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. The Plan denied your request. The Plan says you do not require an 
intensive, multidisciplinary approach to daily therapy. 
 
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 physician reviewer found 
that you were admitted to the acute hospital for weakness, falls and acute renal injury. Your medical problems 
are stable. There are no complex nursing needs. You do not require treatment by multiple therapies, including 
either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. 
 
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF care provided from October 1, 
2020, to October 31, 2020. 
 
You asked the Plan to waive the copayment for SNF care. You say that you believe the Plan and the facility 
should split the difference and write off the expense. The Plan denied your request. The Plan says the 
copayment amount you are being charged is correct. 
 
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 $0 
copayment per day for days 1 to 20 and a $178 copayment per day for days 21 to 100 for Skilled Nursing 
Facility (SNF) care up to an in-network maximum out-of-pocket amount of $6,500 for 2020. At the time this 
claim was processed, $2,337.57 of the $6,500 in-network maximum out-of-pocket amount had been met. This 
SNF stay lasted 31 days, which were days 31 to 62 of the benefit period, resulting in a total copayment amount 
of $4,161.43 because this amount, along with other cost-sharing amounts you have been asked to pay, met the 
$6,500 in-network maximum out-of-pocket amount for 2020.  
 
You have been asked to pay $0 copayment per day for days 1 to 20 and a $178 copayment per day for days 21 
to 100 for SNF care. SNF care falls within the Skilled Nursing Facility (SNF) 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. Therefore, we decided that 
the Plan does not have to waive the copayment for the SNF care provided from October 1, 2020, to October 31, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve powered pressure-reducing air mattress (E0277).

You asked the Plan to pre-approve the hospital bed and air mattress. You say that you are upset that the hospital bed and air mattress was denied. The Plan denied your request. 

The Plan says the enrollee does not meet the criteria for the requested heavy-duty bed or pressure mattress as the enrollee does not weight over 350 lbs. and does not have pressure ulcers or open wounds.

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 air mattress. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not have a history of pressure ulcers, recent skin graft or other surgery, or a condition which requires special positioning or any other indication to help support the request for a hospital bed or air mattress. Therefore, without sufficient support provided, this request for a hospital bed and air mattress will be considered 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 the air mattress have not been met. Therefore, we decided that the Plan does not have to pre-approve powered pressure-reducing air mattress (E0277).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on March 29, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you had a headache and were treated in 
place by the medics. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 29, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on March 29, 
2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve the services. The Plan denied your request. The Plan says the services are 
available in-network. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical 
therapy services to be provided by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve breast surgery (mastopexy) 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 this is considered to be a cosmetic procedure. 
 
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 the enrollee is a male to female transgender individual with gender identity disorder. The enrollee 
underwent breast augmentation in August 2020 due to mammary dysplasia. A note from March 2021 indicates 
that the enrollee prefers that her nipples point inward and would like to be 100cc larger. The request is for 
mastopexy. In this case, the enrollee has already undergone breast augmentation surgery. The provider's note 
indicates that the requested procedure s being performed to improve the enrollee's appearance. The requested 
service is cosmetic in nature.  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 the surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve breast surgery (mastopexy) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says LTACHs do not provide clinical advantage over a non LTACH acute care 
hospitals. 
 
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 is no documentation provided necessitating admission to a LTACH. 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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal surgery/fusion. 
 
You asked the Plan to pre-approve Insertion of interlaminar/interspinous process stabilization/distraction 
device, without open decompression or fusion, including image guidance when performed, lumbar; single level 
(22869) and Insertion of interlaminar/interspinous process stabilization/distraction device, without open 
decompression or fusion, including image guidance when performed, lumbar; second level (22870). You say 
that this procedure is necessary for the enrollee's pain relief. The Plan denied your request. The Plan says a 
review of the current medical literature indicates that this service is 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 Insertion of interlaminar/interspinous 
process stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar; single level (22869) and Insertion of interlaminar/interspinous process 
stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar; second level (22870). Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found the Superion spacer 
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 Insertion of interlaminar/interspinous process stabilization/distraction device, 
without open decompression or fusion, including image guidance when performed, lumbar; single level 
(22869) and Insertion of interlaminar/interspinous process stabilization/distraction device, without open 
decompression or fusion, including image guidance when performed, lumbar; second level (22870) have not 
been met. Therefore, we decided that the Plan does not have to pre-approve spinal surgery/fusion.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup procedure (D2950). 
 
You asked the Plan to pre-approve the core buildup procedure. You say that this service is medically necessary. 
The Plan denied your request. The Plan says this service is not covered by Medicare or by the Plan's 
supplemental dental benefit. 
 
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 
core buildup procedure (D2950).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on January 14, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent 
or emergent, nor were they approved in advance. 
 
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 
physician?s 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 physician's services provided on January 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee currently needs full care at all times. The 
Plan denied your request. The Plan says the IRF services you are requesting do not meet the requirements for 
approval. 
 
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. Our reviewer 
found that 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. Our physician reviewer also 
found that 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 the acute IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa (J7323). 
 
You asked the Plan to pre-approve Euflexxa. You say that the enrollee has tried corticosteroid injections, 
Naproxyn, Tylenol and formal physical therapy. The Plan denied your request. The Plan says the enrollee has 
not tried and failed the preferred step therapy drugs, Monovisc and Orthovisc. The Plan also says that there is 
no indication the preferred drugs would likely be less effective, and/or cause adverse effects for the enrollee. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Euflexxa. Our reviewer says that 
Euflexxa is not medically necessary. Our physician reviewer found the provided documentation does not show 
that the enrollee is allergic to or intolerant of these other forms of hyaluronic acid. The reviewer found there is 
no evidence that the enrollee has tried and not responded to these other forms of hyaluronic acid injections. The 
reviewer found there is no documentation as to why these other forms of hyaluronic acid would not be 
expected to be safe and effective for the enrollee.  Therefore, the reviewer found that Euflexxa is not shown to 
be currently medically necessary and reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa (J7323).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided by an out-of-network provider on 
August 7, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
not authorized. 
 
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 services at issue in this appeal. 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 the lab services provided by an out-of-network provider on 
August 7, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance supplies (A0422) provided on August 18, 
2020. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says the supplies cannot be 
paid separately. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services which include but are not 
limited to oxygen, drugs, extra attendants, supplies, EKG, and night differential are no longer paid separately 
for ambulance services.  
 
We looked at the file and Medicare rules. The requested ambulance supplies are not separately payable. 
Payment for the supplies is included in the ambulance transportation payment. Based on this information, we 
decided that Medicare rules for coverage of the supplies have not been met. Therefore, we decided that the Plan 
does not have to pay for the ambulance supplies (A0422) provided on August 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the podiatry services you received on December 21, 2020. 
 
You asked the Plan to pay for the podiatry services. You say that you cannot afford to pay for this. The Plan 
denied your request. The Plan says the benefit limit has been reached. 
 
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 up to 4 routine 
podiatry visits are covered per year.  
 
Review of the file shows that you had a routine podiatry visit on December 21, 2020. The records show that the 
Plan has already paid for 4 podiatry visits for 2020. The requested visit exceeds the benefit limit. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. Therefore, we 
decided that the Plan does not have to pay for the podiatry services you received on December 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diverticular peroral endoscopic myotomy (D-POEM). 
 
You asked the Plan to pre-approve diverticular peroral endoscopic myotomy (D-POEM). You say that the 
requested diverticular peroral endoscopic myotomy (D-POEM) is medically necessary. The Plan denied your 
request. The Plan says the requested diverticular peroral endoscopic myotomy (D-POEM) 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 diverticular peroral endoscopic 
myotomy (D-POEM). Our reviewer says that the requested diverticular peroral endoscopic myotomy (D-
POEM) is not medically necessary. Our physician reviewer found D-POEM (peroral endoscopic myotomy 
(POEM) in the management of esophageal diverticula using the principles of submucosal endoscopy has been 
requested. 
 
In Yang et al (1) retrospective series of 11 patients with an esophageal diverticulum (Zenker's 7, mid-
esophagus 1, epiphrenic 3) the mean size of the esophageal diverticula was 34.5 mm, the overall technical 
success rate of D-POEM was 90.9 %, with a mean procedure time of 63.2 minutes. There were no adverse 
events, with a decrease in mean dysphagia score from 2.7 to 0.1 (P < 0.001) during a median follow-up of 145 
days (interquartile range 126 - 273). CONCLUSIONS: ?the procedure is feasible, safe, and effective in the 
management of esophageal diverticula [but] larger studies are needed.? 
 
While promising, the technique is experimental, not standard of care, and as such does not meet coverage 
criteria outside of an investigational setting. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of diverticular peroral endoscopic myotomy (D-POEM) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve diverticular peroral endoscopic myotomy (D-
POEM).