Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency taxi transportation (A0100). 
 
You asked the Plan to pre-approve additional transportation. You say that the enrollee does not have 
transportation for which they need transportation from the medical plan. You also say that the enrollee cannot 
miss their dialysis appointments. The Plan denied your request. The Plan says the enrollee has exhausted the 
established benefit of 24 one-way trips. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to twenty-four (24) (one way) trips per year.   
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency taxi transportation (A0100).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an automatic blood pressure monitor (ABPM). 
 
You asked the Plan to pre-approve the ABPM. You say that the enrollee needs to be able to monitor blood 
pressure. The Plan denied your request. The Plan says this is not covered by Medicare for this condition. 
 The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only 
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require 
ABPM to confirm a diagnosis of hypertension.  
 
The records do not show that this monitor is requested in the setting of home dialysis services, or that this 
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home 
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. 
Therefore, we decided that the Plan does not have to pre-approve an automatic blood pressure monitor 
(ABPM).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3 additional home health aide (HHA) service hours per 
week. 
 
You asked the Plan to pre-approve additional HHA service hours. You say that the enrollee needs more than 25 
hours of HHA services per week. The Plan denied your request. The Plan says the enrollee's needs can be met 
with less complex services. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 additional HHA service hours. Our 
reviewer says that additional HHA service hours are not medically reasonable and necessary. Our physician 
reviewer found the enrollee is medically stable without any recent hospitalizations or medical complications. 
Our reviewer found that the approved weekly hours of HHA services allow for appropriate support and care. 
Our physician reviewer also found that the documentation does not support that the additional hours are needed 
to provide adequate support for the enrollee.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional HHA service hours have not been met. Therefore, we decided that 
the Plan does not have to pre-approve 3 additional home health aide (HHA) service hours per week.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires more intense therapy to return 
to his prior level. The Plan denied your request. The Plan says that the member does not have acutely complex 
medical diagnosis that requires supervision by a rehabilitation physician. 
 
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. The enrollee is medically stable and does not need physical medicine and rehabilitation physician supervision 3 
times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic 
medical conditions. There are no acute rehab nursing needs identified or documented in the record. At the 
current functional level, the enrollee does not need intensive therapies, consisting of at least 3 hours of therapy 
per day at least 5 days per week with multidisciplinary approach in an IRF. The enrollee is making appropriate 
progress in the skilled nursing facility (SNF). The enrollee's rehab needs can be met safely and provided at a 
lower intensity and alternate setting. Our physician reviewer found that the enrollee's condition does not meet 
Medicare criteria for IRF 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 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 for the enrollee.
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 an IRF level of care is still needed. The Plan denied 
your request. The Plan says IRF care is 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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical management of pancreatic adenocarcinoma. The enrollee's medical problems are 
stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the enrollee 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 this 
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 a personal emergency response system (PERS). 
 
You asked the Plan to pre-approve the PERS. You say that you feel that this is necessary if you fall. The Plan 
denied your request. The Plan says you do not meet the Medicaid criteria for this PERS. 
 
The Plan must follow Medicare rules. Medicare rules say that telephone alert systems are not covered because 
they do not serve a diagnostic or therapeutic purpose. 
 
Although this may be appropriate, this service is not covered under the Medicare portion of your Plan. Based 
on this information, we decided that Medicare rules for coverage of the PERS have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a personal emergency response system (PERS).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the moderate sedation services (CPT code 99152). 
 
You asked the Plan to pre-approve the moderate sedation services. You say that this procedure would help 
lessen your neck pain, allowing you to return back to work. The Plan denied your request. The Plan says the 
clinical record does not indicate that there are rare or unique circumstances that would require conscious 
sedation for the procedure. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the moderate sedation services have not been met. The rules say 
limitations: General anesthesia is considered not reasonable and necessary for facet joint interventions. Neither 
conscious sedation nor monitored anesthesia care (MAC) is routinely necessary for intraarticular facet joint 
injections or medial branch blocks and are not routinely reimbursable. Individual consideration may be given 
on redetermination (appeal) for payment in rare, unique circumstances if the medical necessity of sedation is 
unequivocal and clearly documented in the medical record. Frequent reporting of these services together may 
trigger focused medical review. Therefore, we decided that the Plan does not have to pre-approve the moderate 
sedation services (CPT code 99152).
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee can safely receive the services he needs in other settings. 
 
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. The 
enrollee is medically stable, has no medical complexity and does not need physical medicine and rehabilitation physician close supervision 3 times per week (at a minimum) for the ongoing management of any active or 
acute exacerbations of chronic medical conditions. There are no rehab nursing needs identified or documented 
in the record. At the functional level as described above, the enrollee does not need 3 hours a day five days a 
week of IRF therapies with interdisciplinary management. The complexity of the enrollee's nursing, medical 
and rehabilitation needs do not require an acute hospital inpatient rehab stay with an interdisciplinary approach 
to rehabilitation care. While you may benefit from physical and occupational therapy, his rehab needs can be 
safely addressed at a low intensity alternate setting. Our physician reviewer found that the enrollee's condition 
does not meet Medicare criteria for IRF 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 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve semi-precision abutments (D6191 and D6192). 
 
You asked the Plan to pre-approve the semi-precision abutments. You say that you believe these services 
should be approved for coverage. The Plan denied your request. The Plan says these services are not covered 
under your benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
semi-precision abutments (D6191 and D6192).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the percutaneous implantation of neurostimulator 
electrode array; peripheral nerve (excludes sacral nerve) (64555). 
 
You asked the Plan to pre-approve the percutaneous implantation of neurostimulator electrode array. You say 
that the service is medically necessary. The Plan denied your request. The Plan says the service is 
experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the percutaneous implantation of 
neurostimulator electrode array. Our reviewer says that the requested services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found there is limited published, large-scale, 
long-term peer-reviewed literature that shows this request to be an effective and/or safe treatment for the noted 
pathology and there is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. 
 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 percutaneous implantation of neurostimulator electrode array have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the percutaneous implantation of 
neurostimulator electrode array; peripheral nerve (excludes sacral nerve) (64555).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation. 
 
You asked the Plan to pre-approve additional transportation. You say that you have dialysis appointments 
every Monday, Wednesday, and Friday, and do not have anyone to take you to these appointments. The Plan 
denied your request. The Plan says the request for additional transportation benefit exceeds plan maximums. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 48 one-way trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional transportation.
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 the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient rehab stay with an interdisciplinary approach to rehabilitation care. Documentation 
does not support the medical necessity for admission to an IRF. While you may benefit from physical and 
occupational therapy, your rehab needs can be safely addressed at a low intensity alternate setting such as in a 
skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the enrollee does not 
have a history of osteoporosis-related fracture or has tried and failed zoledronic acid. 
 
 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 Prolia. Our physician reviewer found 
that the record indicates the enrollee has age related osteoporosis without osteoporotic fracture. The requested 
medication is a new start. The provided records do not indicate that the enrollee has tried and failed the plan's 
preferred step one alternative. The record does not indicate that the enrollee has a contraindication to or would 
have an adverse effect from the plan's preferred step one alternative. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need additional routine 
transportation. The Plan denied your request. The Plan says the routine transportation benefit has been 
exhausted. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage.  
 For that reason, the Plans coverage rules apply in this case. The Plan covers a maximum of 24 one-way trips 
per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and coinsurance for the outpatient clinic visits 
provided from November 4, 2020, to December 7, 2021. 
 
You asked the Plan to waive the copayment and coinsurance for outpatient clinic visits. You say that you don't 
understand why you are being charged a facility fee. The Plan denied your request. The Plan says the 
copayment and coinsurance amounts were applied 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 each Medicare-covered non-surgical visit in an outpatient clinic, for the 2020 dates of service. 
Your contract with the Plan also clearly says that you must pay a $395 copayment for each Medicare-covered 
non-surgical visit in an outpatient clinic after you meet your $395 deductible, for the 2021 dates of service.  
 
You have been asked to pay a total of $344.12 for the outpatient clinic visits.  
 
Date of Service Allowed Amount Standard Cost Member Liability 
November 4, 2020 $140.45 20% Coinsurance $28.09 
November 13, 2020 $140.45 20% Coinsurance $28.09 
November 4, 2021 $143.97 $395 Copayment $143.97 (allowed amount) 
December 7, 2021 $143.97 $395 Copayment $143.97 (allowed amount) 
Total:   $344.12 
 
Outpatient clinic visits falls within the Outpatient hospital services benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment and coinsurance for outpatient clinic visits provided from November 4, 
2020, to December 7, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 15 home health aide hours per week. 
 
You asked the Plan to pre-approve additional home health aide hours. You say that the assessment was 
performed over the phone. You say that that the enrollee has a language barrier. You say that this reduction in 
hours is unfair based on the enrollee's medical condition. The Plan denied your request. The Plan says the 
additional home health hours are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
 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 additional home health aide hours. Our 
reviewer says that the requested additional home health aide hours are not medically necessary. Our physician 
reviewer found the provided documentation indicates that the enrollee is medically stable without any recent 
hospitalizations or medical complications. The reviewer found that the approved weekly hours of home health 
aide services allow for appropriate support and care. The reviewer also found that the documentation does not 
support that the additional hours are needed to provide adequate support for the enrollee. 
 
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 aide services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an additional 15 home health aide hours per week.