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

 
We decided that the Plan does not have to pre-approve a replacement group three power wheelchair and 
accessories. 
 
You asked the Plan to pre-approve a group three power wheelchair and accessories. You say that the item is 
medically necessary. The Plan denied your request. The Plan says the members current Group 3 wheelchair is 
has not reached reasonable useful life, as it is less than 5 years old. 
 
The Plan must follow Medicare rules. Medicare rules say that computation of the useful lifetime is based on 
when the equipment is delivered to the beneficiary, not the age of the equipment. Replacement due to wear is 
not covered during the reasonable useful lifetime of the equipment. During the reasonable useful lifetime, 
Medicare does cover repair up to the cost of replacement (but not actual replacement) for medically necessary 
equipment owned by the beneficiary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a group three power wheelchair and accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a replacement group three power wheelchair and accessories.
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 enrollee's rehabilitation needs to improve 
strength, endurance, activities of daily living (ADLs) and mobility. You say the enrollee is motivated to 
improve and will tolerate three hours of therapy required of acute rehabilitation. The Plan denied your request. 
The Plan says the 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 that the medical problems are stable, and there are no complex nursing or 
rehabilitation needs. The enrollee has a need for physical and/or occupational therapy, however, there is no 
documentation of a need for an intensive rehabilitation program. 
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's condition has stabilized 
and is ready to transfer to LTACH. You say that if the enrollee is discharged to a lower level of care, then he 
will require another 4-6 weeks in acute care. The Plan denied your request. The Plan says authorization denied 
because LTACH is not medically necessary, and 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 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 that the documentation shows the enrollee is receiving appropriate care at the present 
acute care hospital. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. 
 
 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for limb compression device provided on 
April 16, 2021, and May 13, 2021. 
 
You asked the Plan to reduce the coinsurance for limb compression device. You say that your doctor put the 
compression device on your shoulder after having surgery to prevent your shoulder from moving. You also say 
that you should not have to pay this high amount for something that was necessary right after surgery. 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 20% 
coinsurance for durable medical equipment.  
 
 You have been asked to pay $550, which is 20% of the allowed amount for each limb compression device 
($2,750 allowed amount x 20% coinsurance = $550). You have been asked to pay a total of $1,100 for the limb 
compression devices received on April 16, 2021, and May 13, 2021 ($550 coinsurance + $550 coinsurance = 
$1,100). Limb compression device falls within the Durable Medical Equipment 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 reduce the coinsurance for limb compression device provided on April 16, 2021, and May 13, 
2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency ambulance service on April 
30, 2021 
 
You asked the Plan to waive the copayment for an ambulance service. You say that you do not have money for 
this The Plan denied your request. The Plan says the copayment you are being charged 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 a $200 
copayment per one-way trip for ambulance services.  
 
You have been asked to pay a $200 copayment for an ambulance service. An ambulance service 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 an emergency 
ambulance service on April 30, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oxygen concentrator (E1390) and a portable oxygen 
concentrator (E1392) provided on November 2, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an oxygen concentrator and a portable oxygen concentrator. You say that you did 
not receive a denial of payment notice, but you received a bill. You also say that you had filed an appeal for the 
same issue in the past and it was overturned. The Plan denied your request. The Plan says the service was 
denied because precertification/authorization/notification were absent. The Plan also says the provider referred 
the member to an in-network supplier and did not receive communication from the durable medical equipment 
(DME) provider or member indicating a reason why the member would need to get the oxygen supplies from 
an out-of-network supplier. 
 
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 an oxygen concentrator (E1390) and a portable 
oxygen concentrator (E1392) provided on November 2, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair ramp (E1399). 
 
You asked the Plan to pre-approve a wheelchair ramp. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this is a convenience item. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a wheelchair ramp (E1399).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. The Plan denied your request. The Plan says the request for off-
label use is not supported by the drug compendia or peer reviewed literature from a journal eligible for 
coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Keytruda. Our reviewer says that the 
elements of the coverage criteria are not satisfied, and the requested service cannot be recommended. Our 
physician reviewer found that the FDA has not stated that the requested drug is indicated for the enrollee's 
specific clinical condition. The Medicare approved cancer drug compendia do not contain a supportive citation 
for the use of the requested drug for the enrollee's clinical situation and no literature from Medicare approved 
cancer journals were submitted for review. 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a total hip replacement provided on 
September 1, 2021. 
 
You asked the Plan to waive the copayment for a total hip replacement. You say that there was an internal error 
that delayed your surgery three-four weeks. You also say that due to that error the provider was going to waive 
the copayment. 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 $150 
copayment for outpatient surgery at an outpatient hospital facility.  
 
 You have been asked to pay a $150 copayment for a total hip replacement. A total hip replacement falls within 
the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for a total hip replacement 
provided on September 1, 2021.  
 
Your complaint about the providers offer not to bill you is not a valid appeal for medical coverage. This part 
of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram (EKG) provided on 
September 30, 2021. 
 
You asked the Plan to waive the copayment for an EKG. You say that you feel the EKG should be included in 
the office visit. 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 $20 
copayment for non-radiological diagnostic services, including EKGs.  
 
A routine electrocardiogram (code 93000) is a separately paid service, not included in the office visit. You have 
been asked to pay the allowed amount of $15.37, which is less than the $20 copayment for an EKG. An EKG falls 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 electrocardiogram (EKG) provided on September 30, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a cardiology specialist office visit provided 
on November 1, 2021. 
 
You asked the Plan to waive the copayment for a cardiology specialist office visit. You say that you did not 
have an appointment that day. You also say that you cancelled the appointment prior to that day. 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 $50 
copayment for an in-network specialist office visit.  
 
The medical records show you had an office visit with your cardiologist on November 1, 2021. You have been 
asked to pay a $50 copayment for a cardiology specialist office visit. A cardiology specialist office visit falls within the Physician/Practitioner Services, Including Doctors Office Visits benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for a cardiology specialist office visit provided on November 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power mobility device (K0800). 
 
You asked the Plan to pre-approve a power mobility device. You say that the item is medically necessary. The 
Plan denied your request. The Plan says the item 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.  
 
The file shows that your condition can be improved by a walker, cane or manual wheelchair. This means that 
Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a power mobility device (K0800).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity (J3111). 
 
You asked the Plan to pre-approve Evenity. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the required drug, Forteo.  
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 the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
that the enrollee has tried and failed the preferred drug, Forteo. The reviewer also found that there is no 
documentation provided indicating that the plans required drug would likely be less effective and/or likely 
have adverse effects for the enrollee. Therefore, the reviewer found that the step therapy criteria have not been 
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 Evenity have not been met. Specifically, the file does not indicate that the 
enrollee has tried and failed the preferred drug. Therefore, we decided that the Plan does not have to pre-
approve Evenity (J3111).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that the ordering provider noted that bi-level positive 
airway (BiPAP) therapy was used and was not effective. The Plan denied your request. The Plan says the 
denial of authorization for this device is correct, because a ventilator is not covered by Medicare for this 
purpose and a bi-level positive airway pressure (BiPAP) device with average volume assured pressure support 
(AVAPS) mode would meet all of the needs requested by the treating provider. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilators are not covered by Medicare when 
used to provide BiPAP therapy.  
 
We looked at the file and Medicare rules. The requested ventilator is not covered by Medicare for this purpose. 
The Plan says that a BiPAP device with AVAPS mode would meet your needs. Please contact the Plan 
regarding coverage of your treatment options. Based on this information, we decided that Medicare rules for 
coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
home ventilator.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT), heart, without contrast 
material, with quantitative evaluation of coronary calcium (75571). 
 
You asked the Plan to pre-approve the imaging service. You say that the requested service should be covered. 
The Plan denied your request. The Plan says the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the imaging service. Our reviewer says 
that the requested imaging service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is insufficient support in the peer-reviewed literature demonstrating a 
significant benefit of CT imaging of the heart with quantitative evaluation of coronary calcium in guiding 
optimal management of this patient. As such, CT imaging of the heart without contrast material with 
quantitative evaluation of coronary calcium is considered experimental/investigational for the evaluation and 
management of the enrollee's medical condition. Therefore, the requested service is not medically necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the imaging service have not been met. Specifically, the file indicates that the 
requested service is experimental or investigational. Therefore, we decided that the Plan does not have to pre-
approve computed tomography (CT), heart, without contrast material, with quantitative evaluation of coronary 
calcium (75571).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing this denial. The Plan denied your 
request. The Plan says the denial of authorization for IRF service is correct. 
 
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 does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  While you may need physical and/or occupational therapy, there is no documented need for an intensive 
therapy program. There is not a reasonable expectation that you 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 home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the item is not medically necessary. 
 
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 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 home ventilator (E0466).