Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 15 additional chiropractic therapy visits. 
 
You asked the Plan to pre-approve the chiropractic visits. You say that you have been treating the enrollee for 
several weeks since she fell. Please reconsider your request for medical services. The Plan denied your request. 
The Plan says the additional chiropractic visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
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 chiropractic visits. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case Our 
physician reviewer found in this case, the record indicates that the enrollee has chronic cervical, thoracic, and 
lumbar pain that was exacerbated by a fall causing a compression fracture.  The record provided indicates that 
additional clinical advancement cannot logically be expected from constant ongoing care and the chiropractic 
treatment becomes auxiliary rather than curative in nature and the requester services are considered 
maintenance in nature. The record provided does not establish the medical necessity and reasonableness, as 
defined by Medicare rules of the requested additional service. 
 
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 chiropractic visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 15 additional chiropractic therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Surgical Procedures on the Nails provided on October 21, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Surgical Procedures on the Nails. You say that the services provided were 
medically necessary. The Plan denied your request. The Plan says the provider is out-of-network and 
authorization is required prior to an out-of-network visit. 
 
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 Surgical Procedures on the Nails provided on 
October 21, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the specialized therapies are not able to 
be met at the short-term acute hospital. The Plan denied your request. The Plan says the enrollee is receiving 
the care needed in the current hospital. 
 
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 physician 
reviewer found that the enrollee was admitted to the acute care hospital with bacteremia and endocarditis. She 
was diagnosed with acute respiratory failure requiring mechanical ventilation support. Her course was 
complicated by hemoptysis. Recent notes describe the enrollee as recently having been reintubated following 
extubation, with new hypotension and worsening anemia. The enrollee appears to be still somewhat unstable. 
She requires short-term additional acute care services that can be safely administered at the current facility 
There are no services at the LTACH that she requires that are not already available and covered at the current 
facility. Transfer to LTACH is not supported and will be considered not medically necessary at this time as the 
enrollee is still unstable. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit provided on September 22, 2021, by 
an OON provider. 
 
You asked the Plan to pay for the specialist office visit. You say that you were seen at the emergency room and 
the treating physician there referred you to the specialist. The Plan denied your request. The Plan says the 
rendering provider is an OON provider and there was no approved authorization. Also, the service rendered 
was not urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a specialist office visit provided on September 22, 
2021, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-invasive home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested device is medically necessary. 
The Plan denied your request. The Plan says the requested device does not meet criteria. 
 
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 service is not medically necessary. Our physician reviewer found you have a diagnosis of COPD, 
although there are no pulmonary function tests to confirm. You are severely obese, and likely have obesity 
hypoventilation syndrome (OHS). PaCO2 was increased during the most recent hospitalization, although there 
is no ABG done while you are stable as an outpatient. BiPAP is the appropriate treatment for OHS. BiPAP with 
AVAPS has not been tried at home.  Medicare does not pay for 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 non-invasive home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services provided on November 22, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for ophthalmological services. You say that the provider has no prior knowledge of 
which patients he will be required to see. You also say that since most patients require urgent care, it is not 
possible to request authorization before services are rendered. The Plan denied your request. The Plan says this 
provider is out-of-network with the Plan, and authorization was not obtained prior to the services being 
rendered. 
 
 
 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 ophthalmological services provided on November 
22, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hip joint replacement surgery (CPT code 27130) to be 
provided by a provider that opted out of Medicare. 
 
You asked the Plan to pre-approve the surgical services. You say that the services are necessary. The Plan 
denied your request. The Plan says this provider does not participate in federal programs at this time. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pre-approve hip 
joint replacement surgery (CPT code 27130) to be provided by a provider that opted out of Medicare.
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 you appear to be improving and should only require short-term additional acute care 
services that can be safely administered at the current facility until more appropriate for a lower level of care. 
There are no services at the LTACH that you require that are not already available and covered at the current 
facility. Transfer to LTACH is not supported and will be considered not medically necessary at this time as it 
would not be clinically advantageous. 
 
 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: 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 disagree with the denial. The Plan denied your 
request. The Plan says the 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 medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital for hip replacement surgery.  
 She is now medically stable with no complex nursing or rehabilitation needs. She does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While she has a need for physical and/or occupational therapy, there is no documentation of a 
need for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nutritional formula (B4150). 
 
You asked the Plan to pre-approve the nutritional formula. You say that the nutritional drink is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that orally administered enteral nutrition products, 
related supplies and equipment will be denied as non-covered. 
 
We looked at the file and Medicare rules. The nutritional formula is requested for oral use. Orally administered 
enteral nutrition produccts are not covered. Based on this information, we decided that Medicare rules for 
coverage of the nutritional formula have not been met. Therefore, we decided that the Plan does not have to 
pre-approve nutritional formula (B4150).
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 requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 daily 
skilled services are not necessary. Our physician reviewer found you received oral medications, had stable vital 
signs and was treated for pain and anemia. You were at a standby assist to supervision level with functional 
mobility including gait to 50 feet. You do not require skilled nursing or therapy services on a daily basis. You 
do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 
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 skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve group 1 heavy duty power wheelchair, patient weight 
capacity 301 to 450 pounds (K0801). 
 
You asked the Plan to pre-approve the power wheelchair. You say that your current power chair is extremely 
slow. You have fallen while getting in and out of the power chair. It is poorly made and does not fit you and 
you are requesting approval for a new power chair. The Plan denied your request. The Plan says you received a 
power wheelchair in 2020 and it is still in good working condition. The records received did not indicate that 
the current char is not sufficient for your mobility needs. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
 
 The file shows that the enrollee has power wheelchair. The power wheelchair serves the same purpose as the 
enrollees current power wheelchair. Therefore, we decided that the Plan does not have to pre-approve group 1 
heavy duty power wheelchair, patient weight capacity 301 to 450 pounds (K0801).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy duty extra wide hospital bed (E0303). 
 
You asked the Plan to pre-approve a heavy duty extra wide hospital bed. You say that the requested item is a 
necessity for your care. The Plan denied your request. The Plan says rules for coverage for a heavy duty extra 
wide hospital bed have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a heavy duty extra wide hospital bed is covered 
if the enrollee's weight is more than 350 pounds. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a heavy duty extra wide hospital bed have not been met. Specifically, the case record does not support that you weigh more than 350 pounds. Therefore, we decided that the Plan does not have to pre-
approve a heavy duty extra wide hospital bed (E0303).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing visits. 
 
You asked the Plan to pre-approve home health services. You say that your wounds are starting to become 
infected. The Plan denied your request. The Plan says your wound care does not require skilled care. 
 
 The Plan must follow Medicare rules. The rules say that home health care 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 physician 
reviewer found that you have a past medical history significant for diabetic foot wounds with recent worsening 
of foot wounds receiving skilled nursing services. The nursing documentation provides evidence of wound care 
concerns. However, there is no physician order for home health skilled nursing (documented order was not 
signed by a provider). 
 
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 skilled nursing visits.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hot or cold packs therapy (97010) provided on December 
22, 2021. 
 
You asked the Plan to pay for the hot or cold packs therapy (97010). The Plan denied your request. The Plan 
says bundled services are not eligible for separate reimbursement. 
  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 CPT code 97010 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 97010 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the hot or cold packs therapy (97010) have not been met. Therefore, we decided that the Plan does not have 
to pay for the hot or cold packs therapy (97010) provided on December 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid (V5298) provided on December 7, 2021. 
 
You asked the Plan to pay for the hearing aid. You say that you received hearing aids from this provider two 
years ago, and they were covered at that time. The Plan denied your request. The Plan says the provider in this 
case is not part of the specified routine hearing vendor network as required by your contract. The Plan also 
states that you were not enrolled in this plan two years ago, and there is no record of you contacting the 
specified vendor in order to access these hearing aid benefits. 
 
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 up to $500 once every three years, only when they are ordered through the Plans specified routine 
hearing vendor. 
 
We looked at the file and the Plans rules. The provider in this case is not part of the Plans specified routine 
hearing vendor network/group. Based on this information, we decided that the Plans rules for coverage of 
hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aid 
(V5298) provided on December 7, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray (71045) provided on December 15, 2021. 
 
You asked the Plan to pay for the x-ray. You say that the enrollee revoked their hospice election prior to the 
date of service in this case. The Plan denied your request. The Plan says the enrollees claim would be covered 
under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until 
the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to 
verify the enrollees coverage before rendering services and to know proper billing procedures for a Medicare 
Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on December 6, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the chest x-ray 
(71045) provided on December 15, 2021.