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

 
We decided that the Plan does not have to pre-approve the monitoring feature/device, stand-alone or integrated, 
any type, includes all accessories, components and electronics, not otherwise classified (A9279).  

You asked the Plan to pre-approve the monitoring feature/device. You say that you disagree with the decision 
and attached is all the clinicals needed to support as to why the enrollee needed the medical equipment. The 
Plan denied your request. The Plan says the PAP monitoring modem is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the monitoring feature/device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the monitoring feature/device, stand-alone or integrated, any type, includes all accessories, 
components and electronics, not otherwise classified (A9279).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300) and a cup holder, 
phone mount, adjustable push handle (K0108). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the enrollee needs the wheelchair to 
get to doctor appointments. The Plan denied your request. The Plan says your request is not medically 
necessary because these options are not considered primarily medical in nature. 
 
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 power seat elevation system (E2300) and a cup holder, 
phone mount, adjustable push handle (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic propulsion tire (E2211x2), an insert for 
pneumatic propulsion tire (removable) (E2213x2), a spoke protector (K0065x2), a side guard with fender 
(K0108) and a fold down push handle (K0108). 
 
You asked the Plan to pre-approve manual wheelchair accessories. You say that you cannot walk for over 8 
years, and you have had this wheelchair also for 8 years. You would like a replacement for the wheelchair. The 
Plan denied your request. The Plan says the upgraded pneumatic tires, spoke protectors, and side guards are 
primary for outdoor use. The wheelchair comes with tires. Upgrade to pneumatic tire is primarily needed 
outdoors to have a more comfortable ride in different terrain. The spoke protectors and side guards are for 
protect against outside elements. The fold down push handles is for the convenience caregiver assistance 
outdoors and not needed in the home. The requested items do not meet criteria for approval. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a pneumatic propulsion tire (E2211x2), an insert for pneumatic propulsion tire (removable) 
(E2213x2), a spoke protector (K0065x2), a side guard with fender (K0108) and a fold down push handle 
(K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for interrogation device evaluation of a subcutaneous cardiac rhythm monitor system provided on August 30, 2022.

You asked the Plan to pay for interrogation device evaluation of a subcutaneous cardiac rhythm monitor system. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.

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 services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for interrogation device evaluation of a subcutaneous cardiac rhythm monitor system provided on August 30, 2022.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 16 home health physical therapy visits.

You asked the Plan to pre-approve home health services. You say that additional home therapy is medically necessary. 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 home health services. Our reviewer says that the services are not medically reasonable and necessary. Our physician reviewer found that the enrollee does not have documented, ongoing, home health physical therapy needs. The enrollee is functioning at a level appropriate for 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 home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve 16 home health physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300) expandable 
controller upgrade (E2377) harness (E2313) and electronic connection between wheelchair controller and two 
or more power seating system motors (E2311). 
 
You asked the Plan to pre-approve the power seat elevation system and upgraded electronics. You say that the 
medical records provided support the necessity of the services in dispute. The Plan denied your request. The 
Plan says the upgraded electronics that the approved power options come with their own switches and a power 
seat elevation system (E2300) does not serve a primary medical purpose and is statutorily non-covered. 
 
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 power seat elevation system and 
upgraded electronics. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the E2311 electronic connect between 2 
systems, E2377 expandable controller and E2313 expandable controller harness are not medically necessary. 
The requested items exceed the enrollee's medical needs and does not meet Medicare medical necessity criteria. 
The enrollee does not require a ventilator, or non-proportional input devices (e.g., sip and puff, head array, 
etc.). The enrollee does not require a separate display (i.e., for alternate control devices), other electronic 
devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an 
attendant control. The enrollee has 3 power options of tilt, recline, and power elevating leg rests but the 
enrollee does not need to control the power options through a joystick. The enrollee's upper extremity strength 
and function support that the patient can control any power options through their own switches. 
 
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 power seat elevation system and upgraded electronics have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system (E2300) 
expandable controller upgrade (E2377) harness (E2313) and electronic connection between wheelchair 
controller and two or more power seating system motors (E2311).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair repairs. 
 
You asked the Plan to pre-approve power wheelchair repairs. You say that the request for repairs of the 
enrollee's wheelchair is necessary. The Plan denied your request. The Plan says the request does not meet the 
Medicare or health plan coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The records show that the purchase date is unknown. The records 
also show the entirety of the repair history is unknown per the vendor, although the intended repair vendor 
made one previous repair at a cost of $707.90. The current repair cost is $10,710.40. The replacement cost of 
the chair is estimated $8,290.00 - $12,490.00. The expense for repairs exceeds the estimated expense of 
purchasing. Based on this information, we decided that Medicare rules for coverage of power wheelchair 
repairs have not been met. Therefore, we decided that the Plan does not have to pre-approve power wheelchair 
repairs.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) scans of the 
thoracic spine, left shoulder, and both ankles. 
 
You asked the Plan to pre-approve MRIs. You say that this is necessary. The Plan denied your request. The 
Plan says you do not meet criteria for these MRIs. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRIs. Our reviewer says that you do 
not meet criteria for the requested MRIs. Our physician reviewer found the records do not show symptoms or 
findings on physical examination or plain film imaging of the thoracic spine, left shoulder, or ankles showing 
abnormalities that would require the requested MRI scans. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MRIs have not been met. Therefore, we decided that the Plan does not have to 
pre-approve magnetic resonance imaging (MRI) scans of the thoracic spine, left shoulder, and both ankles.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the fundus photography with interpretation (99250) provided on 
September 17, 2022. 
 
You asked the Plan to pay for the fundus photography with interpretation. The Plan denied your request. The 
Plan says that the fundus photography with interpretation is not covered under the supplemental vision benefit, 
and there is no indication that this service was medical in nature. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan denied this fundus photography saying it is not a covered 
service. We find that this service is a Medicare-covered outpatient diagnostic test, and the Plan has not 
supported their denial of payment in this case. Therefore, we decided that the Plan has to pay for the fundus 
photography with interpretation (99250) provided on September 17, 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mental health services provided on September 16, 2022. 
 
You asked the Plan to pay for mental health services. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for mental health services 
provided on September 16, 2022.
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 requires a lot of physical and occupational therapy and is a fall risk. The Plan denied your request. The Plan says the criteria for admission to the acute inpatient rehabilitation setting 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 enrollee does 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 or occupational therapy, there is no documented need for intensive rehabilitation services. 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. Medically necessary care can be provided in a different 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on September 27, 2022. 
 
You asked the Plan to pay for the office visit. You say that the records provided support medical necessity. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit provided 
on September 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a foam propulsion tire (E2218), a plastic side guard, 
standard (K0108) and a release pin stroller handle (K0108). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the enrollee would benefit from her 
ongoing use of a manual wheelchair, preferably custom build for her size. The enrollee feels she cannot 
complete ADLs without a wheelchair, nor can she consistently use a cane or walker. The enrollee needs the 
requested wheelchair fulltime. The Plan denied your request. The Plan says the requested wheelchair 
accessories are not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  

We looked at the file and Medicare rules. The records show the Plan does not allow coverage for the requested 
accessories. Based on this information, we decided that Medicare rules for coverage of wheelchair accessories 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a foam propulsion tire 
(E2218), a plastic side guard, standard (K0108) and a release pin stroller handle (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on October 5, 
2022. 
 
You asked the Plan to waive the copayment for the office visit. You say that you did not request this office 
visit. The Plan denied your request. The Plan says this cost sharing was charged 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 $30 
copayment for each Medicare-covered specialist visit.    
 
You have been asked to pay a $30 copayment for the office visit. This item/service 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 the office visit provided on October 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from July 
4, 2022, to July 13, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged 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 $350 
copayment per day for days 1-5 for inpatient hospital care.  
 
You have been asked to pay a $350 copayment per day for days 1-5 for inpatient hospital care. The total 
amount you are being asked to pay for inpatient care is $1,750 ($350 x 5days = $1,750). This item/service falls 
within the inpatient hospital 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 
inpatient hospital care provided from July 4, 2022, to July 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit and the administration of the 
injection provided on May 10, 2022. 
 
You asked the Plan to waive the copayment for an office visit and the administration of the injection. You say 
that you are disputing the share cost. The Plan denied your request. The Plan says this cost sharing was charged 
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 $15 
copayment for physician/practitioner services, including doctor's office visits.  
 
You have been asked to pay $15 copayment for an office visit and $15 for the administration of the injection. 
These items/services fall within the physician/practitioner services, including doctor's 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 an office visit and the administration of the 
injection provided on May 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electrocardiography to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve electrocardiography. You say that you are requesting reconsideration. The 
Plan denied your request. The Plan says the enrollee must receive their care from a network provider (for more 
information about this, see Section 2 in this chapter). In most cases, care you receive from an out-of-network 
provider (a provider who is not part of our plans network) will not be covered. 
 
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 
electrocardiography to be provided by an out-of-network (OON) provider.