Persius/hicric huggingface dataset:
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 based on the medical records provided it is not clear that the complexity of the patient's nursing, medical and rehabilitation needs requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient does require physical therapy and occupational therapy services but based on the medical records provided it is not clear that the patient requires an intensive inpatient rehabilitation therapy program. There is inadequate documentation to clarify that the 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 IRF admission and services
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the duplex scan and physiologic studies you had on January 8, 2021.
You asked the Plan to waive the copayment for the duplex scan and physiologic studies. You say that your copayment is normally only $25. The Plan denied your request. The Plan says you were charged this copayment 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 $160 copayment for radiological diagnostic services. You have been asked to pay a $160 copayment for the duplex scan and physiologic studies. The duplex scan and physiologic studies fall within the radiological diagnostic 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 the duplex scan and physiologic studies you had on January 8, 2021
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 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 was admitted for a fall, lower extremity weakness, rhabdomyolysis, and metabolic acidosis. 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 documentation does support a need for physical and/or occupational therapy, there
is no documented need for a intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor provided on December 22, 2020.
You asked the Plan to pay for the provided item. The Plan denied your request. The Plan says the documentation did not indicate the provider discussed the need for the billed code.
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 not contain a valid physician order, 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 without success. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor provided on December 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies rendered on March 13, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were not medically necessary.
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the
services were not medically necessary. Our physician reviewer found the enrollee has diabetes and is
maintained on twice daily insulin therapy. The records do not sufficiently document that the criteria for
coverage of the CGM supplies are met. The services are therefore not reasonable or 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 not been met. Therefore, we decided that the Plan does not
have to pay for the continuous glucose monitor (CGM) supplies rendered on March 13, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardiovascular screening provided on March
19, 2021.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the testing is
not the standard of care and exceeds the needs of the enrollee.
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 pay for the testing services. Our physician reviewer
found that medical literature does not support use of multigene panels in cardiac disease evaluation. The
identification of a pathogenic variant in one of the analyzed genes is neither necessary nor sufficient for the
diagnosis of hypertrophic cardiomyopathy. The provided testing was not indicated for the enrollee's condition.
Therefore, the testing was not medically reasonable or necessary to treat the enrollee.
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 testing services have not been met. Therefore, we decided that the Plan does
not have to pay for the hereditary cardiovascular screening provided on March 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) provided April 21, 2021.
You asked the Plan to pay for the comprehensive oral exam. You say that you are allowed 2 oral exams per year and this is your first dental service of the year so you do not understand how you could have exceeded frequency limits. The Plan denied your request. The Plan says you have exceeded frequency limits for this service therefore it is not covered.
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. The Plan covers the comprehensive oral exam once every three years. We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive oral
exam was previously covered on September 8, 2020. Based on this information, we determined that the Plan's frequency limit for the comprehensive oral exam has been exceeded. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) provided April 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on August 27, 2021 with generalized weakness after hemodialysis followed by a fall. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.
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 long term acute care hospital (LTACH) services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99204) provided on March 16, 2021, by an
OON provider.

You asked the Plan to pay for an office visit. You say that you saw this provider due to an emergent situation
and you would like the Plan to cover this visit. The Plan denied your request. The Plan says services should be
received from network providers who are listed in the provider directory, except when urgent or an emergency.

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 records show that you moved
from Arizona to Minnesota. The records also show that you had an annual office visit to establish care with a
new provider. 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. The records provided for review do not
show that the services at issue were urgent or emergent. 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 an office visit
(99204) provided on March 16, 2021, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee brace provided on October 22, 2020.
You asked the Plan to pay for the knee brace. The Plan denied your request. The Plan says there is no documentation of recent injury or surgery to the knee.
The Plan follows Medicare rules. Medicare rules say that knee orthoses are only covered under certain medical indications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the knee brace. Our physician reviewer found that the enrollee is noted to have some laxity on exam, but there are no objective measurements in degrees of laxity to determine whether this is pathological instability or within normal range of laxity. There is no evidence of a recent surgery or injury to the knee. The Medicare criteria for the brace have not been met. Therefore, the knee brace is not considered 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 the knee brace have not been met. Therefore, we decided that the Plan does not have to pay for the knee brace provided on October 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fluid flow injection (Q4206).
You asked the Plan to pre-approve fluid flow injection. You say that this is medically necessary for your
condition. The Plan denied your request. The Plan says medical studies have not proven that the use of the
product is helpful for treatment of your health problem.
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 fluid flow injection. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found you are a 76-year-old man who has osteoarthritis of the knee. You have tried physical
therapy, chiropractic services, acupuncture, and meditation. In this case, this is an experimental/investigational
preparation and is not approved by the Food and Drug Administration. The requested service is not medically
reasonable or 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 fluid flow injection have not been met. Therefore, we decided that the Plan does
not have to pre-approve fluid flow injection (Q4206).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a gingivectomy or gingivoplasty - one to three
contiguous teeth or tooth bounded spaces per quadrant (D4211).
You asked the Plan to pre-approve a gingivectomy or gingivoplasty. You say that you need this surgery
because it will help to cut out infection. The Plan denied your request. The Plan says this service is not covered
under your benefits.
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
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a
gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant (D4211).
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 you need the services due to a past history of a stroke and resulting in poor balance. You state you would be able to get therapy to return home faster. 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 surgical repair of a hip fracture after a fall. Medical problems 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. While the documentation does support a
need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device and appliances provided
on July 30, 2020.
You asked the Plan to pay for the pneumatic compression device (E0675) and appliances (E0673). You say that
the equipment was prescribed by the doctor for use during the enrollee's surgery. The Plan denied your request.
The Plan says the device is not covered by Medicare to prevent deep vein thrombosis during and/or following
surgery and payment for this device would have been included in the facility payment.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the
purpose of prevention of venous thromboembolism (E0675) is a preventive service.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided
that the Plan does not have to pay for the pneumatic compression device and appliances provided on July 30,
2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (Current Procedural Terminology (CPT) code(s): 22869 and 22870), for the enrollee.

You asked the Plan to pre-approve the surgery. You say that the service is medically necessary. The Plan denied your request. The Plan says the services are considered experimental and investigational.

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 items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of the 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 the surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (Current Procedural Terminology (CPT) code(s): 22869 and 22870), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the automatic blood pressure monitor provided on February 18, 2021.
You asked the Plan to pay for the provided device. You say that the device was ordered by the hospital. The Plan denied your request. The Plan says the device is not covered by the plan.
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. Therefore, we decided that the Plan does not have to pay for the automatic blood pressure monitor provided on February 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) month rental of a replacement CPAP device
(CPT code E0601RR).
You asked the Plan to pre-approve the DME. You say that the DME company told you that it was not showing
anything to do with the recall and you have tested positive for Coronavirus over ten (10) days ago. You state
you are still testing positive due to the fact that the machine is full of Coronavirus and you feel like this is
going to cause more harm your health by using the same machine. The Plan denied your request. The Plan says
the DME is not approved for coverage.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. The clinical information provided for review does not show there is irreparable damage to your device. This is not a medical necessity issue but an issue between you, the DME company, and the manufacturer. The manufacturer has indicated they will replace or repair any machine in the recall at no cost to you, so you should work with your DME company for this request. Therefore, we decided that the Plan does not have to pre-approve ten (10) month rental of a replacement CPAP device (CPT code E0601RR).