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 these services are medically necessary. The Plan 
denied your request. The Plan says that ongoing skilled services can be provided in an alternative setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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. Your 
medical status does not currently require intensive physician and nursing oversight only in an IRF. You may 
benefit from multiple therapies such as physical and occupational therapy but the documentation does not 
support that your functional status requires an intensive rehabilitation therapy program provided in an IRF. Our 
physician reviewer found that your condition does not meet Medicare criteria for IRF care. 
 
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to
the enrollee on February 11, 2020.
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request.
The Plan says the test should have been coded with CPT 81479.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare
rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay
for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on February 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit with a tertiary level vascular surgeon. 
 
You asked the Plan to pre-approve the office visit. You say that you would like reconsideration because you 
were referred to this provider for your condition. The Plan denied your request. The Plan says the 
documentation submitted does not show that you need tertiary level care. 
 
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 office visit. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the record does not suggest that you have an unusual or severe condition.  There is no 
documentation that you have seen an in-network provider and obtained non-satisfactory options or care. 
 
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 office visit have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an office visit with a tertiary level vascular surgeon.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copay forthe diagnostic mammogram services provided on December 10, 2019.You asked the Plan to waive the copay forthe services provided. You say that you should not be charged for an annual mammogram.The Plan denied your request. The Plan says the claim was correctly paid and the copay was correctly 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 $75 copay for diagnostic mammography in an outpatient hospital facility. You have been asked to pay a $75 copay for the diagnostic services provided. The services fall within the outpatient diagnostic tests benefit category. This means that you have been asked to pay the correct amount based on your contract withthe 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 copay forthe diagnostic mammogram services provided on December 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit with a tertiary level orthopedic spine 
surgeon. 
 
You asked the Plan to pre-approve the office visit. You say that you would like reconsideration because you 
would feel more comfortable going to this provider. The Plan denied your request. The Plan says the 
documentation does not show that you require a tertiary level of care. 
 
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 office visit. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is a routine orthopedic condition that can be managed by an in-network orthopedic doctor. 
 
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 office visit have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an office visit with a tertiary level orthopedic spine surgeon.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for the nuclear medicine scan and the 
ultrasound provided on February 4, 2020. 
 
You asked the Plan to reduce the cost share for the nuclear medicine scan and the ultrasound. You say that you 
have never paid this amount for daily testing. You said you had these tests on the same day and should not be 
charged separately. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
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 $250 
copayment for nuclear medicine services at an in-network outpatient hospital and 20% coinsurance for 
diagnostic procedures and tests at an in-network outpatient hospital.  
 
You have been asked to pay a $250 copayment for the nuclear medicine scan. You have also been asked to pay 
$640.20 which is 20% of the allowed amount for the ultrasound. The allowed amount is $3,201. ($3,201 x 20% 
= $640.20). The nuclear medicine scan and the ultrasound fall within the ?Outpatient diagnostic tests and 
therapeutic services and supplies? 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 reduce the cost share for the nuclear medicine scan and the ultrasound provided on 
February 4, 2020. 
  
Our decision is only about the February 4, 2020 services. If you have any questions about prior years billing, 
please contact the plan directly.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for skin Protection wheelchair seat cushion (E2622) and Replacement cover for wheelchair seat cushion or back cushion (E2619) purchased April 17, 2020.
You asked the Plan to pay for the wheelchair seat cushion and replacement cover. You say that your present cushion was damaged and could no longer be patched to hold air. You were told you were eligible for a replacement if your doctor submitted a letter authorizing the purchase. The Plan denied your request. The Plan says over the counter DME items are not covered. The provider is not eligible to participate in Medicare.
The Plan must follow Medicare rules. Medicare rules say that a provider must be enrolled in the Medicare program in order to receive payment. If you go to a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the wheelchair seat cushion and replacement cover have not been met. Therefore, we decided that the Plan does not have to pay for skin Protection wheelchair seat cushion (E2622) and Replacement cover for wheelchair seat cushion or back cushion (E2619) purchased April 17, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ELANE genetic testing. 
 
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation of an ANC less than 500 uL, or an ANC less than 500 uL at 
least three times per week for four to six weeks. 
 
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 testing. Our reviewer says that the 
requested testing is not considered medically reasonable and necessary in this case. Our physician reviewer 
found you are noted to have recently discovered, cyclical neutropenia.  Bone marrow and antibody testing has 
been non-diagnostic.  
 
 
Treatment consists of monitoring and as needed G-CSF shots. While ELANE testing may provide a definitive 
diagnosis, it is unclear how the results would affect treatment or the disease?s course.  As such, the requested 
testing is not shown to be medically necessary or 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 the testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve ELANE genetic testing.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve RFA of the genicular nerves.
You asked the Plan to pre-approve the RFA. You say that you would like reconsideration because this service is medically necessary. The Plan denied your request. The Plan says genicular RFA is still being studied to see if the treatment is 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 the RFA. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental/investigational procedure that is the subject of ongoing clinical trials. 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 RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve RFA of the genicular nerves.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit, therapeutic, prophylactic, or 
diagnostic injection, percutaneous tests, noninvasive ear or pulse oximetry for oxygen saturation, and injections 
provided on December 5, 2018 by an OON provider. 
 
You asked the Plan to pay for the outpatient office visit, therapeutic, prophylactic, or diagnostic injection, 
percutaneous tests, noninvasive ear or pulse oximetry for oxygen saturation, and injections. The Plan denied 
your request. The Plan says these services were rendered by an OON provider without prior authorization. The 
Plan also says that the provider did not verify the enrollee's insurance before rendering non-urgent services to 
the enrollee. 
 
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 
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 the outpatient office visit, therapeutic, 
prophylactic, or diagnostic injection, percutaneous tests, noninvasive ear or pulse oximetry for oxygen 
saturation, and injections provided on December 5, 2018 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you would like to appeal the Plan's denial of 
the shower chair. You asked the Plan to reconsider providing coverage for the requested item. The Plan denied 
your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcranial magnetic stimulation (TMS) treatment. 
 
You asked the Plan to pre-approve TMS. You say that this is a safe and effective treatment that would improve 
the enrollee's symptoms. The Plan denied your request. The Plan says the denial of authorization for TMS is 
correct, because the enrollee has not had adequate trials of antidepressants or augmenting medications during 
this episode of illness. 
 
The Plan follows Medicare rules. Medicare rules say that TMS is only covered when the enrollee meets all of 
the clinical criteria listed above. 
 
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 TMS. Our reviewer says that the 
enrollee does not meet the Medicare criteria for the requested TMS. Our physician reviewer found the 
documentation submitted does not show that the enrollee meets one or more of the following criteria: the 
patient has demonstrated resistance to treatment with psychopharmacologic agents as evidenced by lack of 
clinically significant response to 2 trials of such agents, in the current depressive episode from at least 2 
different agent classes or the inability to tolerate pharmacologic agents is evidenced by 2 trials of 
psychopharmacologic agents with distinct side effects or history of response to TMS in a previous depressive 
episode evidenced by greater than 50 percent improvement in the standard rating scale or has had a trial of 
evidence-based psychotherapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TMS have not been met. Therefore, we decided that the Plan does not have to 
pre-approve transcranial magnetic stimulation (TMS) treatment.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested physician's services. 
 
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says an out 
of network provider may be needed if the Plan does not have a doctor who can do the services that are needed 
to treat your problem. 
 
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 the 
requested physician's services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the mouth guard. 
 
You asked the Plan to pre-approve the mouth guard. You say that please reconsider. You are on a fixed income 
and cannot afford $900 for a new mouth guard. You are still paying your hospital visit from last year that the 
plan did not cover. The Plan denied your request. The Plan says that a mouth guard is not among the covered 
services under the plan 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. The health plan contract on 
page 4-67 clearly says that the plan covers occlusal guards and adjustments of occlusal guard as well as 
occlusal guards for the treatment of TMJ dysfunction.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of the mouth guard have been met. Therefore, we decided that the Plan has to pre-approve the mouth 
guard.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from March 26, 
2020 through March 27, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was 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 inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the review has determined that the record did not show that at the time of inpatient 
admission the admitting physician reasonably expected that the patient's necessary hospital care (including 
earlier emergency department (ED) and/or observation care) would span two midnights. 
 
 
 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from March 26, 2020 through March 
27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home ventilator, any type, used with non-invasive 
interface, (e.g., mask, chest shell) (E0466), for the enrollee. 
 
You asked the Plan to pre-approve the home ventilator. You say that the durable medical equipment is 
medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our physician 
reviewer found coverage criteria for a home ventilator are not met.  This patient has Chronic obstructive 
pulmonary disease (COPD) with a recent hospitalization for a COPD exacerbation, with acute-on-chronic 
hypercarbic respiratory failure.  This patient may benefit from BiPAP at night. Failure of BiPAP while in a 
stable state as an outpatient, according to Medicare criteria, has not been demonstrated. Medicare does not 
cover a home ventilator when used as BiPAP. Certain BiPAP devices are capable of providing the AVAPS-AE 
mode of support. A home ventilator is not medically necessary, and the denial is upheld. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell) 
(E0466), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve positioning wedge pillow. 
 
You asked the Plan to pre-approve the item. You say that the item is medically necessary. The Plan denied your 
request. The Plan says personal comfort items are excluded from coverage. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve positioning wedge pillow.