Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee requires supervision not available at home. The Plan denied your request. The Plan says 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 there are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive
rehabilitation therapy program. The patient does require physical and occupational therapy but there is no
documented need for an intensive rehabilitation program. Medically necessary services can be provided in a
different level of care. There is not a reasonable expectation that this patient 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay, with an interdisciplinary approach to rehabilitation care. You were admitted for acute kidney failure, sepsis, acute cholecystitis and respiratory failure. Medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program.
Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that you 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, bitewings, and prophylaxis provided on September 9, 2020 by a Medicare opt out provider.
You asked the Plan to pay for the periodic oral evaluation, bitewings, and prophylaxis. You say that you were not advised that this provider has opted out of Medicare. The Plan denied your request. The Plan says the treating provider opted out of Medicare effective November 4, 2015, to November 4, 2021.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's 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 covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the
Plan does not have to pay for the periodic oral evaluation, bitewings, and prophylaxis provided on September 9, 2020 by a Medicare opt out provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530 and
A6533.
You asked the Plan to pre-approve the compression stockings. You say that you disagree with the denial. The
Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 and
A6533 are noncovered because they do not meet the statutory definition of a surgical dressing.
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530 and A6533.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for a duplex scan of extremity veins (93971) provided on January 29, 2021, by an out-of-network provider.
You asked the Plan to pay for a duplex scan of extremity veins. You say that the services were medically necessary. The Plan denied your request. The Plan says unless urgent or emergent, services must be provided by a network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for a duplex scan of extremity veins (93971) provided on January 29, 2021, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve topical oxygen (Epiflo) delivery system (E0446).
You asked the Plan to pre-approve topical oxygen delivery system. You say that this medical DME is a great benefit to the enrollee since it is smaller and more direct for healing of ulcers. The Plan denied your request. The Plan says the use of topical oxygen for wound healing is not medically necessary per Medicare guidelines.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at this the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of topical oxygen delivery system have not been met. Therefore, we decided that the Plan does not have to pre-approve topical oxygen (Epiflo) delivery system (E0446).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Hoyer lift
You asked the Plan to pre-approve a Hoyer lift. You say that since your fall you have not been able to care for yourself. Most of the time you need help and have to depend on your wife. Your wife must lift you with a gait belt and help you sit on the bed. It is a lot of lifting and straining. The Plan denied your request. The Plan says the request for a Hoyer lift in the home is not considered reasonable and 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 Hoyer lift. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that the enrollee has been receiving home health and a review of the records demonstrates this enrollee is requiring moderate assistance with transfers. He uses a walker and is able
to walk 50 feet as of 04/27/2021. The enrollee also uses a wheelchair outside of the home. Clinical exam records from 01/2021 demonstrate the enrollee has good muscle strength of the extremities. It does not appear that this enrollee is considered bedbound and meets the criteria for a Hoyer lift. The medical records provided do not meet the requirements listed in the LCD for Medicare coverage for a Hoyer lift. 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 Hoyer lift have not been met. Therefore, we decided that the Plan does not have to pre-approve a Hoyer lift
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an urgent care visit provided by a
participating provider on January 25, 2021.
You asked the Plan to waive the copayment for an urgent care visit. You say that you do not agree with this
copayment. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $25
copayment for urgently needed services.
You have been asked to pay a $25 copayment for an urgent care visit. The correct copayment has been applied
to the services that were provided. An urgent care visit falls within the urgently needed services 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 urgent care visit provided by a participating
provider on January 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a stabilizing or separating device into the lower spine.
You asked the Plan to pre-approve the insertion of a stabilizing or separating device into the lower spine. You say that the records provided support the need for the requested service. The Plan denied your request. The Plan says the requested service is considered experimental and investigational. The Plan says that the requested procedure is not widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature.
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 the insertion of a stabilizing or separating device into the lower spine. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the interspinous spacer device remains experimental for the treatment of spinal stenosis. More research is needed to show safety and efficacy. 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 insertion of a stabilizing or separating device into the lower spine have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a stabilizing or separating device into the lower spine.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to adjust the cost share for the dental extraction you had on December 21, 2020.
You asked the Plan to adjust the extraction. The Plan denied your request. The Plan says you have been charged the correct amount.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are subject to a cost share responsibility. The Plan contract clearly states that there is a 55% coinsurance for out-of-network dental extractions and a 75% coinsurance for oral surgery services. You are also responsible to pay the
difference between the Plan's contracted rate and the amount billed by the out-of-network provider. This all totals $488.20, which means that you have been asked to pay the correct amount. Therefore, we decided that the Plan does not have to adjust the cost share for the dental extraction you had on December 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), teeth cleaning (D1110), fluoride (D1208), and an intraoral complete series of radiographic images (D0210) provided on February 23, 2021.
You asked the Plan to pay for a comprehensive oral evaluation, teeth cleaning, fluoride, and an intraoral complete series of radiographic images. You say that you want the Plan to pay for the services. The Plan denied your request. The Plan says you are not covered for these services when seen by an out-of-network provider.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of a comprehensive oral evaluation, teeth cleaning, fluoride, and an intraoral complete series of radiographic images have not been met. Specifically, services were provided by an out-of-network provider without prior authorization. The Plan has contracted providers available to provide these services. 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 a comprehensive oral evaluation (D0150), teeth cleaning (D1110), fluoride (D1208), and an intraoral complete series of radiographic images (D0210) provided on February 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit with an out-of-network provider.

You asked the Plan to pre-approve the out-of-network office visit. You say that the patient needs routine follow
up for her spine fusion surgery. You say that this doctor is the surgeon who performed the operation, and the
appointment would be to assess the status and progression of the fusion. The Plan denied your request. The
Plan says in-network providers are available.

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
the office visit with an out-of-network provider.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve thyroid nodule destruction with radioiodine (RAI).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says that the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee had a benign thyroid biopsy in 2020 with symptoms in the neck and largest nodules at 2.5 centimeters. He has difficulty swallowing. Although surgery is usually done for local symptoms of benign nodules, RAI is an option for patients who cannot undergo surgery. The RAI is within the guidelines for the enrollee's condition and is reasonable and 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 these services have been met. Therefore, we decided that the Plan has to pre-approve thyroid nodule destruction with radioiodine (RAI).
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve partial medial meniscectomy and debridement for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation of conservative treatment.
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 the surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines.
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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve partial medial meniscectomy and debridement for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids (V5274) purchased from an online retailer on December 23, 2020.

You asked the Plan to pay for the hearing aids. You say that you should be reimbursed for the hearing aids. The Plan denied your request. The Plan says this online retailer is not under contract with the health plan and is not certified with Medicare. A provider or supplier must be enrolled in the Medicare program in order for items or services to be covered.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when they are purchased from a provider who is part of the Medicare program. 

We looked at the file and the Plan's rules. The online retailer in question is not a Medicare-certified or Medicare-participating provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5274) purchased from an online retailer on December 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an incision for a nerve stimulator.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says there is collapse of the soft palate.
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 the services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the AHI on the most recent sleep study was 75. This was a home sleep study, and therefore may underestimate the AHI. Criteria include AHI 15 to 65. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve an incision for a nerve stimulator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99215) provided on January 22, 2021.
You asked the Plan to pay for an office visit. You say that this was billed correctly. The Plan denied your request. The Plan says this should be billed with an emergency department visit code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. If the emergency department physician requests that another physician evaluate a given patient, the other physician should bill an emergency department visit code. We find that CPT code 99215 is not supported in the medical record. Specifically, the records show that the consultation at issue was provided in the emergency department and should be billed with an emergency department visit code. Based on this information, we decided that Medicare rules for coverage of an office visit have not been met. Therefore, we decided that the Plan does not have to pay for an office visit (99215) provided on January 22, 2021.