Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the x-ray examination of the swallowing function 
(74230) provided on March 1, 2022. 
 
You asked the Plan to waive the copayment for the x-ray. You say that this may be an oversight and you think 
this should be covered fully for this exam, as your mother struggles to swallow. The Plan denied your request. 
The Plan says that this copayment is correct to apply as per the plan benefits. 
 
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 says that enrollees must pay a 
$0 copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
The Plan says the enrollee must pay a $93.72 copayment for the x-ray. Based on the plan contract, however, the 
enrollee cannot be asked to pay more than a $0 copayment for the x-ray. The 2022 Evidence of Coverage does 
not state what types of x-rays are or are not considered to be standard. Therefore, we decided that the Plan has 
to waive the copayment for the x-ray examination of the swallowing function (74230) provided on March 1, 
2022.  
 
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 pay for a heavy duty walker (E0149, E0156). 
 
You asked the Plan to pay for the heavy duty walker. You say that the walker 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 a heavy-duty walker (E0148, E0149) is covered 
for beneficiaries who meet coverage criteria for a standard walker and who weigh more than 300 pounds. 
 
We looked at the file and Medicare rules. The record shows the enrollee is 259 pounds. Based on this 
information, we decided that Medicare rules for coverage of the heavy duty walker have not been met. 
Therefore, we decided that the Plan does not have to pay for a heavy duty walker (E0149, E0156).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two home health skilled nursing visits. 
 
You asked the Plan to pre-approve these services. 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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has been receiving home 
health services since April of 2022 for post-operative care. The records do not show that she requires further 
skilled nursing services to effectively provide treatment, care, and/or services to improve her condition or to 
establish/perform a maintenance program. The services are not needed to prevent deterioration. The records do 
not document any acute or unstable medical conditions or changes in medication or treatment which would 
necessitate any further skilled nursing visits, patient evaluation or instruction beyond what have already been 
approved. No medical notes from the enrollee's treating physician are provided documenting an order or need 
for additional skilled nursing services. Records do not document the need for intravenous medications, new 
tube feeding or ostomy care or daily complex wound care. The services are therefore not reasonable or 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve two home health skilled nursing visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a recliner chair (A9270). 
 
You asked the Plan to pre-approve a recliner chair. You say that you are appealing the denial of a recliner 
chair. The Plan denied your request. The Plan says this item does not meet the definition of DME and is not 
covered. 
 
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 recliner chair (A9270).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. 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 is not 
medically necessary. 
 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 admission. Our reviewer says 
that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have 
documented skilled nursing or skilled therapy needs. You are ambulating more than 100 feet and tending to 
activities of daily living with minimal supervision. You live in a supervised setting. Your care needs, custodial 
and intermittent, can, as a practical matter, be provided at a lower level of 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 the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the in-person office visit provided on December 8, 2021, and 
the phone call evaluation provided on December 21, 2021, by an out-of-network (OON) facility. 
 
You asked the Plan to pay for the office visit and phone call evaluation. You say that you did not go into the 
office on December 21, 2021. The Plan denied your request. The Plan says these services have been provided 
out-of-network and were not approved in advance. 
 
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 the in-person office visit provided on December 8, 
2021, and the phone call evaluation provided on December 21, 2021, by an out-of-network (OON) facility.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from April 21, 2021, 
to April 27, 2021, billed with diagnosis related group (DRG) code 871. 
 You asked the Plan to pay for the inpatient hospital services billed with DRG 871. You say that the data and 
clinical evidence documented by the treating physicians supports this condition as the principal diagnosis. The 
Plan denied your request. The Plan says DRG 871 is not supported as the diagnosis of Sepsis, unspecified 
organism. 
 
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.   
 
In this case, you billed the inpatient services provided with principal diagnosis code, A41.9, defined as Sepsis, 
unspecified organism. 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 the inpatient hospital 
services billed with DRG 871. Our reviewer says that the submitted DRG is not supported. Our physician 
reviewer found the review has determined that the medical records did not support the billing of Sepsis, 
unspecified organism.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital services provided from April 21, 2021, to April 27, 2021, billed with diagnosis related 
group (DRG) code 871.
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 you were admitted to the hospital 
for sepsis and respiratory failure after recent hip fracture repair. You are now medically stable with no complex 
nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a colonoscopy (45380) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve an out-of-network colonoscopy. You say that this service is urgent because 
you are overdue for this screening. The Plan denied your request. The Plan says out-of-network care is only 
covered in certain limited circumstances. You are not currently showing symptoms. The requested screening is 
not urgent or emergent and can be performed by an in-network provider. This service has been approved to be 
received from a specified in-network provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a colonoscopy (45380) to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consult and office visit to be provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve a consult and office visit. You say that you want your consultation for major 
surgery to be closer to home. The Plan denied your request. The Plan says the medical care you require can be 
provided by a network provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a consult and office visit to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair with features. 
 
You asked the Plan to pre-approve a manual wheelchair with features. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the requested 
item. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a manual wheelchair with features is being requested for use in a long-term care facility. 
The long-term facility you are currently at is not considered home. Therefore, we decided that the Plan does not 
have to pre-approve a manual wheelchair with features.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. 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 ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a portable ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the provided primary source 
documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. The enrollee could be treated with a bilevel positive airway pressure (BiPAP) machine with average 
volume-assured pressure support (AVAPS) capability. The plan has indicated coverage such a device is 
available. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve a SNF admission. You say that you feel you would benefit from additional 
therapy. The Plan denied your request. The Plan says this request is not reasonable and necessary. 
 
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 a SNF admission. 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. Although you have skilled therapy needs, 
these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of 
a SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled 
nursing facility (SNF) admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat elevation system and joystick. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
services are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   The file shows that a power seat elevation system was requested. This item does not serve a purpose that is 
primarily medical in nature. A Q-Logic joystick was also requested. A joystick is included as part of the 
approved expandable control system. Therefore, we decided that the Plan does not have to pre-approve a seat 
elevation system and joystick.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Alimta (J9305) to be used in combination with 
Keytruda and carboplatin. 
 
You asked the Plan to pre-approve Alimta. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the requested drug is not medically necessary. 
 
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 Alimta. Our reviewer says that the 
requested drug, Alimta, is not medically necessary. Our physician reviewer found the Food and Drug 
Administration (FDA) has not stated that the requested drug is indicated for the enrollee's condition. The 
Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested 
drug in the enrollee's clinical situation. Therefore, the reviewer found that the elements of the coverage criteria 
are not satisfied. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Alimta have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Alimta (J9305) to be used in combination with Keytruda and carboplatin.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electric scooter. 
 
You asked the Plan to pre-approve an electric scooter. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested item. 
 
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 the enrollee cannot safely operate the PMD being requested. 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 an electric scooter.
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 needs IRF care. The Plan denied your 
request. The Plan says an intensive rehabilitation program 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 complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary 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.