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

 
We decided that the Plan does not have to pay for podiatry services provided on August 15, 2022. 
 
You asked the Plan to pay for the podiatry services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and 
available and requires authorization for certain services. No medical necessity for an out-of-network provider 
such as an urgent or an emergent situation that has been documented.   
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for podiatry services provided on August 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lightweight wheelchair (K0003). 
 
You asked the Plan to pre-approve a lightweight wheelchair. You say that the request is medically necessary 
due to the enrollee's age, history of arthritis, mobility issues, and his current wheelchair is too heavy to 
maneuver around. The Plan denied your request. The Plan says the requested wheelchair is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a lightweight wheelchair. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has bilateral OA of the knees and is not a surgical candidate. She is able 
to ambulate around her home with serial cortisone injections which given mild relief. She is not a candidate for 
a knee replacement. The appeal states she was last seen on January 31, 2023, and treated with cortisone 
injections. Her physical condition is unchanged. The progress note indicates on ROS she has joint pain. She 
was given knee cortisone injections. The documentation does not reveal an objective physical examination 
indicating that the enrollee is unable to self-propel a standard wheelchair in the home and does self-propel a 
lightweight wheelchair. 
 
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 lightweight wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a lightweight wheelchair (K0003).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of an oxygen concentrator (E1390). 
 
You asked the Plan to pre-approve an oxygen concentrator. You say that the oxygen concentrator is medically 
necessary. The Plan denied your request. The Plan says the request was denied due to lack of clinical 
information. The enrollee has moved out of the state/service area. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order and relevant medical records which support medical necessity.  
 
 
 
 
 The record does not contain a valid physician order, proof of delivery, or relevant medical records which 
support medical necessity for the supplies provided in this case. The record shows that the Plan made several 
attempts to obtain the necessary documentation from your physician without success. The records also show 
you have moved out of the service area. Therefore, we decided that the Plan does not have to pre-approve 
continuation of an oxygen concentrator (E1390).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 calf rest/pad, replacement only (E0995). 
 
You asked the Plan to pre-approve 2 calf pads. You say that the enrollee needs these items. The Plan denied 
your request. The Plan says the requested items are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that calf pads are included in the allowance of a 
center mount power elevating leg rest/platform.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of 2 calf pads have not been met. Specifically, the file indicates that the Plan has previously approved 
a center mount power elevating leg rest/platform, thus there is no need to request calf pads. Therefore, we 
decided that the Plan does not have to pre-approve 2 calf rest/pad, replacement only (E0995).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the inpatient hospital stay provided from 
October 22, 2022, to October 28, 2022. 
 
You asked the Plan to reduce the copayment for the inpatient hospital stay. You say that the enrollee was never 
considered outpatient during this service. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $295 copayment per day, for days 1 to 7 and a $0 copayment per day, for days 8 to 90 for each 
Medicare-covered hospital stay.  
 The enrollee has been asked to pay a $295 copayment per day, for days 1 to 6 of the inpatient hospital stay. 
You have been asked to pay a total of $1,770 ($295 copayment x 6 days = $1,770). You have not been charged 
for any additional days. This item/service falls within the inpatient hospital care benefit category. This means 
that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing 
is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the 
Plan does not have to reduce the copayment for the inpatient hospital stay provided from October 22, 2022, to 
October 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the inpatient hospital care provided from 
December 5, 2022, to January 15, 2023. 
 You asked the Plan to waive the cost share for the inpatient hospital care. You say that the provider did not 
spend the amount of time they are claiming they did. 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 
2022 contract with the Plan says that there is a $200 in-network deductible which applies to in-network 
inpatient hospital care. Your 2022 contract with the Plan also says that you must pay 10% coinsurance after 
meeting the deductible for in-network inpatient hospital care. 
 
Your 2023 contract with the Plan says that there is a $150 in-network deductible which applies to in-network 
inpatient hospital care. Your 2023 contract with the Plan also says that you must pay 10% coinsurance after 
meeting the deductible for in-network inpatient hospital care. 
 
Date of Service CPT Allowed Amount Deductible Coinsurance 
December 5, 2022 99222 $114.04 $114.04 $0 
December 6, 2022 93306 $58.47 $26.08 $3.23 
December 6, 2022 99232 $59.88 $59.88 $0 
December 7, 2022 99232 $59.88 $0 $5.98 
January 14, 2023 99223 $166.72 $150 $1.67 
January 15, 2023 99232 $59.88 $0 $5.98 
Total $366.86 
 
The item or service you asked the Plan to waive the cost share for falls within the inpatient hospital care benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the 2022 contract that there is a $200 
in-network deductible which applies to in-network physician/practitioner services. The Plan has also clearly 
disclosed in the 2023 contract that there is a $150 deductible which applies to in-network inpatient hospital 
care. This cost sharing is a contractual obligation that had not been met at the time the physician services were 
received from December 5, 2022, to January 15, 2023.  
 
You have also been asked to pay up to 10% coinsurance after meeting the deductible for the inpatient hospital 
care. This item/service falls within the inpatient hospital care benefit category. Therefore, we decided that the 
Plan does not have to waive the cost share for the inpatient hospital care provided from December 5, 2022, to 
January 15, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a suprascapular nerve block provided on April 15, 2021. 
 
You asked the Plan to pay for the suprascapular nerve block. You say that the services were medically 
necessary. The Plan denied your request. The Plan says that experimental/investigational services and supplies 
are not covered under the member's Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided a rule or a review to substantiate their 
denial. Therefore, we decided that the Plan has to pay for a suprascapular nerve block provided on  
April 15, 2021.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) scan of the heart, without 
contrast material, with quantitative evaluation of coronary calcium. 
 
You asked the Plan to pre-approve a CT scan. You say that you believe the Plan's denial of a CT scan of the 
heart with an evaluation of blood vessel calcification was unfair considering your symptoms, diagnoses, family 
history and the national statistics of heart attacks. The Plan denied your request. The Plan says you do not meet 
the guidelines for medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 CT scan. Our reviewer says that the 
service is not medically necessary at this time. Our physician reviewer found you do not have a high enough 
cardiovascular event risk (5% +) to justify calcium score measurement testing, if we take the documented 
atherosclerotic cardiovascular disease (ASCVD) at face value. It was not discussed which interventions were 
being considered that would be based on the results of the testing. Therefore, without sufficient support made, 
the CT scan will be considered not medically necessary at this time. 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 CT scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve computed tomography (CT) scan of the heart, without contrast material, with quantitative 
evaluation of coronary calcium.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services provided on November 9, 2022. 
 
You asked the Plan to pay for podiatry services. You say that your toenails were long and hard that made it 
painful to walk or wear shoes. The Plan denied your request. The Plan says routine foot care is not a covered 
Medicare benefit. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
Records do not show that any of these conditions are present. The services you are asking the Plan to pay for 
are routine foot care services. Based on this information, we decided that Medicare rules for coverage of 
podiatry services have not been met. Therefore, we decided that the Plan does not have to pay for podiatry 
services provided on November 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (K0800). 
 
You asked the Plan to pre-approve a power operated vehicle. You say that you cannot use a standard 
wheelchair. The Plan denied your request. The Plan says the requested POV is not medically necessary. 
 
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 a power operated vehicle. Our reviewer 
says that the coverage criteria has not been met. Our physician reviewer found that there is insufficient clinical 
documentation indicating that you are unable to propel a manual wheelchair for mobility and accomplishing 
your daily activities. More importantly you are noted to have Alzheimers disease and impaired gate and it is 
unclear if you can safely transfer to and from the requested power mobility device as well as operate it and 
maintain postural stability while using it. There is also no mobility assessment indicating that your home is 
accessible for the requested power mobility device. 
 
 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 power operated vehicle have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a power operated vehicle (K0800).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for medical supplies provided on July 15, 2022. 
 
You asked the Plan to pay for the medical supplies. You say that you have provided the proof of delivery for 
these items. The Plan denied your request. The Plan says that the documentation requirements have not been 
met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does contain a valid proof of delivery. Review of the file does not reveal any reason that the 
required documentation is invalid. Therefore, we decided that the Plan has to pay for medical supplies provided 
on July 15, 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office or other outpatient visit provided on 
January 5, 2023. 
 
You asked the Plan to pay for the office or other outpatient visit. You say that the patient was not enrolled in 
hospice on this date of service. 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. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for an office or other outpatient visit provided on 
January 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (33285, C1764, E0616). 
 
You asked the Plan to pre-approve an implantable loop recorder. You say that you disagree with the denial. 
The Plan denied your request. The Plan says the enrollee does not meet the Plan criteria for an ILR implant. 
 
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 implantable loop recorder. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has a rare history of presyncope (not complete syncope) and a 
short run of A. Afib on one week of noninvasive heart monitoring is not a candidate for an implantable loop 
recorder. The enrollee will not benefit from this invasive procedure. 
 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 implantable loop recorder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an implantable loop recorder (33285, C1764, E0616).
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 requesting an expedited reconsideration 
stating the enrollee meets full IRF criteria. The Plan denied your request. The Plan says the service requested 
is not supported based on the records received. 
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The clinical 
documentation shows that the enrollee requires ongoing physical and occupational therapy but does not show 
that the enrollee would tolerate or require an intensive rehabilitation regimen. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for alcohol and/or substance (other than tobacco) misuse. 
structured assessment and brief intervention provided on August 2, 2022. 
 
You asked the Plan to pay for alcohol and/or substance (other than tobacco) misuse. structured assessment and 
brief intervention. You say that the services were medically necessary. The Plan denied your request. The Plan 
says that the Plan requires utilization of network providers when possible and available and requires 
authorization for certain services. No medical necessity for an out-of-network provider such as an urgent or an 
emergent situation that has been documented.    
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for alcohol and/or substance (other than tobacco) misuse. structured 
assessment and brief intervention provided on August 2, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the services are medically necessary as the enrollee 
urgently requires care. The Plan denied your request. The Plan says the enrollee's record does not show that 
they require daily skilled nursing or skilled therapy in a SNF setting. 
 
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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have any parental medication; complex wound care or nutrition 
given via a feeding tube. The enrollee is medically stable without any acute exacerbations of chronic medical 
problems. The enrollee's physical function is at or near their baseline and the enrollee can receive services at a 
lower level of care. Admission to a SNF for inpatient skilled rehab services is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.