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

 
We decided that the Plan does not have to pre-approve 13 skilled nursing visits,12 physical therapy visits, and 
14 occupational therapy visits. 
 You asked the Plan to pre-approve home health services. You say that that it is medically necessary to continue 
home health services, and you would like reconsideration based on the records submitted. The Plan denied your 
request. The Plan says the services 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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled 
therapy needs. The services of a home health aide are not shown to be medically necessary to assist in the 
treatment of an acute illness or injury. The enrollee appears to require long-term, daily and custodial care. As 
such, the requested home health 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 13 skilled nursing visits,12 physical therapy visits, and 14 occupational therapy 
visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for over-the-counter COVID-19 test kits provided on June 26, 
2023. 
 
You asked the Plan to pay for over-the-counter COVID-19 test kits. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says over the counter (OTC) COVID-19 tests are 
not covered by Medicare after May 11, 2023. 
 
  The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and over-the-
counter COVID-19 test kits is an OTC item. The Plan does not offer coverage for OTC items, which includes 
COVID-19 test kits.  Therefore, we decided that the Plan does not have to pay for over-the-counter COVID-19 
test kits provided on June 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. 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 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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not 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 a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. There is no arterial blood gas (ABG) done while stable, to document chronic carbon dioxide (CO2) 
retention. If that is present, the enrollee may benefit from bilevel positive airway pressure (BiPAP) with 
average volume-assured pressure support (AVAPS) during sleep. Medicare does not cover a home ventilator 
when used at settings that can be provided with 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 ventilator (E0466).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency room (ER) visit (A4217, A4930, A6250) 
provided on June 26, 2023. 
 
You asked the Plan to pay for the ER 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 the rendering provider 
is not enrolled with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for an emergency room (ER) visit (A4217, 
A4930, A6250) provided on June 26, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on August 29, 2023. 
 You asked the Plan to pay for the ambulance services. You say that the enrollee was no longer enrolled in 
hospice at the time the services were rendered. The Plan denied your request. The Plan says Original Medicare 
is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on August 22, 2023. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the ambulance 
services provided on August 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic images (D0230) provided on June 
29, 2023. 
 
You asked the Plan to pay for the dental services. You say that you have not been to the dentist for over a year 
and a half so the denial must be a mistake. The Plan denied your request. The Plan says your benefit for the 
requested items or services has already been exhausted. 
 
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, certain limitations apply. The record 
shows the Plan paid for an intraoral radiographic image (D0220) and an intraoral radiographic image (D0230) 
on June 29, 2023; therefore, your benefit for the requested items or services was exhausted on the date of 
service of June 29, 2023. Therefore, we decided that the Plan does not have to pay for the intraoral 
radiographic images (D0230) provided on June 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye examination and a determination of refractive state. 
 You asked the Plan to pay for an eye examination and a determination of refractive state. You say that this was 
not a routine eye examination. The Plan denied your request. The Plan says they do not cover routine eye 
examinations and glasses. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we 
decided that the Plan does not have to pay for an eye examination and a determination of refractive state.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an immediate maxillary denture (D5130) provided on April 
21, 2023. 
 
You asked the Plan to pay for the dental services. 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 do not fall 
within your dental benefits. 
 
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. Therefore, we decided that the Plan does not have to pay for an 
immediate maxillary denture (D5130) provided on April 21, 2023.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for an emergency room (ER) visit (99283) provided on September 9, 2022. 
 
You asked the Plan to pay for the ER visit. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says that the services denied correctly as they do not meet 
the clinical requirements to be approved. 
 
The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson 
standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be 
such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of 
immediate medical attention would result in serious jeopardy to their health.  
 
We decided that this case does meet prudent layperson criteria for emergency care. A prudent layperson with 
an average knowledge of medicine would reasonably expect the absence of immediate medical care to 
seriously jeopardize their health in this case. Therefore, we decided that the Plan has to pay for an emergency 
room (ER) visit (99283) provided on September 9, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home mechanical ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that without the requested ventilator, the 
enrollee is at high risk for hospital readmission and potentially life-threatening exacerbations. The Plan denied 
your request. The Plan says the enrollee does not meet criteria for approval of a ventilator. 
 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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not 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 a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has obesity 
hypoventilation syndrome (OHS) with chronic respiratory failure but appears developed acute on chronic 
respiratory failure for volume overload requiring mechanical ventilation. The enrollee was documented on 
BIPAP but not trial of BIPAP with average volume-assured pressure support (AVAPS), which has not been 
attempted. The enrollee admission note is unfortunate but does not indicate the cause of the acute failure was 
from OHS. It appears the enrollee had a secondary cause. BIPAP with AVAPS would be indicated at this time 
and re-evaluation of the enrollee's course. A home ventilator is not indicated at this time given documentation 
provided. 
 
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 mechanical ventilator (E0466).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered medications from August 7, 2023, through 
August 11, 2023. 
 
You asked the Plan to pay for the medication. You say that you do not agree with the responsibility on this 
claim. The Plan denied your request. The Plan says the medication is not covered as a medical benefit under the 
Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered medications 
from August 7, 2023, through August 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy visits (97110x36, 97112x36, 97162, 
97530x36, 97750x36, 97535x36) to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve physical therapy visits. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the enrollee must use network providers to get her medical care and 
services. 
 
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 
physical therapy visits (97110x36, 97112x36, 97162, 97530x36, 97750x36, 97535x36) to be provided 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 zero-gravity chair (A9270). 
 
You asked the Plan to pre-approve a zero-gravity chair. You say that you disagree with the denial. The Plan 
denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a zero-gravity chair is not covered because they 
are not primarily medical in nature.  
 
While a zero-gravity chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
this item. Therefore, we decided that the Plan does not have to pre-approve a zero-gravity chair (A9270).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an immediate upper denture (D5130) and an extraction 
(D7140) for tooth #6, #11, and #12 provided on August 1, 2023. 
 You asked the Plan to pay for the dental services. You say that you needed an emergency procedure, and you 
would like the Plan to pay some of the dental bill. The Plan denied your request. The Plan says the denial of 
payment for these services is correct, because the immediate upper denture and the extractions are not covered 
by the Plan. 
 
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. Therefore, we decided that the Plan does not have to pay for an 
immediate upper denture (D5130) and an extraction (D7140) for tooth #6, #11, and #12 provided on August 1, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for remote physiologic monitoring provided on July 31, 2023. 
 
You asked the Plan to pay for remote physiologic monitoring. You say that the services were medically 
necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for remote physiologic 
monitoring provided on July 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the precision attachments (D5862) provided on May 24, 
2023, June 7, 2023, and July 6, 2023. 
 
You asked the Plan to pay for the dental services. You say that you should have some coverage since you have 
had implants most your life. The Plan denied your request. The Plan says the denial of payment for these 
services is correct, because the precision attachments are not covered by the Plan. 
 
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. Therefore, we decided that the Plan does not have to pay for the 
precision attachments (D5862) provided on May 24, 2023, June 7, 2023, and July 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and the repair of broken 
complete mandibular denture base (D5511) provided on June 20, 2023. 
 
You asked the Plan to pay for a limited oral evaluation (D0140). You say that the Plan has never paid for any 
denture service for you. The Plan denied your request. The Plan says the service or item in question is not 
covered under any normal circumstances. 
 
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. Therefore, we decided that the Plan does not have to pay for a limited 
oral evaluation (D0140) and the repair of broken complete mandibular denture base (D5511) provided on June 
20, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occupational therapy provided on January 13, 2023, to 
January 19, 2023. 
 
You asked the Plan to pay for occupational therapy. You say that you are asking reconsideration of the denied 
claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for occupational therapy 
provided on January 13, 2023, to January 19, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy visits. 
 You asked the Plan to pre-approve the home health physical therapy visits. The Plan denied your request. The 
Plan says the services 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 the home health physical therapy visits. 
Our reviewer says that the services are not medically reasonable and necessary. Our physician reviewer found 
clinical documentation does not specify clinical rational or provider order for home health physical therapy 
thus the records do not show that home health physical therapy services are required to effectively provide 
treatment, care, and/or services in order to improve your level of function, or to establish/perform a 
maintenance program to maintain your level of function or prevent deterioration. 
 
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 home health physical therapy visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve home health physical therapy visits.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility provided on July 01, 2023, to July 07, 
2023. 
 
You asked the Plan to pay for skilled nursing facility. You say that you thought these services would be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for skilled nursing facility 
provided on July 01, 2023, to July 07, 2023.