Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the assistant surgeon services rendered on April 20, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that the assistant surgeon services were not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary 
are not covered. Medicare rules say that for procedures with an assistant surgery indicator of 0, the payment 
restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to 
establish medical necessity. In this case, you billed assistant surgery services for Current Procedural 
Terminology (CPT) code 28750. The Medicare Fee Schedule Database contains a surgical indicator of 0 for 
this procedure.  
 
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 pay for these services. Our reviewer says that the 
assistant surgeon services were medically necessary. Our physician reviewer found the records document in the 
operative report that the surgical assistant "was required to assist with exposure and reduction of the poor 
quality bone. She minimized the patient's blood loss and exposure to anesthesia." The records also document 
the assistant applied the splint. The records indicate the medical necessity of the assistant surgeon for procedure 
code 28750. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pay for 
the assistant surgeon services rendered on April 20, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport, and ground mileage provided on March 29, 2023. 
 
You asked the Plan to pay for the ambulance transport service and ground mileage. You say that the enrollee is 
bed confined and requires additional personnel or equipment to safely handle patient due to morbid obesity and 
any other form of transport is unsafe for the patient. The Plan denied your request. The Plan says the enrollee 
did not require the expertise of trained personnel or the equipment available only in an ambulance in order to 
effectuate a safe transport. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same 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 pay for the ambulance transport service and ground 
mileage. Our reviewer says that the ambulance transport service was not medically necessary.  
 Our physician reviewer found the transportation via ambulance from the emergency department to the 
enrollee's living facility was not medically necessary. The enrollee did not require the expertise of trained 
personnel or the equipment available only on an ambulance in order to effectuate a safe transport. 
Transportation could have been provided by other means (stretcher van, wheelchair van, private car, taxi) 
without endangering the enrollee's condition. 
 
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 ambulance transport service and ground mileage have not been met. 
Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-
emergency transport, and ground mileage provided on March 29, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Enhertu. 
 
You asked the Plan to pre-approve the drug. You say that the drug is for the enrollee's cancer. The Plan denied 
your request. The Plan says Enhertu is not medically necessary.  
 
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 the drug. Our reviewer says that 
Enhertu is not medically necessary. Our physician reviewer found that the requested use of Enhertu is not 
FDA-approved. Enhertu is also not supported by one of the major compendia or by clinical research. 
 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 Enhertu.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an eye examination. 
 You asked the Plan to pre-approve an eye examination. You say that you do not want to see a different 
optometrist due to you are not willing to go back to the previous optometrist. The Plan denied your request. 
The Plan says you are allowed one eye examination per year. 
 
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 one routine eye examination per year. 
 
We looked at the file and the Plan's rules. The Plan rules say that they will pay for one routine examination 
every year. The record shows you had an eye examination in February of 2023. Based on this information, we 
decided that the Plan's rules for coverage of an eye examination have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an eye examination.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that a CGM is necessary for the enrollee to control their 
sugar levels. The Plan denied your request. The Plan says the Medicare criteria was not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM. Our reviewer says that the 
CGM coverage criteria was not met. Our physician reviewer found that the coverage criteria for a CGM 
requires low blood sugars or insulin use. It would be very unlikely to be having symptomatic low blood sugars 
on Metformin alone. If indeed the enrollee is having low blood sugars, a log should be provided and the case 
resubmitted. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), a harness for upgrade to expandable controller 
(E2313), and an expandable controller (E2377).  
 
You asked the Plan to pre-approve an electronic connection, a harness and an expandable controller. You say 
that the records provided support the need for the items in dispute. The Plan denied your request. The Plan says 
the items in dispute are 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 an electronic connection, a harness and 
an expandable controller. Our reviewer says that the requested items are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the enrollee has amyotrophic lateral sclerosis (ALS) but 4/5-5/5 strength in her upper extremities. The enrollee has adequate upper body strength to manage 
standard power drives. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection, a harness and an expandable controller have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection between 
wheelchair controller and two or more power seating system motors (E2311), a harness for upgrade to 
expandable controller (E2313), and an expandable controller (E2377).
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided on October 5, 2022, and October 7, 
2022.  
 
You asked the Plan to pay for home health services. You say that the request is medically necessary. The Plan 
denied your request. The Plan says that the request is denied because the service is excluded. 
 
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 pay for home health services. Our reviewer says that 
the services are medically reasonable and necessary. Our physician reviewer found the enrollee had adjustment 
to an infusion. Per plan this was from an out of network provider, but the plan did not identify in network 
services. Per Chapter 4 Medicare managed care manual and chapter 7 for skilled nursing services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have been met. Therefore, we decided that the Plan has to 
pay for the home health services provided on October 5, 2022, and October 7, 2022.   
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided January 24, 2023, to January 
26, 2023. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this admission was medically 
necessary. The Plan denied your request. The Plan says that the required services could have bene provided 
under observation care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the enrollee was not considered medically stable for discharge until January 26, 2023. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided January 24, 2023, to January 26, 2023.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve the drug. The Plan denied your request. The Plan says Keytruda is not 
medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 the drug. Our reviewer says that 
Keytruda is not medically necessary. Our physician reviewer found that the requested use of Keytruda is not 
FDA-approved. Keytruda is also not supported by one of the major drug compendia or by clinical research. 
 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 Keytruda.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 heavy duty power wheelchair and accessories 
(K0850, E1028, E1007, E2606, E2311, E2376, E2620, E2313, E2361, E0955, and E2312). 
 
You asked the Plan to pre-approve a group 3 heavy duty power wheelchair and accessories. 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 power mobility devices are covered when specific 
criteria 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 a group 3 heavy duty power wheelchair 
and accessories. Our reviewer says that the services are not medically necessary. Our physician reviewer found 
you are not high risk for skin breakdown, use a catheter intermittently, have spasticity or require an alternative 
means of managing power drive, nor do you have neurological impairment, congenital spinal abnormality or a 
myopathy. 
 
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 group 3 heavy duty power wheelchair and accessories have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a group 3 heavy duty power wheelchair and 
accessories (K0850, E1028, E1007, E2606, E2311, E2376, E2620, E2313, E2361, E0955, and E2312).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a new office visit, a medical eye examination, and a 
follow up consultation to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a new office visit, a medical eye examination, and a follow up consultation. 
You say that the member is losing her eyesight as the days go by. The Plan denied your request. The Plan says 
the requested provider is not a network provider. The Plan also says that there are providers in-network they 
have approved a referral for. 
 
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 new office visit, a medical eye examination, and a follow up consultation to be provided by an out-of-
network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services rendered from June 
21, 2022, to June 30, 2022.  
 You asked the Plan to pay for the SNF services. You say that the documentation provided supports the services 
in dispute.  The Plan denied your request. The Plan says the records do not support a diagnosis of chronic 
obstructive pulmonary disease (COPD) or diabetes mellitus.  
 
The Plan follows Medicare rules. Medicare rules say that active diagnoses are intended to code diseases that 
have a direct relationship to the residents current functional status, cognitive status, mood or behavior status, 
medical treatments, nursing monitoring, or risk of death.  
 
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 pay for the SNF services. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found there is no evidence that the enrollee had 
or was actively treated for a chronic respiratory condition. There is no evidence that the enrollee had or was 
actively treated for diabetes. 
 
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 services have not been met. Therefore, we decided that the Plan does 
not have to pay for skilled nursing facility (SNF) services rendered from June 21, 2022, to June 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit and a determination of 
refractive state provided on March 30, 2023. 
 
You asked the Plan to waive the copayment for an office visit and a determination of refractive state. You say 
that you were instructed to not pay 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 a $20 
copayment for Medicare-covered visit. 
 
You have been asked to pay a $20 copayment for an office visit and a determination of refractive state. This 
item/service falls within the Medicare-covered visit 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 an office visit and a determination of refractive state provided on March 30, 2023.
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 enrollees current condition requires an IRF 
admission. The Plan denied your request. The Plan says records show that the enrollee's needs can be met in a 
lower level of care. 
 
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, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary care can 
be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0100). 
 
You asked the Plan to pre-approve the additional transportation trips. You say that you need the additional 
transportation for monthly appointments with urology for catheter changes. The Plan denied your request. The 
Plan says the plan only allows 24 trips which have already been used for this benefit period.  
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 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve the 
additional routine transportation trips. Based on this information, we decided that you have exhausted the Plan 
maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to 
pre-approve additional routine transportation trips (A0100).