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

 
We decided that the Plan does not have to pre-approve 15 skilled nursing visits and 5 home health aide visits. 
 You asked the Plan to pre-approve home health services. You say that the services are necessary. 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 the 
documentation indicates that there is no recent order by a physician that documents the current frequency of 
needs. In addition, the last documented visit on October 4, 2023, shows your wound was 0.7x0.7x0.1 cm in size 
without any recent documentation to show that the wound is still there and continues to need wound care. The 
review has determined that the records do not show that skilled nursing services are required to effectively 
provide treatment, care, and/or services in order to improve your condition, or to establish/perform a 
maintenance program to maintain your condition and/or prevent deterioration. The records do not show that 
skilled 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 and/or 
prevent deterioration. Regarding the requested home health aide visits, the services do not meet the definition 
of home health aide services. The home health aide services are not reasonable and necessary to the treatment 
of your illness or injury by the skilled professional staff. 
 
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 15 skilled nursing visits and 5 home health aide visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on 
September 06, 2023, to September 09, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that this services was fully 
covered in the past. 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 $245 
copayment for in-network inpatient hospital care. 
 
You have been asked to pay a $245 copayment for the inpatient hospital stay. This item/service falls within the in-network inpatient hospital 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. You have been asked to pay a total of $735 for the inpatient hospital stay ($245 
copayment x 3 days = $735). You have not been charged for the day you were discharged. Therefore, we 
decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on 
September 06, 2023, to September 09, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A9273 billed for date of service November 
22, 2022. 
 
You asked the Plan to pay for procedure code A9273. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code A9273 has a Status Indicator of N on the Physician Fee Schedule. This means that procedure code A9273 is non-covered. Based on this information, we decided that Medicare rules for coverage 
of procedure code A9273 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code A9273 billed for date of service November 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for durable medical equipment (DME) provided 
on July 9, 2023. 
 
You asked the Plan to waive the cost share for DME. You say that you disagree with the cost share. 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. Your 
contract with the Plan says that there is 10% coinsurance and a $800 deductible which applies to durable 
medical equipment (DME).  
 
The item or service you asked the Plan to waive the cost share for falls within the durable medical equipment 
(DME) benefit category. You are being asked to pay $263.74 towards your deductible and a $29.31 towards 
your coinsurance. The Plan has followed Medicare rules by clearly disclosing in the contract that there is 10% 
coinsurance and a $800 deductible which applies to durable medical equipment (DME). This cost sharing is a 
contractual obligation that had not been met at the time DME was received on July 9, 2023. Therefore, we decided that the Plan does not have to waive the cost share for durable medical equipment (DME) provided on 
July 9, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric treatment. 
 
You asked the Plan to pre-approve inpatient psychiatric treatment. 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 inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric treatment. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based upon review 
of the records provided this enrollee does not meet the criteria for December 12, 2023 forward as this enrollee 
was not shown to be a danger to herself or others. No delusions, auditory or visual hallucinations were noted. 
She was cooperative/compliant with treatment while not showing any threats the safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric treatment have not been met. Therefore, we decided that 
the Plan does not have to pre-approve inpatient psychiatric treatment.
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 you are appealing the denial with supporting 
documentation. The Plan denied your request. The Plan says the criteria for admission to an IRF has not been 
met.  
 
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 complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable. There are no complex nursing or rehabilitation needs. 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 and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from May 16, 2022, to June 
14, 2022. 
 You asked the Plan to pay for the home health services. You say that the Plan gave you no explanation as to 
why your claim was denied. The Plan denied your request. The Plan says the NOA was not received timely. As 
such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is May 16, 2022. The NOA was not received by the Plan until June 17, 2023. 
As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on 
this claim. Therefore, we decided that the Plan does not have to pay for home health services provided from 
May 16, 2022, to June 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Inspire hypoglossal nerve stimulator.  
You asked the Plan to pre-approve the nerve stimulator. You say that your sleep study showed you need this 
procedure. The Plan denied your request. The Plan says the records do not show that you had a sleep study 
performed within 24 months of the first consultation for hypoglossal nerve stimulator implant. 
 
The Plan must follow Medicare rules. Medicare rules say that FDA-approved hypoglossal nerve 
neurostimulation is considered medically reasonable and necessary for the treatment of moderate to severe 
obstructive sleep apnea when all of the criteria listed in the LCD have been met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the nerve stimulator. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found Medicare criteria have not been met. You have obstructive sleep apnea. 
Polysomnography on April 30, 2023, showed an apnea hypopnea index of 27.4, and a respiratory disturbance 
index of 54.8. However, the records do not include a consultation note for the Inspire device, documentation of 
CPAP trial and intolerance, or upper airway examination under anesthesia to exclude complete circumferential 
collapse of the soft palate.  
 
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 nerve stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Inspire hypoglossal nerve stimulator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies.  
You asked the Plan to pre-approve a CGM and supplies. 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. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that you have not had an in-person visit 
with your treating physician to evaluate your diabetes control and to determine whether the criteria for 
coverage have been met. Based on this information, we decided that Medicare rules for coverage of a CGM 
and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM) and supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy. 
 
You asked the Plan to pre-approve proton beam therapy. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
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 proton beam therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found proton beam therapy is not medically reasonable and necessary in this case. There is 
insufficient prospective, long-term clinical data available to determine whether or not proton beam radiation 
therapy for prostate cancer is superior, inferior, or equivalent to external beam radiation therapy, intensity-modulated radiation therapy (IMRT), or brachytherapy with regards to safety and efficacy. Recent data shows 
no significant differences in late (years one, two, and three) patient-reported toxicity outcomes between proton 
beam therapy and IMRT. The most recent AUA and NCCN guidelines state that proton beam therapy offers no 
clinical advantage over other forms of definitive treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam therapy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH services are medically 
necessary. The Plan denied your request. The Plan says you can receive the necessary services at your current 
health care 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 there are no services at the LTACH that you require that are not already available and 
covered at the current facility being offered by the health Plan. Transfer to the LTACH is not medically 
necessary as it would not be clinically advantageous. 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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy. 
 
You asked the Plan to pre-approve hyperbaric oxygen therapy. You say that this therapy is medically 
necessary. The Plan denied your request. The Plan says the requested therapy does not meet the requirements 
for approval. 
 
The Plan follows Medicare rules. Medicare rules say that hyperbaric oxygen therapy is covered when the 
criteria listed in the Medicare rules section are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve hyperbaric oxygen therapy. Our 
reviewer says that the requested therapy is not medically necessary. Our physician reviewer found that your 
wounds have been healing appropriately since November 29, 2023, with standard wound care. The medical 
documentation does not support that these are Wagner grade III ulcerations.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hyperbaric oxygen therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve hyperbaric oxygen therapy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient mental health treatment. 
 
You asked the Plan to pre-approve continued inpatient mental health treatment. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 continued inpatient mental health 
treatment. Our reviewer says that the services are not medically necessary. Our physician reviewer found based 
upon review the records provided this enrollee does not meet the criteria for December 19, 2023 forward as this 
enrollee was not shown to be a danger to herself or others. No delusions, auditory or visual hallucinations were 
noted. She was cooperative/compliant with treatment while not showing any threats the safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued inpatient mental health treatment have not been met. Therefore, we 
decided that the Plan does not have to pre-approve continued inpatient mental health treatment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the motorized wheelchair purchased on December 16, 2022. 
 
You asked the Plan to pay for these services. You say that you were given incorrect information. The Plan 
denied your request. The Plan says the provider is not Medicare-certified. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are 
furnished by a provider or supplier enrolled in the Medicare program. 
 
We looked at the file and Medicare rules. The file shows that the provider was not Medicare-certified for the 
dates of service at issue. Therefore, we decided that the Plan does not have to pay for the motorized wheelchair 
purchased on December 16, 2022.  
 
Your complaint about the Plan providing misinformation is not a valid appeal for medical coverage. This part 
of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
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 medical necessity has not been established. Therefore, coverage criteria have 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 the provided primary source 
documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. The enrollee could be treated with a bilevel positive airway pressure (BiPAP) machine with average 
volume-assured pressure support (AVAPS) capability and failure of such a device has not been documented. 
Furthermore, ventilators fall under the Frequent and Substantial Servicing (FSS) payment category, and 
payment policy requirements preclude FSS payment for devices used to deliver continuous and/or intermittent 
positive airway pressure, regardless of the illness treated by the device. The elements of the coverage criteria 
are not satisfied. The requested service cannot be recommended. 
 
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).