and do not 
require intensive therapy in a hospital setting. 
 
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 is a female with a history of Sjogren's syndrome who underwent mitral valve replacement. The postoperative course was complicated by diffuse coagulopathy and bleeding from the 
sternum and soft tissue. On 6/22/22, the enrollee ambulated 50 feet with a wheeled walker with minimal 
assistance.  
 
The documentation does not support that the enrollee's nursing, medical and rehabilitation needs require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does 
not support that the enrollee requires at least 3 hours a day for 5 days a week, or 15 hours over 7 consecutive 
days, of therapy services. While the enrollee may be able to participate in and benefit from an intensive 
rehabilitation therapy program, the documentation supports that the enrollee's care can be provided in a less 
intensive 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids purchased out of network on August 5, 2021. 
 
You asked the Plan to pay for hearing aids out of network. You say that these hearing aids should be covered 
by the Plan. The Plan denied your request. The Plan says you did not purchase these hearing aids in network. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased in-network with prior authorization. You purchased the hearing aids in 
appeal out of network and without prior authorization. No exceptions are being made to following the rules for 
supplemental benefits due to COVID-19. Therefore, we decided that the Plan does not have to pay for hearing 
aids purchased out of network on August 5, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on February 2, 
2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you think this charge should be 
covered. The Plan denied your request. The Plan says the copayment applied 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 $150 
copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a 
physicians office or at a free-standing facility (such as a radiology center or medical clinic).  
 
 
 
 You have been asked to pay $124.42 which is less than the standard $150 copayment for an ultrasound. 
Ultrasounds fall within the Outpatient Diagnostic Tests and Therapeutic Services and 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 copayment for an ultrasound provided on February 2, 2022.