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

 
We decided that the Plan does not have to pre-approve a group three power wheelchair with multiple power 
options. 
 
You asked the Plan to pre-approve a group three power wheelchair with multiple power options. 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 items. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
2. Myopathy; or 
3. Congenital skeletal deformity. 
 
While the file does show that the enrollee may have a mobility limitation that is due to a neurological 
condition, myopathy or congenital skeletal deformity, the documentation does not support that the requested 
multiple power options. Therefore, we decided that the Plan does not have to pre-approve a group three power 
wheelchair with multiple power options.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine transportation (A0120). 
 
You asked the Plan to pre-approve routine transportation. You say that you need transportation for your 
dialysis appointments three times a week and your doctor's appointments. You also say that you were advised 
by your sales agent that routine transportation was included with this Plan. The Plan denied your request. The 
Plan says you do not have transportation benefits. 
 
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. 
The Plan follows the same rule.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Medicare rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve routine transportation (A0120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated scooter. 
 
You asked the Plan to pre-approve a power operated scooter. You say that you disagree with the plan's decision 
because you have had back surgery. The Plan denied your request. The Plan says you do not meet criteria for 
the requested device. 
 
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 you do not have a mobility deficit that impairs your participation in MRADLs. 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 operated scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for administration of a Shingrix vaccine provided on September 
30, 2021. 
 
You asked the Plan to pay for immunization. You say that you had this done in an office setting. The Plan 
denied your request. The Plan says the denial of payment for this service is correct, because this immunization 
is not covered by Medicare Part B and should be covered by your Part D benefits instead. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide immunization. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to immunization. 
Therefore, we decided that the Plan does not have to pay for administration of a Shingrix vaccine provided on 
September 30, 2021.  
 
Benefits for immunization may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider 
from August 11, 2021, to August 19, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 services at issue in this appeal. 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 the services provided to you by an out-of-network provider from 
August 11, 2021, to August 19, 2021.
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 the enrollee's left leg needs some additional 
work, and would benefit from additional SNF services so she can live independently. The Plan denied your 
request. The Plan says the enrollee does not meet Medicare's medical necessity criteria for coverage of SNF 
services. 
 
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 the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee 
does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a 
skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized 
skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled 
nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 skilled nursing visits. 
 
You asked the Plan to pre-approve 8 skilled nursing visits. 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 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 8 skilled nursing visits. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found based on the medical records 
provided there is no documentation that the 8 denied skilled home health nursing visits are required to 
effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to 
establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. 
Provided records do not document any acute or unstable medical conditions or changes in medication or 
treatment which would necessitate any further skilled nursing visits beyond what have already been approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 8 skilled nursing visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 8 skilled nursing visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional domiciliary/rest home visit services provided to 
the enrollee on June 17, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records submitted do not indicate that two separate services were performed/supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 In this case, the CPT Code Manual definition of code 99336 is "Domiciliary or rest home visit for the 
evaluation and management of an established patient, which requires at least 2 of these 3 key components: A 
detailed interval history; A detailed examination; Medical decision making of moderate complexity. 
Counseling and/or coordination of care with other physicians, other qualified health care professionals, or 
agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. 
Usually, the presenting problem(s) are of moderate to high severity. Typically, 40 minutes are spent with the 
patient and/or family or caregiver." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found there was payment for CPT code 
99336 with claim 12849895-00. The documentation does not support that additional services were completed. 
The review has determined that the records did not support that the denied code was rendered more than once 
in this case. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for additional domiciliary/rest home visit services provided to the enrollee on June 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a group 4 power wheelchair (K0884) and accessories 
(E2300, E2301, E1028, K0108, E0952, E2620, E2624, E2363, E1007, E2377, E2313, E2323, E2311, E0957, 
E0978, E0960, E0955, E0953, and E0950). 
 
You asked the Plan to pay for a group 4 power wheelchair and accessories. You say that this is medically 
necessary. The Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Group 4 power wheelchairs (PWCs) (K0868, 
K0869, K0870, K0871, K0877, K0878, K0879, K0880, K0884, K0885, K0886) have added capabilities that 
are not needed for use in the home. Therefore, if these wheelchairs are provided, they will be denied as not 
reasonable and necessary. If the PWC base is not covered, then related accessories will be denied.  
 
We looked at the file and Medicare rules. The requested wheelchair is not considered reasonable and necessary. 
Based on this information, we decided that Medicare rules for coverage of a group 4 power wheelchair and 
accessories have not been met. Therefore, we decided that the Plan does not have to pay for a group 4 power 
wheelchair (K0884) and accessories (E2300, E2301, E1028, K0108, E0952, E2620, E2624, E2363, E1007, 
E2377, E2313, E2323, E2311, E0957, E0978, E0960, E0955, E0953, and E0950).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Adakveo. 
 
You asked the Plan to pre-approve Adakveo. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
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 Adakveo. Our reviewer says that the 
requested drug is medically reasonable and necessary. Our physician reviewer found the enrollee has been 
diagnosed with sickle cell disease. Currently, the enrollee is on voxelotor. The requested drug Adakveo is not 
medically reasonable and necessary because it would be considered duplicative treatment with the enrollee 
already taking voxelotor. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Adakveo have not been met. Therefore, we decided that the Plan does not have to pre-approve Adakveo.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial lower denture (D5214). 
 
You asked the Plan to pre-approve a partial denture. You say that you lost your dentures last year and need a 
replacement. The Plan denied your request. The Plan says you previously received a partial lower denture on 
March 10, 2020. Your benefit covers this denture once every five plan years. 
 
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 documentation supports that this 
denture is requested in a frequency that is not covered under this benefit. Therefore, we decided that the Plan 
does not have to pre-approve a partial lower denture (D5214).
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the ophthalmoscopy (92225). We decided that the Plan does not have to 
pay for the anti-reflective coating (V2750).  
 
You asked the Plan to pay for the ophthalmoscopy (92225) and anti-reflective coating (V2750). You say that 
you would like to know why this was covered and reimbursed last time, but not this time. The Plan says that 
payment will remain denied for the anti-reflective coating because your benefit limit has been met. The Plan 
also says that payment will remain denied for the extended ophthalmoscopy because the service rendered is not 
a covered benefit. 
 
We decided that the Plan has to pay for the ophthalmoscopy (92225).  
 
The Plan follows Medicare rules. Medicare rules say that a health plan must disclose to its enrollees in clear, 
accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).  
 
The file shows that you received an ophthalmoscopy (92225). This service is considered a Medicare covered 
diagnostic service. The contract clearly says that you pay a $5 copayment for diagnostic procedures and tests. 
Therefore, we decided that the Plan has to pay for the ophthalmoscopy (92225) and you are only responsible 
for the $5 copayment for this service.  
 
We also decided that the Plan does not have to pay for the anti-reflective coating (V2750). 
 
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 the Plan offers a $200 
vision allowance for routine contact lenses or eyewear every 2 years. The record shows that the Plan paid $200 
toward the frames (V2020) and lens sphere (V2300) provided on January 10, 2022, which exhausted your 
vision benefit allowance. Therefore, we decided that the Plan does not have to pay for the anti-reflective 
coating (V2750) provided on January 10, 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: 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 need physical therapy. The Plan denied your 
request. The Plan says criteria for admission to the Acute Inpatient Rehabilitation setting have 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 you do not require the intensity of services provided at an IRF. Our reviewer found 
that specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. Our physician reviewer also found that your care needs can be met 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 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 pre-approve physician's services to be provided by the requested  
out-of-network provider. 
 
You asked the Plan to pre-approve physician's services to be provided by the requested out-of-network 
provider. You say that you would like to see this provider who has more experience than the provider who does 
the procedure of this sort 1 to 2 times a month versus the provider who does 26 in a month. The Plan denied 
your request. The Plan says we have the necessary providers in our network to assist you. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the requested out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition, endoskeletal knee-shin system, stance 
flexion feature, adjustable (L5845) for a prosthetic leg. 
 
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your 
request. The Plan says the knee unit already comes with knee flexion as a part of the knee adjustability. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
It would not be appropriate to report L5845 separately with the requested and approved prosthetic knee. Based 
on this information, we decided that Medicare rules for coverage of the item have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an addition, endoskeletal knee-shin system, stance flexion 
feature, adjustable (L5845) for a prosthetic leg.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Proton Beam Radiation Therapy (PBRT). 
 
You asked the Plan to pre-approve PBRT. 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. 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 PBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found any potential benefit or detriment of proton therapy over standard intensity-modulated radiation 
therapy (IMRT) is an investigational question. Other treatment approaches intensity-modulated radiation 
therapy/image-guided radiation therapy (IMRT +/- IGRT) are also highly effective and well tolerated. Thus, 
whether proton therapy affords a benefit over other standard approaches (IMRT/IGRT) for prostate cancer is an 
area of investigation and remains controversial. To date, there are no compelling data to suggest that proton 
therapy is superior to or more beneficial than IMRT/IGRT. The generally accepted standard of care for prostate 
cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to patients. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Proton Beam Radiation Therapy (PBRT).
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 the close medical supervision and 
intensive therapies that can only be provided at an IRF. The Plan denied your request. The Plan says an IRF 
admission 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 although provider documentation suggests that the enrollee may benefit from close medical supervision and the diagnosis is not IRF compliant, evaluating therapists document that the 
enrollee does not require intense or multi-disciplinary rehabilitation. 
 
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.