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

 
We decided that the Plan does not have to pre-approve a slant board. 
 
You asked the Plan to pre-approve a slant board. You say that this is needed for exercises at home. The Plan 
denied your request. The Plan says that a slant board is a non-covered benefit. 
 
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 slant board.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) provided on November 29, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as they are non-emergent 
and prior authorization was not 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 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 an office visit (99214) provided on November 29, 
2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that the requested supplies are medically 
needed. The Plan denied your request. The Plan says the requested items are not covered by Medicare or the 
plan. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance image guided high intensity 
focused ultrasound (MRgFUS) (0398T). 
 
You asked the Plan to pre-approve MRgFUS. You say that this testing is medically necessary, and a safer 
alternative to deep brain stimulation. The Plan denied your request. The Plan says the criteria for coverage of 
MRgFUS are not met in this case. The documentation shows that your tremor is mild and not disabling and 
there is no documentation to show that you are not a candidate for deep brain stimulation. 
 
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 MRgFUS. Our reviewer says that the 
criteria for coverage of MRgFUS are not met in this case. Our physician reviewer found that although it is 
noted that your condition has not been responsive to at least two accepted medications, no formal measurement 
of your tremor was noted in the record. The chart note also suggested a dystonic tremor, which would be a 
separate classification. In addition, the provided records did not contain the results of any form of standardized 
assessments, and you have no mentioned contraindications to the performance of deep brain stimulation aside 
from personal preference. For these reasons, this request does not meet Medicare criteria for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MRgFUS have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance image guided high intensity focused ultrasound (MRgFUS) (0398T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diabetic supplies (K0553) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the diabetic supplies. You say that the services should be covered as they 
are medically necessary. The Plan denied your request. The Plan says they will cover a transitional 30-day 
supply but will no longer cover these items as there are in-network providers who can provide the same 
supplies. 
 
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 
diabetic supplies (K0553) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the specialist office visit. You say that the in-network provider you saw 
before cannot determine your symptoms and you would like to see an OON provider. The Plan denied your 
request. The Plan says there are multiple in-network providers available that provide the same quality of 
service that is within the enrollee's service area. 
 
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 
a specialist office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve remote blood pressure monitoring services to be 
provided by the requested out-of-network provider. 
 
You asked the Plan to pre-approve remote blood pressure monitoring services to be provided by the requested 
out-of-network provider. The Plan denied your request. The Plan says members must receive their care from a 
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 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 remote 
blood pressure monitoring services to be provided by the requested out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that SNF care is medically necessary, and the 
enrollee can discharge from IRF to SNF. The Plan denied your request. The Plan says SNF care is not 
medically necessary, and all the services you need are offered at the inpatient rehabilitation hospital. 
 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 the SNF admission. Our reviewer says 
that the requested SNF care is not shown to be medically reasonable and necessary. Our physician reviewer 
found the enrollee does not have documented skilled nursing needs.  The enrollee does not have documented 
skilled therapy needs. The enrollee is ambulating household distances. The enrollees care needs, custodial and 
intermittent, 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 the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar support chair. 
 
You asked the Plan to pre-approve a lumbar support chair. 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. 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 lumbar support chair.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pembrolizumab. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the clinical notes showed the next generation sequencing (NGS) testing did not support 
use of this medication. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found that there are no 
markers to indicate likely response to treatment. The documentation does not support that this drug would be 
medically reasonable or necessary, safe, or effective. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Pembrolizumab.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the $75 allowance for Over-the-Counter (OTC) Drugs 
be carried over from the first quarter of the 2022 plan year to the second quarter of 2022. 
 
You asked the Plan to pre-approve the $75 allowance to be carried over to the second quarter. You say that 
when you signed up you were not told about the OTC benefit, and feel it is unfair that you lost your allowance 
for the first quarter of the 2022 plan year. The Plan denied your request. The Plan says quarterly allowances 
cannot be carried over to another quarter. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items. However, your 
Plan offers a quarterly OTC allowance which the contract clearly states cannot be carried over to another 
quarter. Therefore, we decided that the Plan does not have to pre-approve the $75 allowance for Over-the-
Counter (OTC) Drugs be carried over from the first quarter of the 2022 plan year to the second quarter of 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a standard wheelchair (K0001) with seat cushion 
(E2601). 
 
You asked the Plan to pre-approve a standard wheelchair with seat cushion. You say that the requested items 
are a medical necessity for you. The Plan denied your request. The Plan says medical necessity rules for 
coverage of the requested items have 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 a standard wheelchair with seat 
cushion. Our reviewer says that the requested items are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that, based on the medical records provided, there is no documentation 
that you have a personal mobility deficit that impairs participation in mobility related activities of daily living 
such as toileting, feeding, grooming and bathing in customary locations within the home to the extent that a 
wheelchair is required. There is no documentation that your mobility deficit cannot be helped by the use of a 
walker. The available records document that you are walking 150 feet with a rolling walker with contact guard 
assistance. As you do not meet criteria for the requested wheelchair, you also do not meet the criteria for a 
wheelchair seat cushion. 
 
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 standard wheelchair with seat cushion have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a standard wheelchair (K0001) with seat cushion (E2601).
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 LTACH services. You say that LTACH admission is medically necessary. 
The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient care at the current 
hospital and the LTACH would offer no additional services. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where she is currently receiving 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient office visit (99204) provided 
on January 31, 2022. 
 
You asked the Plan to waive the copayment for the outpatient office visit. You say that you did not see the 
specified provider on this date of service and do not recognize their name. The Plan denied your request. The 
Plan says the medical records confirm you had a medical eye exam on January 31, 2022, with an optometrist, 
and you are responsible for the $30.00 copayment. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for a medical eye exam.  
 
 
  You have been asked to pay a $30 copayment for the outpatient office visit. The outpatient office visit falls 
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 the 
outpatient office visit (99204) provided on January 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC). 
 
You asked the Plan to pre-approve the PWC. You say that the requested PWC is medically necessary. The Plan 
denied your request. The Plan says the criteria for the requested PWC are not met. 
 
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.  
 
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 PWC. Our reviewer says that the 
documentation is not clear that criteria for a PWC are met in this case. Our physician reviewer found the 
documentation notes the patient has a mobility deficit that impairs MRADLs in the home. The documentation 
notes that the patient ambulates with a rollator but there are concerns regarding fall risk. The documentation 
states the patient cannot use a manual wheelchair due to weakness, shortness of breath, and right shoulder 
limitations. The documentation is conflicting that the patient can safely use the power wheelchair. The patient is noted to have forgetfulness and memory problems. The patient has very poor short-term memory. 
 
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 PWC have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Group 3 power wheelchair (PWC).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a ventilator. The Plan denied your request. The Plan says a setting 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 ventilator. Our physician reviewer 
found that a home ventilator is not medically necessary. You have COPD, with mild carbon dioxide retention 
during an exacerbation. You may benefit from BiPAP with AVAPS during sleep. This has not been tried at 
home, so there is no failure of BiPAP by Medicare criteria. The placing of BiPAP does not immediately 
normalize partial pressure of carbon dioxide. Medicare does not cover a home ventilator when used as 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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve ventilator. You say that the enrollee wishes to stay with you due to the 
quality of care you provide. The Plan denied your request. The Plan says the denial of authorization for this 
item is correct, because this provider is out-of-network with the Plan and this item can be obtained from an in-
network supplier. 
 
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 
a ventilator to be provided by an out-of-network (OON) provider.
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 meets the full criteria for an inpatient 
acute rehabilitation stay. The Plan denied your request. The Plan says authorization denied because the IRF 
care is not medically necessary, and the enrollee's needs can be met at a lower level of care, such as a skilled 
nursing facility (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 the intensity of services provided at an IRF.  
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. 
 
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.