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

We decided that the Plan does not have to waive the copayments for ambulance, outpatient surgery, and inpatient hospital services (58558, A0427, 49320) provided November 5, 2020.

You asked the Plan to waive the copayments for the ambulance services, outpatient surgery, and inpatient hospital services. You say that the copayments should be waived. The Plan denied your request. The Plan says the correct cost sharing was 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 $280 copayment for ambulance services, a $325 per day copayment for inpatient care, and a $180 copayment for outpatient surgery. 

You have been asked to pay a $280 copayment for ambulance services and a $180 copayment for outpatient surgery. Only $236.50 was applied as a copayment for the inpatient stay, as your out-of-pocket maximum had been met. 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 copayments for ambulance, outpatient surgery, and inpatient hospital services (58558, A0427, 49320) provided November 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transfer bench without a commode opening (E0247).

You asked the Plan to pre-approve a transfer bench. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says this item is not a covered benefit under the enrollee's contractual policy or by Medicare.

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 transfer bench may be appropriate for the enrollee 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 transfer bench without a commode opening (E0247).
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 require this for your safety. The Plan denied your request. The Plan says that this is not covered by Medicare.

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 Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided by the out-of-network provider.

You asked the Plan to pre-approve the physical therapy to be provided by the out-of-network provider. You say that you need manual physical therapy, which is not provided through the Plan's physical therapy provider. The Plan denied your request. The Plan says there is no medical necessity to authorize an out-of-network physical therapy provider when the enrollee has multiple in-network options that can provide the same/similar services.

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 to be provided by the out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an adjunctive pre-diagnostic test (D0431), scaling in presence of generalized moderate or severe gingival inflammation (D4346), localized delivery of antimicrobial agents (D4381), and three drugs or medicaments dispensed in the office for home use (D9630 x3).
You asked the Plan to pre-approve the adjunctive pre-diagnostic test, scaling, localized delivery of antimicrobial agents, and drugs or medicaments. The Plan denied your request. The Plan says these services are not covered under the enrollee's benefit plan.
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 an adjunctive pre-diagnostic test (D0431), scaling in presence of generalized moderate or severe gingival inflammation (D4346), localized delivery of antimicrobial agents (D4381), and three drugs or medicaments dispensed in the office for home use (D9630 x3).
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve an implantable loop recorder for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says that this is considered experimental and investigational.
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 the services. Our reviewer says that the requested iservices are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee did not tolerate anticoagulation in the immediate post-op period due to gastrointestinal bleeding from anastomic ulcer. Although she had perioperative paroxysmal atrial fibrillation (PAF) as well, she had no known history of atrial fibrillation and the AF burden on the Zio patch was fairly limited (1%). She does have a significantly elevated CHA2DS2VASc score though and if she has recurrent PAF now that she is out of the perioperative period, anticoagulation should be reconsidered given the high embolic stroke risk. Assessing recurrence of PAF over a more extended period now that she is out of the perioperative period is clinically reasonable and an implantable loop recorder will have the highest yield of detecting asymptomatic PAF over an extended period of time. If PAF is detected, consideration for restarting Eliquis anticoagulation should be entertained. An implantable loop recorder, in this clinical scenario, would therefore meet the applicable CMS Section 1862(a)1 (A) criteria for medical reasonableness and necessity. 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 been met. Therefore, we decided that the Plan has to pre-approve an implantable loop recorder for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure (22899, C9752, C9753).

You asked the Plan to pre-approve an Intracept procedure. You say that this is medically necessary. The Plan denied your request. The Plan says this is experimental.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve an Intracept procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept procedure remains experimental for low back pain. More research is needed to show it is safe and effective.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure (22899, C9752, C9753).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power wheelchair to be provided by an out-of-network provider.

You asked the Plan to pre-approve the power wheelchair. You say that the wheelchair was denied for being out-of-network, but you are in the process of contract negotiations. You say that the request should be approved. 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 power wheelchair to be provided by an out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional non-emergency transportation trips.
You asked the Plan to pre-approve the additional trips. You say that you are requesting reconsideration of the decision to deny your request for additional transport. You have no means of transportation to go to your health care providers and you have several appointments coming up. The Plan denied your request. The Plan says this request exceeds the benefit maximum allowed.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 16 trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional non-emergency transportation trips.
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 need LTACH care. The Plan denied your request. The Plan says rules for LTACH care have not been met.
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 that the enrollee is a 65-year-old woman for whom admission to a long-term acute care hospital (LTACH) has been requested. The enrollee was involved in a motor vehicle accident a year ago that resulted in a spinal injury and paraplegia. The enrollee has a chronic sacral pressure wound, and an indwelling urinary catheter with a history of urinary tract infections. The enrollee was admitted to the acute care hospital on May 8, 2021, with sepsis. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214).
You asked the Plan to pre-approve the mandibular partial denture. You say that you would like to appeal this service. The Plan denied your request. The Plan says this service is only covered one time in a 60 month period. The Plan also says that you have already received 1 of these services within that time period.
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, pre-existing removable prosthesis (includes partial and full dentures), must be at least 5 years old and unserviceable to qualify for replacement. The record shows that you received a mandibular partial denture (D5214) on February 4, 2019 and your mandibular partial denture benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture (D5214).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One.
You asked the Plan to pre-approve Gel-One. You say that this is medically necessary. The Plan denied your request. The Plan says step therapy requirements have not been met.
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 Gel-One. Our reviewer says that the criteria for coverage of Gel-One have not been met. Our physician reviewer found the Plan requires a trial of Orthovisc and Monovisc before they will approve the requested drug. It is not documented that the enrollee has tried Orthovisc and Monovisc or that these drugs would likely be less effective or have adverse effects. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Gel-One.
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 IRF care is medically necessary. The Plan denied your request. The Plan says they would approve admission to a lower level of care but IRF care is not necessary at this time.

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 enrollee is a 66-year-old female who was admitted to an acute care hospital on April 20, 2021. Based on the documentation provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure (22899, C9752).

You asked the Plan to pre-approve an Intracept procedure. You say that the requested procedure is a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested procedure is not medically necessary because it is experimental/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 an Intracept procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has chronic low back pain which radiates into the enrollee's buttock. The enrollee has tried physical therapy, chiropractic therapy, epidural steroid injections, medial branch blocks and transcutaneous electrical nerve stimulation (TENS). The requested procedure is considered an experimental/investigational procedure at this point.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure (22899, C9752).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan of the lumbar spine.

You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the scan. Our reviewer says that Our physician reviewer found there is no documentation of a recent trial of physical therapy for back pain. More conservative measures are needed. There are no red flags for this scan at this time. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT scan of the lumbar spine.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve allograft for a back surgery for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says these materials are considered to be experimental, investigational, and unproven in spinal surgery.

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 services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of a contraindication to the use of iliac crest autograft. Iliac crest autograft is the gold standard bone graft material for lumbar surgery. Osteocel remains controversial and experimental for alone use in the lumbar spine fusion surgery. 

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 allograft for a back surgery for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Mohs surgery to be provided by an out-of-network dermatologist.
You asked the Plan to pre-approve Mohs surgery. You say that you have cancer on your ear that needs scraping that you want done out-of-network. The Plan denied your request. The Plan says in-network providers are available to treat your condition.
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 Mohs surgery to be provided by an out-of-network dermatologist.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says overall, there is a lack of evidence to support this device as safe and effective compared to the gold standard of decompression.
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.