Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 additional skilled physical therapy (PT) visits in your 
home (G0151). 
You asked the Plan to pre-approve 6 additional home health PT visits. You say that the requested services are 
medically necessary. The Plan denied your request. The Plan says additional visits 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 6 additional home health PT visits. Our 
reviewer says that the requested 6 additional home health PT visits are not medically necessary. Our physician 
reviewer found the provided documentation does not indicate that the enrollee has documented skilled home 
health physical therapy (PT) needs.  Therefore, the reviewer found that the additional PT services are not 
medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 6 additional home health PT visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 6 additional skilled physical therapy (PT) visits in your home 
(G0151).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2300, 
E2311, E2313, E2377). 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee's upper limb strength and function are adequate for the enrollee to be 
able to control the power options using their own switches which are included in the allowance of these power 
options. 
 
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 accessories. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the power seat elevation feature (E2300) is statutorily non-covered. The provided records 
document that you have 3/5 upper extremity/hand strength and you are independent with feeding thus 
indicating you have adequate upper extremity strength and function to operate the wheelchairs power options 
with 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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional power wheelchair accessories (E2300, E2311, E2313, E2377).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional days in the skilled nursing facility. 
 
You asked the Plan to pre-approve additional days in the skilled nursing facility. You say that the continued 
care is medically necessary. The Plan denied your request. The Plan says skilled nursing facility care beyond 
100 days per benefit period is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from November 24, 2021, 
through March 31, 2022. The Plan has covered 100 days of SNF care. 
 
   
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve additional days in the skilled nursing facility.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that compression stockings are 
medically necessary. The Plan denied your request. The Plan says the requested compression stockings are not 
covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be 
appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. 
Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code 
A6530.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anti-reflective coating (V2750), eye exam (92014), 
frames purchase (V2020), and lens sphere trifocal (V2300) provided on December 17, 2021. 
 
You asked the Plan to pay for the anti-reflective coating, eye exam, frames purchase, and lens sphere trifocal. 
You say that you needed the eye exam to confirm your vision condition was getting worse. The Plan denied 
your request. The Plan says anti-reflective coating is not a covered service. The Plan also says that you last 
received an eye exam, glasses frames and lenses on August 17, 2020, so you are not eligible for the vision 
allowance until August 17, 2022. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers routine eye exams and routine eyewear once every two years. The Plan also does not 
cover lens options. 
 
We looked at the file and the Plan's rules. The anti-reflective coating is a lens option which is not covered. The 
contract says that routine eye exams and routine eyewear once every two years. The record shows that you 
received an eye exam, glasses frames and lenses on August 17, 2020, and your routine eye exam and routine 
eyewear benefits have been exhausted. Based on this information, we decided that the Plan's rules for coverage 
of the anti-reflective coating, eye exam, frames purchase, and lens sphere trifocal have not been met. Therefore, 
we decided that the Plan does not have to pay for the anti-reflective coating (V2750), eye exam (92014), 
frames purchase (V2020), and lens sphere trifocal (V2300) provided on December 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an onabotulinumtoxina injection (J0585) 
rendered on September 9, 2021. 
 
You asked the Plan to waive the coinsurance for an onabotulinumtoxina injection. You say that you only went 
and got the injection and then went home directly after the injection was given. You also say that you were not 
billed this much previously when this was done, and you are unable to afford the bill. The Plan denied your 
request. The Plan says you were charged the correct cost sharing amount. 
 
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 20% 
coinsurance for Medicare Part B non-chemotherapy prescription drugs.   
You have been asked to pay $1030.03 in coinsurance, which is 20% of the allowed amount for an 
onabotulinumtoxina injection ($5,160.16 allowed amount x 20% coinsurance = $1030.03). An 
onabotulinumtoxina injection 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 an onabotulinumtoxina injection (J0585) rendered on September 9, 2021.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve pembrolizumab (Keytruda). 
 
You asked the Plan to pre-approve Keytruda. The Plan denied your request. The Plan says that a negative gene 
mutation has not been confirmed. 
 
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 Keytruda. Our physician reviewer 
found that the enrollee has stage IV non-small cell cancer of the lung. The requested drug is supported by the 
National Comprehensive Cancer Network (NCCN) guidelines. For squamous cell cancers, molecular testing is 
optional. The use is not listed as not indicated, not supported, or not recommended in any of the compendia. 
The documentation does support that the requested drug is safe and effective and otherwise reasonable and 
necessary for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have been met. Therefore, we decided that the Plan has to pre-approve 
pembrolizumab (Keytruda).  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pathology services (CPT code 88305) to be provided 
by an out-of-network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the lab that they had requested is 
who they are contracted with to send biopsies to. The Plan denied your request. The Plan says there is no 
indication that another tertiary contracted facility cannot provide this interpretation. The Plan states the 
provider can use any of the tertiary labs within the Plan's network. 
 
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 
the pathology services (CPT code 88305) to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical eye exam provided on December 
2, 2021. 
 
You asked the Plan to waive the copayment for a medical eye exam. You say that routine eye exams are free 
once a year. The Plan denied your request. The Plan says the copayment applied was correct because the 
service was a medical eye exam, and not a routine vision exam. 
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 $45 
copayment for each Medicare-covered outpatient visit for services to diagnose and/or treat a disease or 
condition of the eye.  
 
You have been asked to pay a $45 copayment for a medical eye exam. Medical eye exams fall within the 
vision 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 a medical eye exam 
provided on December 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex device. 
 
You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically 
necessary. The Plan denied your request. The Plan says the requested Vertiflex device is not medically 
necessary. 
 
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 a Vertiflex device. Our reviewer says 
that the requested Vertiflex device is not medically necessary. Our physician reviewer found the requested 
Vertiflex device is experimental. More research is needed. At this time, the requested Vertiflex device is not 
medically necessary or the enrollee in this case. 
 
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 Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Vertiflex device.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 13 home health physical therapy visits. 
 
You asked the Plan to pre-approve 13 home health physical therapy 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 13 home health physical therapy visits. 
Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee does 
not have documented, ongoing, home health physical therapy needs. The enrollee is functioning at a level 
commiserate with a lower level of care. As such, ongoing, home health physical therapy services are not 
medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 13 home health physical therapy visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 13 home health physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions (D7210 x 12), lower partial denture with 
flexible base (D5212), and denture reline (D5761) provided from June 10, 2021, to August 25, 2021 by the out 
of network provider. 
 
You asked the Plan to pay for the dental services. You say most offices do not accept your insurance. You also say that these services were necessary due to the severe pain you were in. The Plan denied your request. The Plan says the claims were denied correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, dental services received out of network 
are not among those covered under this benefit. Additionally, the record shows there are in network dentist that could provide these services. Therefore, we decided that the Plan does not have to pay for the extractions 
(D7210 x 12), lower partial denture with flexible base (D5212), and denture reline (D5761) provided from June 
10, 2021, to August 25, 2021 by the out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two hearing aids (V5257 x2) provided on November 15, 
2021. 
 
You asked the Plan to pay for the hearing aids. You say that these are your very first hearing aids and you meet 
the requirement of once every 60 months. You also say that the cost of $1,395.00 per aid falls within the 
allotted allowance of $1,400.00. The Plan denied your request. The Plan says this claim processed correctly. 
The Plan also says that your hearing aid allowance for both ears has been exhausted. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays up to 
$1,400 per ear for hearing aids every 60 months.  
 
 We looked at the file and the Plan's rules. The record shows that the hearing aids (V5257) cost $1,495 each. 
Your hearing aid benefit only covers $1,400 per ear, and you are responsible for any difference because the 
hearing aids you purchased cost more than $1,400 each. Based on this information, we decided that the Plan's 
rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to 
pay for the two hearing aids (V5257 x2) provided on November 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upright walker with seat (CPT code E1399). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says this CPT code is not covered. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the durable medical equipment (DME) have not been met. A gait 
trainer (or sometimes referred to as a rollator) is a term used to describe certain devices that are used to support 
a beneficiary during ambulation. Gait trainers are billed using one of the codes for walkers. If a gait trainer has 
a feature described by one of the walker attachment codes (E0154, E0156, E0157) that code may be separately 
billed. Other unique features of gait trainers are not separately payable and may not be billed with code E1399. 
If a supplier chooses to bill separately for a feature of a gait trainer that is not described by a specific HCPCS 
code, then code A9900 must be used. Additionally, the provider is requesting coverage for an unlisted code 
when there is a more appropriate code for this service. A review of CMS guidelines states an unlisted code 
cannot be covered if there is an appropriate code for the requested service. Unlisted codes should be reported 
only if no other specific codes adequately describe the procedure or service. Therefore, we decided that the 
Plan does not have to pre-approve the upright walker with seat (CPT code E1399).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires a multi-disciplinary 
approach to help manage her multiple medically complex issues. The LTACH is the most appropriate setting 
for the enrollee's on-going care. The Plan denied your request. The Plan says authorization denied because 
LTACH is not medically necessary, and the enrollee's medical needs are being met in the current acute setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require extensive or complex wound care management by 
skilled nursing of at least 6.5 hours per day. There is no documentation provided indicating medical necessity 
for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. 
 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve Vertiflex. You say that this procedure is recommended when conservative 
treatment has failed and as a safer alternative to laminectomy or spinal fusion. The Plan denied your request. 
The Plan says the denial of authorization for Vertiflex is correct. 
 
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 Vertiflex. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertiflex device is experimental. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex procedure.