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

 
We decided that the Plan does not have to pre-approve a seat lift mechanism and chair. 
 
You asked the Plan to pre-approve a seat lift mechanism and chair. You say that you need this chair because of 
your back.  You said that you have chronic pain and you can't stand on your own because you are in too much 
pain. The Plan denied your request. The Plan says you do not meet criteria for a seat lift mechanism. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section are met. The rules also say that seat lift chairs are not covered. Coverage is 
limited to a seat lift mechanism.  
 
Medicare does not cover the actual chair portion of a seat lift, so the Plan is not required to provide that item.  
Regarding the lift mechanism, 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. Our reviewer says that you 
do not meet criteria for a seat lift mechanism. Our physician reviewer found the documentation does not reveal 
objective imaging evidence of (a) severe arthritis of the knee or hip; and/or (b) a neuromuscular disease.  The medical progress notes do include a seat lift in the course of treatment. The seat lift is not likely to effect 
improvement in your condition or arrest or retard deterioration in your condition. The records do not show that 
you are totally incapable of standing from a chair in the home and the records show that you are ambulatory. 
 
Although a seat lift chair may be appropriate, Medicare does not cover this item and the Plan must provide 
coverage only for items that Medicare covers. 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 seat lift mechanism and 
chair have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat lift 
mechanism and chair.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary visits provided on September 7, 2021, to October 
5, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the domiciliary visits. You say that the services were medically necessary. The 
Plan denied your request. The Plan says no prior authorization was 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.  
The requested provider in this case is not a network provider with the Plan. 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. The 
records provided for review do not show that the services at issue were urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for domiciliary visits provided on September 7, 2021, to October 5, 
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 a radiofrequency ablation procedure (64634, 64633). 
 
You asked the Plan to pre-approve the radiofrequency ablation procedure. You say that the procedure is 
medically necessary. The Plan denied your request. The Plan says coverage criteria is not met. 
 
The Plan follows Medicare rules. Medicare rules say that thermal radiofrequency destruction of cervical, 
thoracic, or lumbar paravertebral facet joint (median branch) nerves will be considered to be medically 
necessary after the patient has had at least two (2) medically reasonable and necessary diagnostic medial 
branch blocks, with each one providing a minimum of 80% relief of primary (index) pain. 
 
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 radiofrequency ablation procedure. 
Our reviewer says that the procedure is not medically necessary. Our physician reviewer found the records do 
not reflect any cervical neck pain or that two sets of diagnostic medial branch blocks were performed. 
 
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 radiofrequency ablation procedure have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a radiofrequency ablation procedure (64634, 64633).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary.  
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the wheelchair. Our reviewer says that 
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found while the 
enrollee may have the cognition to use the requested power wheelchair, the documentation from the physician 
does not support that the enrollee has a mobility deficit that is due to a Group 3 qualifying diagnosis. The 
mobility deficit is due to amputations. The physician documentation does not indicate a diagnosis of 
Parkinson's Disease and the physical therapy note indicates a diagnosis of essential tremor, which is not the 
same as a Parkinsonian tremor. The criteria for the requested Group 3 power wheelchair and accessories is not 
met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 3 power wheelchair.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on March 12, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 72125 
is a column II code to column I code 72126. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for imaging services provided to the enrollee on March 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient mental health services you 
received at an outpatient hospital facility on October 28, 2021. 
 
You asked the Plan to waive the copayment for the outpatient mental health services. You did not provide an 
argument with your appeal request. The Plan denied your request. The Plan says you were charged this 
copayment 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 $100 
copayment for outpatient mental health services at an outpatient hospital facility.  
 
 
 You have been asked to pay a $100 copayment for the outpatient mental health services. 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 mental health services you received at an outpatient 
hospital facility on October 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vimpat. 
 
You asked the Plan to pre-approve Vimpat. You say that the drug is medically necessary for seizures. The Plan 
denied your request. The Plan says this drug is not eligible for coverage under the Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Vimpat.  
 
Benefits for Vimpat may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
October 28, 2021, to October 30, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that the services should be 
covered in full as you were cold and they overcharged for services. The Plan denied your request. The Plan 
says the cost-sharing applied correctly based on your contract. 
 
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 $325 
copayment for Inpatient hospital care.  
 
 
 
 
 
 You have been asked to pay a $325 copayment for an inpatient hospital stay. 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 hospital stay provided from October 28, 2021, to October 30, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
November 4, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you should not be responsible for the 
copayment since you pay your premiums each month. 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 $90 
copayment for each emergency care visit.  
 
You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the Emergency Care 
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 emergency room (ER) visit 
provided on November 4, 2021.
Appeal type: Drugs
Decision: Partially Favorable

 
You asked the Plan to waive the coinsurance for abatacept and chemotherapy administration. You say that the 
enrollee had this service based on the confirmation that it would be paid in full, and you have no way to pay 
this amount. The Plan says that the coinsurance amounts the enrollee is being charged are correct. 
 
We decided that the Plan has to waive the coinsurance for chemotherapy administration (code 96413).  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The Plan contract does not say in clear and accurate terms how 
much enrollees should expect to pay for chemotherapy administration services associated with Medicare Part B 
chemotherapy drugs.  
 
We looked at the contract between the enrollee and the Plan. We did not see where the contract says enrollees 
must pay 20% coinsurance for chemotherapy administration services. The Plan contract does not clearly say 
how much enrollees must pay for chemotherapy administration services. This means that the Plan did not 
follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to 
waive the coinsurance for chemotherapy administration.  
 
We also decided that the Plan does not have to waive the coinsurance for abatacept (code J0129). 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay 20% coinsurance for Medicare Part B chemotherapy drugs. The allowed amount of this drug is 
$4,265.03, resulting in a coinsurance amount of $853.01. 
 
The enrollee has been asked to pay 20% coinsurance for abatacept. Abatacept falls within the Medicare Part B 
Prescription Drugs benefit category. This means that the enrollee has been asked to pay the correct amount 
based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay 
upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for 
abatacept. 
 
Therefore, we decided that the Plan has to reduce the enrollees total cost-sharing amount for this claim from 
$881.19 to $853.01. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that your feet are swollen, and you are in constant 
pain while walking. 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) stay. 
 
You asked the Plan to pre-approve the SNF stay. You say that you feel you were discharged too soon, and need 
more rehabilitation. The Plan denied your request. The Plan says that the documentation fails to indicate that 
you have any daily skilled needs, and the criteria for coverage are 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 the SNF stay. Our reviewer says that 
you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily 
skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. Our reviewer found that you do not have daily skilled therapy needs that require the specialized skill, 
knowledge, and judgment of a skilled professional therapist. Our physician reviewer also found that you do 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 the SNF stay have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) stay.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the magnetic resonance imaging (MRI) 
you had on October 25, 2021. 
 
You asked the Plan to waive the coinsurance for the MRI. You say that you cannot afford this coinsurance. The 
Plan denied your request. The Plan says you were charged this coinsurance 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 20% 
coinsurance for diagnostic radiology services.  
 
You have been asked to pay 20% coinsurance for the MRI. The MRI falls within the diagnostic radiology 
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 coinsurance for the magnetic resonance 
imaging (MRI) you had on October 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided from March 28, 2021, to 
April 3, 2021, billed with Diagnosis Related Group (DRG) 871. 
 
You asked the Plan to pay for inpatient services billed with DRG 871. You say that these services were billed 
and coded appropriately. The Plan denied your request. The Plan says DRG 871 is not supported as a principal diagnosis of sepsis, organism unspecified (A41.9) with sequence diagnosis of pneumonia, unspecified (J18.9) 
is not supported. Instead, the Plan says that DRG 193 is more appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes. DRG 871 requires a primary diagnosis of sepsis, organism 
unspecified (A41.9). 
 
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 services as billed with DRG 871. 
Our reviewer says that the medical records provided do not support the billing of primary diagnosis A41.9. Our 
physician reviewer found that the emergency room physician documented that the enrollee was brought to the 
emergency department (ED) by emergency medical services. Though lactic acidosis and leukocytosis are noted 
upon presentation, these values promptly improved with treatment in the ED. The enrollee presented with 
normal creatinine and bilirubin per lab results, and eventually shows no significant mild decrease on platelet 
levels. The enrollee experienced non-persistent hypotension and remained alert and oriented throughout the 
admission. Although sepsis is documented by the provider, all diagnoses should be supported by clear 
physician documentation as well as have reasonable support through clinical data. The diagnosis in this case is 
not supported. 
 
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 services billed with DRG 871 have not been met. Therefore, we 
decided that the Plan does not have to pay for the inpatient hospital care provided from March 28, 2021, to 
April 3, 2021, billed with Diagnosis Related Group (DRG) 871.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for eyeglasses provided on 
October 12, 2021. 
 
You asked the Plan to pay an additional amount for the eyeglasses. The Plan denied your request. The Plan 
says the benefit of $250 allowance was applied to the purchase, leaving you with a responsibility of $134, 
which was paid at the time of purchase. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan 
covers these services with a $250 allowance. 
 
We looked at the file and the Plan's rules. The file shows that the Plan has paid the maximum eyewear 
allowance of $250. Therefore, we decided that the Plan does not have to pay an additional amount for 
eyeglasses provided on October 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that it is hard for you to stand in the shower. The 
Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair 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 pre-approve a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Kyleena intrauterine device (IUD). 
 
You asked the Plan to pay for the Kyleena IUD. You say that you feel that the IUD is medically necessary as 
without it you experience excessive bleeding and pain. The Plan denied your request. The Plan says this is a 
contraceptive device that cannot be covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that items/services for the purposes of preventing 
conception (contraception) are not considered medically reasonable and necessary. The rules say that providers 
must submit sufficient information to determine that coverage criteria are met.  
 Though you state this device is not primarily needed for contraception, we were unable to obtain medical 
records from the prescribing physician to support this. The documentation does not show that this service is 
being requested to treat a specific illness/injury. As such, the Medicare rules for coverage of this item/service 
have not been met. Therefore, we decided that the Plan does not have to pay for the Kyleena intrauterine device 
(IUD).