Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections.
You asked the Plan to pre-approve the requested services. You say that the inflammation and degenerative
changes at the L4-5 facets are contributing to spinal stenosis. The Plan denied your request. The Plan says there
is insufficient clinical response to prior injections
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are only covered under
certain medical indications.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician
reviewer found that the enrollee has chronic low back pain. She tried medication trials and other conservative
therapy that failed. She has multi-level degenerative disc changes, hypertrophied ligamentum Flavaum, as well
as facet arthropathy. She has had Epidural steroid injection and additionally Right L4-L5 facet injection. The
latter is characterized in a note as providing little benefit. The enrollee had a prior right facet joint injection
which produced little benefit. The enrollee has multiple other pain generators which are not being addressed.
Therefore, the requested procedure is considered not medically reasonable or necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan
does not have to pre-approve facet joint injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation. 
 
You asked the Plan to pre-approve the services. You say that your hidradentitis might lead to infection. The 
Plan denied your request. The Plan says this is not covered by your plan under any circumstances. 
 
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 
bone replacement graft for ridge preservation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 4 additional chiropractic visits. 
 
You asked the Plan to pay for 4 additional chiropractic visits. You say that you need these services to treat your 
pain. The Plan denied your request. The Plan says your care can be transferred to a home program. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
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 4 additional chiropractic visits. Our reviewer 
says that the requested services are non-covered maintenance care. Our physician reviewer found despite the 
number of treatments rendered, only two chart notes and a re-exam are included in the submitted records. The 
two submitted chart notes reveal low back pain. The only finding is tenderness to palpation throughout the 
spine, with Thompson and Activator techniques used for analysis and treatment consisting of manipulation, 
traction and electrical stimulation for the low back. Re-exam reveals range of motion pain and reflexes at zero. 
The dates of the visits suggest maintenance and you state deteriorating degenerative disc disease, a chronic 
condition, among your conditions. The treatment is to prevent deterioration of a chronic condition and there is 
no evidence that clinical improvement has or will occur with additional chiropractic visits. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 4 additional chiropractic visits have not been met. Therefore, we decided that 
the Plan does not have to pay for 4 additional chiropractic visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hearing aids. 
 
You asked the Plan to pre-approve these services. You say that you need a hearing aid for your left ear. The 
Plan denied your request. The Plan says the services are not covered. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan?s coverage rules apply in this case. The Plan covers a 
hearing aid fitting/evaluation once per year only. 
 
We looked at the file and the Plan's rules. The request is for a hearing aid. The Plan covers an evaluation and 
fitting only; hearing aids are not covered by Medicare or your supplemental hearing benefit. Based on this 
information, we decided that the Plan's rules for coverage of these services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve hearing aids.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is not homebound and free transportation available.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 medically reasonable or necessary. Our physician reviewer found there is no indication that you are home-confined. As such, the necessary for these services is not substantiated. Therefore, the request is 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health services.
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 this is medically necessary. The Plan 
denied your request. The Plan says ongoing needs for skilled therapy, respiratory therapy, and skilled nursing 
can be completed in a lower level of care, such as IRF or even SNF. 
 
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 the enrollee is currently undergoing treatment at an ACH for acute-on-chronic 
respiratory failure. The enrollee was transiently intubated/ventilated, but is no longer intubated/ventilated. 
There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs 
are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. 
The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can 
then be transferred/discharged to a lower level of care for any ongoing long term care needs. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Swivel Car Seat. 
 
You asked the Plan to pre-approve the car seat. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
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 the Swivel Car Seat.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the outpatient surgery services provided 
from January 7, 2020 to January 28, 2020 and from February 4, 2020 to February 25, 2020. 
 
You asked the Plan to waive the copayments for the outpatient surgery services. You say that you feel you 
should not be responsible for this cost share amount and you would like the Plan to reconsider your request. 
The Plan denied your request. The Plan says you received outpatient surgery services provided in an outpatient 
hospital setting on the dates of service at issue in this appeal. The Plan says that the correct copayments have 
applied per your contract with the Plan. 
 
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 $345 
copayment for surgery services provided in an Outpatient hospital setting.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received surgical services 
provided in an outpatient hospital setting from January 7, 2020 to January 28, 2020 and from February 4, 2020 
to February 25, 2020. You have been asked to pay a $307.55 copayment for the January 7, 2020 Outpatient 
services, which is less than the contracted $345 copayment amount. You have been asked to pay a $345 
copayment for the February 4, 2020 Outpatient services. You have been asked to pay a $307.55 copayment for 
the February 25, 2020 Outpatient services, which is less than the contracted $345 copayment amount. The 
outpatient surgery services fall within the Outpatient hospital services benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayments for the outpatient surgery services provided from January 7, 2020 to 
January 28, 2020 and from February 4, 2020 to February 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that the requested supplies are medically 
necessary for you because you have excessive drainage from your bladder. You say that you have to change 
your briefs multiple times a day and you have already had to purchase over three hundred briefs. You stated 
that your incontinence is extremely severe, and you asked the Plan to reconsider providing coverage for the 
requested supplies. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 2 additional home skilled nursing visits.
You asked the Plan to pre-approve 2 additional home skilled nursing visits. You say that you would like the
plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not
medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 2 additional home skilled nursing visits.
Our reviewer says that the documentation does not support that the requested home health services are
medically reasonable or necessary. Our physician reviewer found he enrollee's vital signs are within normal
range. The documentation does not support that skilled nursing services are required to effectively provide
treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a
maintenance program to maintain the enrollee's condition and/or prevent deterioration. The enrollee's condition
is chronic and she is medically stable. The enrollee has no complex wounds or new enteral feedings or other
ongoing skilled nursing need. Therefore, the enrollee does not meet criteria for the requested skilled nursing
visits.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 2 additional home skilled nursing visits have not been met. Therefore, we
decided that the Plan does not have to pre-approve 2 additional home skilled nursing visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested bunion surgery. 
 
You asked the Plan to pre-approve the bunion surgery. The Plan denied your request. The Plan says that the 
enrollee's Plan requires the enrollee to receive care from in-network providers with the exception of emergency 
or urgent care or if the care cannot be provided with an in-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 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 bunion surgery.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) services. 
 
You asked the Plan to pre-approve the CT scan. You say that the requested CT scan should be covered because 
she had an x-ray done on her back, which showed that there was compression of L2 and a compression 
fracture. You say that the x-ray gave additional reasoning to have the CT done. The Plan denied your request. 
The Plan says the CT scan is not reasonable and necessary and is not supported by the enrollee's symptoms or 
complaints. 
 
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 CT scan. Our reviewer says that the 
requested CT scan is not medically necessary. Our physician reviewer found there is no specific clinical 
rationale for the requested CT scan of the lumbar spine. There is no indication of neurological deficits that 
correlate with pathology expected. 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve computed tomography (CT) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair lift. 
 
You asked the Plan to pre-approve a stair lift. You say that the requested stair lift is not a convenience item for 
you. You say that your knees are very weak, and your treating physician has supported your medical need for a 
stair lift. You stated that previously you have fallen while going down your stairs and you were injured in the 
fall. You asked the Plan to reconsider their denial and provide coverage for a stair lift. The Plan denied your 
request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift 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 stair lift.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit (99283) provided 
April 12, 2020. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that the copayment should 
be waived. The Plan denied your request. The Plan says the correct copayment 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 a $120 
copayment for Emergency Care.  
 
You have been asked to pay a $120 copayment for the emergency room visit. The emergency room visit falls 
within the Emergency 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 an 
emergency room visit (99283) provided April 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on 
October 11, 2019 to October 17, 2019. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the durable medical equipment have not been met. Specifically, medical records do not support a 
prior face-to-face examination with the ordering physician within 6 months of ordering the DME or an 
appropriate use of telehealth. The submitted consultation notes do not support that a physical examination was 
performed. The information submitted does not confirm that Medicare coverage criteria have been met. 
Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the 
enrollee on October 11, 2019 to October 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyewear purchased on March 21, 2020. 
 
You asked the Plan to pay for the eyewear. The Plan denied your request. The Plan says that you must use a 
provider in the Plan's specialty medical network. 
 
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 eyewear when you use a doctor in their vision network. 
 
We looked at the file and the Plan's rules. The file indicates you did not go to a doctor in the Plan?s vision 
network. Based on this information, we decided that the Plan's rules for coverage of the eyewear have not been 
met. Therefore, we decided that the Plan does not have to pay for the eyewear purchased on March 21, 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 for the enrollee. 
 
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 the enrollee does not require an intensive therapy program and would 
benefit from a less intensive level of 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 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.  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. Our physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Purewick urine collection system, 90 units of female external catheters for Purewick urine collection system and 3 units of a monthly Purewick urine collection system accessory kits.
You asked the Plan to pre-approve incontinence supplies. You say that you are incontinent and unable to get out of bed due to lymphedema in both legs. The Plan denied your request. The Plan says these items are not covered under Medicare. They are considered hygienic items and are not classified as DME items.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve the Purewick urine collection system, 90 units of female external catheters for Purewick urine collection system and 3 units of a monthly Purewick urine collection system accessory kits.