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

 
We decided that the Plan does not have to pre-approve the seat lift mechanism (E0627). 
 
You asked the Plan to pre-approve the seat lift mechanism. You say that you feel the service should be covered 
because it is very painful for you to go from a seated position to a standing position The Plan denied your 
request. The Plan says the records do not support that the enrollee meets the criteria. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section are met. 
 
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 seat lift mechanism. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided records (medical visit note of 0 July 28, 2022, document severe arthritis 
of the hip. The visit note does not include a seat lift in the treating practitioner's course of treatment. The visit 
note does not indicate that the seat lift is likely to: (a) effect improvement in the patient's condition; or (b) arrest or retard deterioration in the patient's condition. The visit note does not indicate that the enrollee is completely 
incapable of standing from a chair in the home and does show that the enrollee has the ability to ambulate.  
 
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 seat lift mechanism have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the seat lift mechanism (E0627).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device 
and associated equipment 
 
You asked the Plan to pre-approve the CPAP device. You say that you request for approval of your 
authorization and have attached all the requested documents requested. The Plan denied your request. The Plan 
says a request for similar equipment and/or supplies has already been approved. A second purchase of the 
CPAP device and supplies is not medically necessary 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee has a continuous positive airway pressure (CPAP) device. The continuous 
positive airway pressure (CPAP) device serves the same purpose as the CPAP device. The case file shows paid 
claims for the current CPAP device on 8/13/2022 and for associated face mask and headgear on August 24, 
2022. The Plan contacted the enrollee on October 24, 2022, and the enrollee confirmed purchase of the device 
and other necessary DME, use as stated above and that you currently have all the equipment necessary and do not require any replacements. Therefore, we decided that the Plan does not have to pre-approve a continuous 
positive airway pressure (CPAP) device and associated equipment
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee is making extreme progress and the 
one-on-one services provided are very helpful for regaining her independence. The Plan denied your request. 
The Plan says the skilled nursing facility services you are requesting does not meet the requirements for 
approval. 
 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not 
have documented skilled therapy needs. The enrollee appears to be dependent for mobility and in need of 
extensive assist for activities of daily living.  Daily skilled services are not shown to be required to establish a 
maintenance program or to prevent deterioration of the enrollees condition.  The enrollees care needs 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat. 
 
You asked the Plan to pre-approve a raised toilet seat. You say that you have Parkinson's disease and have 
difficulty balancing. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat 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 raised toilet seat.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3010) and a metatarsal bar wedge 
(L3410). 
 
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 footwear) 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 footwear may be appropriate for you, neither Medicare nor the Plan provides coverage of these 
items for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics 
(L3010) and a metatarsal bar wedge (L3410).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 office visits with a chiropractor. 
 
You asked the Plan to pre-approve chiropractic care. You say that the enrollee has low back pain that radiates 
to lower extremities. You say that you have right knee pain. You say that you are participating in physical 
therapy (PT) for your knee pain. You also say that you will be started PT for your back pain soon. The Plan 
denied your request. The Plan says the requested services are not coverable. 
 
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.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of chiropractic care have not been met. Specifically, the file does not support that subluxation is 
present. Therefore, we decided that the Plan does not have to pre-approve 2 office visits with a chiropractor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal mucosal grafting. 
 
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 covered. 
 
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 requested items or services are not 
among those covered under this benefit or the medical benefit. Therefore, we decided that the Plan does not 
have to pre-approve periodontal mucosal grafting.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tracheostomy shower protector. 
 
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 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. Furthermore, the 
requested provider is not a network provider with the Plan. Therefore, we decided that the Plan does not have 
to pre-approve a tracheostomy shower protector.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee has a past medical history of 
significant advanced lung disease with chronic hypoxemic respiratory failure, interstitial lung disease, 
bronchiectasis with severe obstruction secondary to lupus. Prior to his last office visit the above-mentioned, the 
enrollee had an ABG which showed a PCO2 of 56. He is in the end stages of lung disease with limited 
treatment options at this point. The ventilator is medically necessary. The Plan denied your request. The Plan 
says the request for a home mechanical ventilator set in iVAPS 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 the enrollee has COPD, interstitial 
lung disease, bronchiectasis, and systemic lupus. ABG done as an outpatient while stable shows mild chronic 
CO2 retention. The enrollee may benefit from BiPAP with AVAPS. This has not been tried and failed. 
Medicare does not cover a home ventilator when used at settings that can be provided by BiPAP. 
 
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 waive the coinsurance for Medicare Part B drugs provided on 
August 09, 2022. 
 
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you were told there 
would be no charge for this. 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for Medicare Part B drugs. This item/service falls within the 
Medicare Part B prescription drugs 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 coinsurance for 
Medicare Part B drugs provided on August 09, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional routine transportation trips for 2022. 
 
You asked the Plan to provide additional transportation. You say that the enrollee is seeing multiple specialists 
at this time, and this transportation is necessary for attendance at these appointments. The Plan denied your 
request. The Plan says the enrollee's transportation benefit covers a maximum of 48 trips per year. Additional 
trips are not a covered benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the enrollee has exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to provide additional routine transportation trips for 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy duty, extra wide hospital bed. 
 
You asked the Plan to pre-approve these services. You say that you would like your partner to be able to sleep 
next to you. 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 rules say that a heavy duty extra wide hospital bed (E0301, E0303) is covered if the 
beneficiary meets one of the criteria for a fixed height hospital bed and the beneficiary's weight is more than 
350 pounds but does not exceed 600 pounds. 
 
We looked at the file and Medicare rules. The file shows that you are requesting a heavy duty, extra wide hospital bed so that your partner may sleep next to you. This is not a purpose that is primarily medical in 
nature. Furthermore, the records show that you do not weight more than 350 pounds but not more than 600 
pounds. Therefore, we decided that the Plan does not have to pre-approve a heavy duty, extra wide hospital 
bed.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing. 
 
You asked the Plan to pre-approve neuropsychological testing. You say that neuropsychological testing is 
medically necessary. The Plan denied your request. The Plan says neuropsychological testing is not medically 
necessary. 
 
The Plan follows Medicare rules.  
 
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 neuropsychological testing. Our 
reviewer says that neuropsychological testing is not medically necessary. Our physician reviewer found that 
this testing is intended to diagnose and characterize the neurocognitive effects of medical disorders that 
impinge directly on or indirectly on the brain including detection of neurologic disease based on quantitative 
assessment of neurocognitive abilities, differential diagnosis between psychogenic and neurogenic syndromes, 
delineation of neurocognitive effects of central nervous system disorders, neurocognitive monitoring of 
recovery or progression of central nervous system disorders or assessment of neurocognitive function for the 
formulation of rehabilitation and/or management strategies among individuals with neuropsychiatric disorders. 
This enrollee does not meet the criteria as the enrollee is not showing severity of symptoms that would warrant 
this type of diagnostic treatment and is therefore not appear medically necessary or reasonable. The 
neuropsychological testing as outlined documentation is unclear the questions needed to be answered by this 
testing. This enrollee could be treated via clinical assessment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuropsychological testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve neuropsychological testing.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Otolaryngologist specialist visit to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an Otolaryngologist specialist visit. You say that you are appealing the 
denied referral for consult with the requested Otolaryngologist. You say that this specific provider believes his 
treatment can alleviate the pain that no other treatment has successfully done. The Plan denied your request. 
The Plan says the provider requested is out-of-network and services can be performed by an 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 
an Otolaryngologist specialist visit to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on June 27, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says if the enrollee needs Medicare-covered medical care and a network provider is 
unable to provide this care, the enrollee may be able to get care from an out-of-network provider. Our plan 
must confirm there is not a network provider available and contact the plan to request authorization for the 
enrollee to obtain services from an out-of-network provider. If approved, the out-of-network provider will be 
issued an authorization to provide the service(s).  
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 lab testing provided on June 27, 2022, 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 the ventilator is needed. The Plan denied 
your request. The Plan says the home ventilator, any type used with noninvasive interface you and/or your 
provider is/are requesting do not meet the requirements for approval. 
 
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 the enrollee was recently hospitalized 
with pneumonia, sepsis, and hypoxemia.  There is no diagnosis of COPD, thoracic restrictive disease, or 
neuromuscular disease. An ABG while acutely ill was consistent with mild hyperventilation.  There is no 
evidence of chronic CO2 retention. Thus, there is no indication for ventilatory support during sleep. 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 pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that Prolia is medically necessary. The Plan denied your 
request. The Plan says the drug is being provided by a pharmacy and is not eligible for coverage under the Part 
B medical benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy. Since the 
medication does not represent an expense to the physician and will not be included in the physician's bill, it is 
not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Prolia.  
 
Benefits for Prolia 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 pre-approve sacroiliac (SI) joint radiofrequency ablation. 
 
You asked the Plan to pre-approve SI joint radiofrequency ablation. 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 follows Medicare rules. Medicare rules say that sacroiliac (SI) joint injections would be considered 
medically reasonable and necessary for the diagnosis and/or treatment of chronic low back pain that is 
considered to be secondary to suspected sacroiliac joint dysfunction. 
 
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 SI joint radiofrequency ablation. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found SI joint 
radiofrequency ablation is experimental. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SI joint radiofrequency ablation have not been met. Therefore, we decided that 
the Plan does not have to pre-approve sacroiliac (SI) joint radiofrequency ablation.