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

 
We decided that the Plan does not have to pre-approve the over-bed table (E0274). 
 
You asked the Plan to pre-approve the over-bed table. You say that you have an ultra-light wheelchair that you 
sit down to eat in and you currently have to set your platter on your lab and try to balance it with your knees 
while you are eating. The Plan denied your request. The Plan says this item does not serve a medical purpose 
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 the over-bed table (E0274).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychiatric inpatient stay provided on November 1, 2021, 
to November 30, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a psychiatric inpatient stay. You say that the beneficiary needed this treatment. 
The Plan denied your request. The Plan says there was no preauthorization (this is different than a referral) for 
an OON provider or facility, and this was not an emergency. Therefore, the decision is upheld. 
 
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 a psychiatric inpatient stay provided on November 
1, 2021, to November 30, 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 home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that ventilator is to be used for the treatment of 
COPD. The Plan denied your request. The Plan says the request for a home mechanical ventilator set in VAPS 
mode with Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found provided records document that the 
home ventilator is being requested for use in average volume assured pressure support (AVAPS) mode with 
auto-titration (AE) which could be provided by a BiPAP device with AVAPS and a back-up rate. As stated in 
the Local Coverage Determination (L33800): Claims for ventilators used to provide CPAP or bi-level CPAP 
therapy for conditions described in this RAD policy will be denied as not reasonable and 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from June 15, 2022, to 
June 17, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that you were given medication to alleviate 
your pain. You also say that you were given no alternative whether it should be intravenous or oral. The Plan 
denied your request. The Plan says self-administered drugs are not covered services under your plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided from June 15, 2022, to June 17, 2022.  
 Benefits for the self-administered drugs 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Oximeter device (E0445). 
 
You asked the Plan to pre-approve the Oximeter device. You say that you are at risk for pneumonia so this 
device is medically necessary. The Plan denied your request. The Plan says the requested equipment is non-
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Oximeters (E0445) and replacement probes 
(A4606) will be denied as non-covered. 
 
We looked at the file and Medicare rules. Medicare does not cover the requested equipment for enrollee 
purchase. Based on this information, we decided that Medicare rules for coverage of the Oximeter device have 
not been met. Therefore, we decided that the Plan does not have to pre-approve an Oximeter device (E0445).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray exam of the cervical spine (72050), office visit 
(99204), and the x-ray exam of the lumbar spine (72114) provided on June 6, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not covered under your 
contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the x-ray exam of the cervical spine (72050), office visit (99204), and the 
x-ray exam of the lumbar spine (72114) provided on June 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve orthopedic shoes (L3219) and foot orthotics (L3020). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says these items are not a covered benefit under your 
contractual policy or by Medicare for your condition. 
 
Medicare rules state that supportive devices for the feet (such as orthopedic shoes and orthotics) are only 
covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these 
same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthopedic shoes and orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of 
these items for your condition. Additionally, with the exception of the situations described, orthopedic footwear 
billed using codes L3020 and L3219 will be denied as non-covered Therefore, we decided that the Plan does 
not have to pre-approve orthopedic shoes (L3219) and foot orthotics (L3020).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA1 and BRCA2 full sequence analysis and full 
duplication/deletion analysis (81162). 
 
You asked the Plan to pre-approve BRCA1 and BRCA2 gene analysis. You say that your mother died of 
ovarian cancer, and you are worried about your risk. The Plan denied your request. The Plan says BRCA 
screening without a personal history of cancer is not reasonable and necessary. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 The test at issue in this appeal, BRCA1 and BRCA2 gene analysis, is being requested solely for screening 
purposes. A test is considered screening when it is provided in the absence of signs/symptoms of illness or 
injury. In this case, the genetic test at issue is used to determine the presence of inherited cancer-causing 
mutations. However, the records do not show that you have any signs or symptoms suggestive of cancer. The 
documentation supports that this testing is requested due to a family history alone of ovarian cancer. This 
would be considered screening testing which is excluded from Medicare coverage. Therefore, we decided that 
the Plan does not have to pre-approve BRCA1 and BRCA2 full sequence analysis and full duplication/deletion 
analysis (81162).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided from February 12, 2022, to 
February 13, 2022. 
 
You asked the Plan to pay for the physician services. The Plan denied your request. The Plan says they are not 
responsible for payment because you were enrolled in hospice at the time services were provided. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
You were under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we 
decided that the Plan does not have to pay for physician services provided from February 12, 2022, to February 
13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ophthalmological services provided on May 23, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the ophthalmological services. You say that the services provided should be 
covered under the authorization number that the facility received. The Plan denied your request. The Plan says 
no prior authorization was obtained. 
 
 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 
ophthalmological services. We found no exception that would require the Plan to pay for the ophthalmological 
services. The records provided for review do not show that the services at issue were urgent or emergent. 
Therefore, we decided that the Plan does not have to pay for the ophthalmological services provided on May 
23, 2022, by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services and brain wave test provided from 
February 11, 2022, to February 12, 2022. 
 
You asked the Plan to pay for the physician services and test. The Plan denied your request. The Plan says they 
are not responsible for payment because you were enrolled in hospice at the time services were provided. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
You were under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we 
decided that the Plan does not have to pay for the physician services and brain wave test provided from 
February 11, 2022, to February 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that you have a difficult time with 
transfers due to a diagnosis of melanocytic. The Plan denied your request. The Plan says the requested hospital 
bed is not covered under your benefit package. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0265).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton-beam therapy to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve proton-beam therapy. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for OON care have 
not been met. 
 
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 
proton-beam therapy to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair accessory, power seat elevation system 
(E2300). 
 
You asked the Plan to pre-approve a wheelchair accessory. You say that the requested accessory is medically 
necessary. The Plan denied your request. The Plan says a power seat elevation feature is non-covered because 
they are not 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 wheelchair accessory, power seat elevation system 
(E2300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 heavy-duty power operated vehicle (POV). 
 
You asked the Plan to pre-approve these services. You say that you do not feel secure in the current power 
operated vehicle. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Group 2 POVs are denied as not medically 
necessary. 
 
We looked at the file and Medicare rules. The requested services are a Group 2 POV. This type of POV is 
denied by Medicare as not medically necessary. Therefore, we decided that the Plan does not have to pre-
approve a Group 2 heavy-duty power operated vehicle (POV).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair (E0240). 
 
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this item is not a covered benefit under the enrollee's 
contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair (E0240).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cyclosporine. 
 
You asked the Plan to pre-approve Cyclosporine. The Plan denied your request. The Plan says this is not 
covered under the enrollee's Part B plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Cyclosporine.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would like reconsideration based on the 
records submitted The Plan denied your request. The Plan says IRF is not medically necessary. The enrollee 
does not need specialized training, staff or equipment available only in an IRF. The enrollees needs can be met 
in a lower level of care. The enrollee can receive the care they need in a SNF. 
 
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, at an intensive rehabilitation therapy program. The enrollee can receive further services 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve coverage under the Special Supplemental Benefits for 
Chronically Ill (SSBCI) benefit. 
 
You asked the Plan to pre-approve the SSBCI benefit. You say that this is medically necessary. The Plan 
denied your request. The Plan says the requirements for the SSBCI benefit have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the SSBCI benefit have not been met. Specifically, we have confirmed that you do not have one of 
the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to 
pre-approve coverage under the Special Supplemental Benefits for Chronically Ill (SSBCI) benefit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair and accessories (E1161, K0108x3, 
E2231, E2203, E2211x2, E0990x2, K0040x2, E1225, E0973x2, E0971x2, E0978, E0954, E2609, E2617, 
E0955, E1028, E0956x2). 
 
You asked the Plan to pre-approve a manual wheelchair and accessories. You say that the requested wheelchair 
and accessories are medically necessary. The Plan denied your request. The Plan says you are a resident of a 
long-term care facility; therefore, the wheelchair and accessories are not a covered benefit. 
 
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 and accessories is being requested for use in a SNF or hospital. 
Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair and accessories (E1161, 
K0108x3, E2231, E2203, E2211x2, E0990x2, K0040x2, E1225, E0973x2, E0971x2, E0978, E0954, E2609, 
E2617, E0955, E1028, E0956x2).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve attendant care services (S5125). 
 
You asked the Plan to pre-approve attendant care services. You say that the services at issue are a medical 
necessity for you. The Plan denied your request. The Plan says custodial care is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of attendant care services have not been met. Specifically, we find that the services at issue in this 
case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve 
attendant care services (S5125).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Air Hawk power wheelchair, power mobility device, 
not coded by DME PDAC or does not meet criteria as maintained by CMS (K0899). 
 
You asked the Plan to pre-approve the Air Hawk power wheelchair. You say that you need the Hawk power 
wheelchair because it comes with two batteries, is easily collapsible and weighs only 41 pounds and would be 
the same price as an average wheelchair. The Plan denied your request. The Plan says under Medicare guidelines this request is not medically necessary because the Hawk Power Wheelchair serves the purpose of 
equipment already available to you with an approved Medicare code but with additional features for convenient 
use outside of the home. 
 
The Plan must follow 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 or your 
condition can be improved by a walker, cane or manual wheelchair.  Based on this information, we decided that 
Medicare rules for coverage of the Air Hawk power wheelchair have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the Air Hawk power wheelchair, power mobility device, not coded by 
DME PDAC or does not meet criteria as maintained by CMS (K0899).