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 IRF admission is medically necessary. The Plan
denied your request. The Plan says you do not not meet coverage criteria requirements.
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. Our
physician reviewer found the enrollee does not require the intensity of services provided at an IRF.
Specifically, the enrollee is not shown to require, or to currently be able to perform, fifteen hours per week of
rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at an alternate
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the urological supplies provided on January 16, 2020.
You asked the Plan to pay for the urological supplies. You say that the Plan should pay this claim. The Plan denied your request. The Plan says this claim cannot be paid separately based on Medicare guidelines for inpatient services.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF to be a home. Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to an enrollee. Records show that the urological supplies was used in a SNF. The facility must furnish all necessary covered supplies to the beneficiary either directly or under arrangements made with outside providers. Theses supplies would have been included in the global payment submitted to the plan by the facility. Therefore, we decided that the Plan does not have to pay for the urological supplies provided on January 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the frames and lenses.
You asked the Plan to pre-approve the vision services. You say that your glasses broke and you need a
replacement. You do not feel that you should pay out of pocket for a new pair of glasses. The Plan denied your
request. The Plan says this benefit has been exhausted.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers up to $300 for eyewear every 2 years.
We looked at the file and the Plan's rules. The eyewear benefit is covered once every 2 years. The records show
this benefit was last used June 20, 2019. This benefit will not be available until June 1, 2021. Based on this
information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore,
we decided that the Plan does not have to pre-approve the frames and lenses.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray provided by a participating provider on January 23, 2020. You asked the Plan to waive the copayment for an x-ray. You say that you were told you would get a $15 gift card. You say that this was supposed to be free. The Plan denied your request. The Plan says the correct copayment has been applied. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 copayment for outpatient diagnostic tests/x-rays. You have been asked to pay a $25 copayment for an x-ray. An x-ray falls within the outpatient diagnostic tests/x-rays benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an x-ray provided by a participating provider on January 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe full mouth debridement (D4355).You asked the Plan to pre-approvethe dental services. You say that if she is not able to receive removal of plaque and calculus, how can it be determined what further treatment she needs. If this procedure is not covered, Then what is so she can begin the process of fixing her teethThe Plan denied your request. The Plan says this service is not covered 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.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-approvethe full mouth debridement (D4355)
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat sacroiliac (SI) joint injection.
You asked the Plan to pre-approve SI joint injection. You say that you are appealing with medical records. The
Plan denied your request. The Plan says the denial of authorization for this service is correct, because the
previous injection did not provide at least 50% pain reduction.
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 SI joint injection. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the standard criteria is at least 50% pain reduction in order for a block injection to be
successful. The previous block injection was not successful and, therefore, the request is deemed not medically
reasonable and 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 SI joint injection have not been met. Therefore, we decided that the Plan does
not have to pre-approve a repeat sacroiliac (SI) joint injection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Euflexxa injection on December 12, 2019.You asked the Plan to waive the coinsurance for the Euflexxa injection. You say that you feel you are being overcharged. You say you were not told about the additional charge at the time of service. 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 20% of the cost for Part B covered drugs covered under Medicare Part B. You have been asked to pay $29.71 which is 20% of the allowed amount for the Euflexxa injection. The allowed amount is $148.54. ($148.54 x 20% = $29.71). The Euflexxa injection falls within the "Medicare Part B prescription drugs" 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 coinsurance for the Euflexxa injection on December 12, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvebilateral shoulder joint aspiration.You asked the Plan to pre-approvethese 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. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic multi-site pain after being hit by a bus in 2018. Recent subjective complaints have included low back, neck, shoulder, knee and hip pain with bilateral lower extremity numbness and tingling. There is insufficient documentation to support the medical necessity of injection therapy for this enrollee. There is no documentation of a clinical exam in the submitted medical records. Detailed evidence of a recent, reasonable and/or comprehensive treatment protocol trial and failure has not been submitted. The requested 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 pre-approvebilateralshoulder joint aspiration.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a home visit provided on January 8, 2020.
You asked the Plan to pay for the home visit. The Plan denied your request. The Plan says in-area urgent care
must be received in-network. The enrollee is not home bound, and the care was not urgent enough to be needed
out of network while in-area.
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
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 a home visit provided on January 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from October 7, 2019 through October 11, 2019.
You asked the Plan to waive the copayment for the inpatient stay. You say that you were informed to return to the hospital as soon as possible. You say that you were informed the visit was taken care of. The Plan denied your request. The Plan says the copayment applied 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 $250 per day, days 1-7 for each in-network, Medicare-covered hospital admission/stay. You have been asked to pay a $1,000 copayment for the inpatient stay. ($250/day x 4 days = $1,000). The inpatient stay falls within the "Inpatient hospital 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 inpatient stay provided from October 7, 2019 through October 11, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of an interlaminar/interspinous process stabilization/distraction device (22869).
You asked the Plan to pre-approve the insertion of an interlaminar/interspinous process stabilization/distraction device. 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 the insertion of an interlaminar/interspinous process stabilization/distraction device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental/ investigational device. Robust Head to head trials with open decompressive surgery have not been conducted with long enough follow-up. Furthermore, there is a significant incidence of re-operation. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the insertion of an interlaminar/interspinous process stabilization/distraction device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of an interlaminar/interspinous process stabilization/distraction device (22869).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve consultation services to be provided by an out of network (OON) provider.You asked the Plan to pre-approve these OON services. You say that you would like the plan to reconsider their decision.The Plan denied your request. The Plan says the requested services can be provided by a network provider.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 consultation services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve increased homecare to assist the enrollee at lunch.
You asked the Plan to pre-approve increased homecare to assist the enrollee at lunch. You say that the enrollee
needs to be escorted to encourage good food choices. The Plan denied your request. The Plan says this is not
necessary.
The Plan must follow Medicare rules. Medicare rules say that PACE plans must cover all services determined
necessary by the IDT to improve and maintain the enrollee's overall health status.
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 increased homecare to assist the
enrollee at lunch. Our reviewer says that the requested service do not meet criteria for coverage. Our physician
reviewer found the documentation does not support that additional resources are needed to assist the enrollee in
not eating dairy products.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of increased homecare to assist the enrollee at lunch have not been met. Therefore,
we decided that the Plan does not have to pre-approve increased homecare to assist the enrollee at lunch.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar microdiscectomy (low back surgery).
You asked the Plan to pre-approve the low back surgery. You say that the records provided support the need for the requested service. The Plan denied your request. The Plan says the clinical information received does not support the requirements of medical necessity guidelines for the requested 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 low back surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records do not support the need for spinal surgery. The MRI does not show evidence of severe nerve root compression. There is no correlation between an exam and MRI. 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 low back surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar microdiscectomy (low back surgery).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee scooter (E0118) purchased August 15, 2019.You asked the Plan to pay for the knee scooter. You say that the medical supply stores you contacted about the medically necessary knee scooter all informed you that they do not accept insurance for knee scooters so you had to pay out of pocket.The Plan denied your request. The Plan says there is insufficient published clinical literature demonstrating safety and effectiveness in the Medicare population to establish the medical necessity for crutch substitutes.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the knee scooter have not been met.Therefore, we decided that the Plan does not have to pay for the knee scooter (E0118) purchased August 15, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for panoramic x-rays (D0330) provided February 18, 2020. You asked the Plan to pay for the dental services. You say that you went to this provider due to facial pain you've had since November 2019. Please reconsider the decision to deny and cover this payment to the provider The Plan denied your request. The Plan says this service exceeds the benefit frequency limitations. 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. This service is covered once every 3 years. The records show this service was provided May 1, 2018. 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 pay for panoramic x-rays (D0330) provided February 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. You asked the Plan to pre-approve IRF care. You say that the IV and treatments are too much for her husband to manage even with a home health aide. The Plan denied your request. The Plan says do not have medical conditions so complex that they need a lot of monitoring by a doctor on an inpatient basis in an IRF. 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. Our physician reviewer found the records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at an alternate level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at another 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the comprehensive eye exam (92004) provided October 7, 2019.
You asked the Plan to waive the copayment for the vision services. You say that there should be no copay for this, however, the provider keeps billing you for $25. They coded your exam 92004 and you did not get a new prescription for your eyes. The Plan denied your request. The Plan says the copayment has been applied correctly for eye exam related to cataracts.
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 $25 copayment for Medicare covered exams to diagnose and treat diseases and conditions of the eye.
You have been asked to pay $25 copayment for the vision services. The vision services fall within the Vision 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 comprehensive eye exam (92004) provided October 7, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an MRI of the neck.
You asked the Plan to pre-approve an MRI of the neck. You say that the requested MRI of the neck is
medically necessary. The Plan denied your request. The Plan says the requested MRI of the neck is not
medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of the neck. Our reviewer says
that the requested MRI of the neck is not medically necessary. Our physician reviewer found the enrollee is
with severe pain in the neck, arm and shoulder. Medicare criteria for the requested MRI have not been met.
There is no documentation of a recent and adequate trial of physical therapy for neck pain. There are no red
flags documented for the requested MRI 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 an MRI of the neck have not been met. Therefore, we decided that the Plan does
not have to pre-approve an MRI of the neck.