Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care from December 18, 2020, forward. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is 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 Medicare pays for care in a SNF when the four factors listed 
above are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not 
necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable 
skilled therapy service needs. The beneficiary does not require skilled nursing or therapy services on a daily basis. This 
beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare 
rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF 
care from December 18, 2020, forward.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is 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 LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided necessitating admission to a LTACH. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where they are 
currently receiving care. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be 
furnished safely and effectively only on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for echocardiography provided. 
 
You asked the Plan to waive the copayment for echocardiography. You say that you got a letter stating that all 
copayments would be waived until August. The Plan denied your request. The Plan says the claims were 
processed correctly and you are being charged the correct 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 $25 
copayment for non-radiological diagnostic services.  
 
You have been asked to pay a $25 copayment for echocardiography. Echocardiography falls 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 waive the copayment for echocardiography provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 12, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says unauthorized, non-plan care is not covered. 
 
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 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 services. Therefore, we decided 
that the Plan does not have to pay for the medical services provided on August 12, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture services 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 the main chief complaint is cervical neck pain. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
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 acupuncture is not 
covered for neck pain. It is only covered for chronic low back pain. Therefore, the request is deemed 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve acupuncture services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a standing frame. 
 
You asked the Plan to pre-approve standing frame. You say that you are in a wheelchair and need assistance 
pulling yourself up. The Plan denied your request. The Plan says the denial of authorization for this item is 
correct, because you do not possess the functional strength or active range of motion in your lower extremities 
to perform standing activities of any kind. 
 
The Plan follows Medicare rules. Medicare rules say that mobility assistive equipment may be covered to 
restore the beneficiary's ability to participate in MRADLs in the home. 
 
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 standing frame. Our reviewer says that 
you do not meet the Medicare criteria for this standing frame. Our physician reviewer found you are paraplegic 
and do not possess the lower extremity strength to stand.  
 
Standers and standing frames are not considered medically necessary for recipients with complete paralysis of 
the hips and legs, such that lower body range of motion is not improved or maintained by the standing position, 
or if using the stander/frame would create an unsafe situation for the recipient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of standing frame have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a standing frame.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound provided on August 25, 
2020. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that your doctor insists the ultrasound 
is mandatory with your history of cancer. You say that the total bill should be covered. 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 a $50 
copayment for all other diagnostic tests from an in-network provider.  
 
You have been asked to pay a $50 copayment for the ultrasound. The ultrasound falls within the "Outpatient 
diagnostic tests and therapeutic services and supplies" benefit category. The ultrasound is considered diagnostic 
imaging. 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 ultrasound provided on August 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the immunizations provided on July 25, 2020, by an out-of-
network provider. 
 
You asked the Plan to pay for the immunizations. You say that the Plan should pay this claim. The Plan denied 
your request. The Plan says you did not request prior authorization. 
 
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 has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. Immunizations absent of injury or exposure are not covered. 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 immunizations provided on July 25, 2020, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Flex-Walk System. 
 
You asked the Plan to pre-approve these 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 a prosthesis is covered when specific criteria are 
met. 
 
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 acquired absence of the 
right leg below the knee. There is no documentation to support that he has a functional level of three or above. 
The criteria for coverage are not met; therefore, the Flex-Walk System is not reasonable or medically necessary 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Flex-Walk System.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care provided on October 16, 2020. 
 
You asked the Plan to waive the copayment for emergency care. You say that you are not happy with the care you 
received and disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly 
and you are being charged the correct 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 $90 copayment 
for emergency care.  
 
You have been asked to pay a $90 copayment for emergency care. Emergency care 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 emergency care provided on October 16, 2020.  
 
Your quality of care concerns have been handled separately by the health plan. Medicare does not permit us to 
make a decision on this type of complaint.
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 a review of the current medical literature indicates that this service is considered 
experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the 
requested device is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee presents with persistent low back pain radiating to the posterior thighs, right greater than 
left. She has signs/symptoms of neurogenic claudication. Clinical exam findings are generally consistent with 
imaging evidence of severe spinal and moderate to severe bilateral foraminal stenosis at L4/5 and L5/S1, 
moderate spinal stenosis and severe bilateral foraminal stenosis at L3/4, and mild spinal stenosis and moderate 
bilateral foraminal stenosis at L1/2 and L2/3. There is radiographic evidence of severe multilevel degenerative 
disc disease with scoliosis. She had failed at least 6 months of reasonable and/or comprehensive conservative 
treatment. Under consideration is a request for the Vertiflex device at L3/4 and L4/5. Current evidence based 
medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure 
over the gold standard of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed 
outcome studies to support the use of this device for this enrollee's medical condition as discussed above. FDA 
indications include implantation of the Superion device at one or two adjacent lumbar levels in patients with 
moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, from L1 to L5. 
This enrollee has at least moderate spinal stenosis at all lumbar levels from L1/2 to L5/S1, severe at L3/4 and 
L4/5, and would not meet FDA indications. FDA contraindications include scoliosis. There is reported 
radiographic evidence of scoliosis of the lumbar spine with no documentation of the Cobb angle. Superion 
 
 
indirect lumbar decompression would not be considered the standard of care for the enrollee's medical 
condition. Therefore, this request does not meet Medicare criteria as medically reasonable and necessary for 
treatment of this enrollee's medical condition. 
 
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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglasses provided on August 11, 2020. 
 
You asked the Plan to pay for the eyeglasses. The Plan denied your request. The Plan says you must use a 
provider who participates in the Plan's routine vision vendor network. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan 
covers these services when you use a doctor in the Plan's vision network. 
 
We looked at the file and the Plan's rules. The file shows that the requested provider in this case is not a 
network vision provider with the Plan. Based on this information, we decided that the Plan's rules for coverage 
of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses 
provided on August 11, 2020.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for skin grafts (15273, 15274) provided on October 28, 2019. 
 
You asked the Plan to pay for skin grafts. You say that this was billed correctly. The Plan denied your request. 
The Plan says that these codes are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code 15273is application of skin substitute graft to trunk, arms, legs, total wound surface area greater than or 
equal to 100 sq. cm; first 100 sq. cm wound surface area, or 1% of body area of infants and children; and 15274 
is application of skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 
sq. cm; each additional 100 sq. cm wound surface area, or part thereof, or each additional 1% of body area of 
infants and children, or part thereof (List separately in addition to code for primary procedure). 
 
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 skin grafts. Our reviewer says that these 
codes are supported in the record. Our physician reviewer found the operative report documents two 
procedures performed on trunk, measuring over 200 sq. cm. Puraply AM, a skin substitute, was applied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of skin grafts have been met. Therefore, we decided that the Plan has to pay for 
skin grafts (15273, 15274) provided on October 28, 2019.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special pump services (99190) provided on April 2, 2020. 
 
You asked the Plan to pay for the special pump services. You say that you are requesting a reconsideration of 
the Plan's denial for payment. The Plan denied your request. The Plan says this service is statutorily excluded 
by Medicare. The facility must furnish all necessary covered services to the beneficiary either directly or under 
arrangements made between the facility and outside vendors. 
 
The Plan must follow Medicare rules. The Medicare rules say that all items and non-physician services 
furnished to inpatients must be furnished directly by the hospital or billed through the hospital under 
arrangements.  
 
We find that Medicare rules for coverage of this service have not been met. Specifically, Medicare does not 
pay any provider or supplier other than the hospital for non-physician services furnished to the beneficiary 
while an inpatient in the hospital. The facility must furnish these services to the beneficiary either directly or 
under arrangements made between the facility and outside vendors. Therefore, we decided that the Plan does 
not have to pay for the special pump services (99190) provided on April 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Tenex procedure. 
 
You asked the Plan to pre-approve these 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 intermittent 
right lateral-sided hip pain. She has been diagnosed with gluteal tendinitis of the right hip. There is a lack of 
large volume, long-term peer-reviewed outcome studies to support the use of the Tenex procedure for this 
enrollees medical condition as safe and effective. This procedure would be considered investigational for this 
enrollees medical condition and 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Tenex procedure.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) of the knee (73721) 
provided on October 29, 2019. 
 
You asked the Plan to pay for the MRI of the knee. You say that you should not be responsible for the 
copayment since you were not advised of the cost prior to receiving the service. The Plan denied your request. 
The Plan says based on Medicare billing criteria, the claim was billed 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 a $100 
copayment for a Medicare-covered MRI at a freestanding provider.  
 
You have been asked to pay $100 for the MRI of the knee. 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 pay for the magnetic 
resonance imaging (MRI) of the knee (73721) provided on October 29, 2019.