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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary for you. The 
Plan denied your request. The Plan says that you can safely receive the services you need in other settings. 
 
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 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You do require physical therapy and occupational 
therapy services but based on the medical records provided you do not require an intensive inpatient 
rehabilitation therapy program. There is concern that you will not be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Our physician 
reviewer found that your condition does not meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Budesonide-Formoterol. 
 
You asked the Plan to pre-approve Budesonide-Formoterol. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Budesonide-Formoterol.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam rendered on September 25, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim is a duplicate. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the 
Plan on a separate claim for the same date of service. 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 
pay for the eye exam rendered on September 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occipital nerve block.
You asked the Plan to pre-approve the block. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered experimental, investigational, and not helpful for the enrollee's condition.
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 block. Our reviewer says that the requested block is not considered medically reasonable and necessary in this case. Our physician reviewer found occipital nerve blocks can be applied for diagnostic, prognostic, and therapeutic purposes in patients with headache, neuralgia, and other painful conditions of the posterior aspect of the head. In a review of the literature, commonly used treatments for pain relief from cervicogenic headache and occipital neuralgia include the use of local injected anesthetics, with or without the addition of corticosteroid preparation, to block the affected nerve(s). It is noted that these injections can be used as therapeutic treatment measures for pain relief, although the duration of pain relief varies from hours to months. However, the scientific evidence regarding injection therapy or percutaneous nerve block for occipital neuralgia and cervicogenic headache has been limited. The review has determined that the requested occipital nerve block is 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 block have not been met. Therefore, we decided that the Plan does not have to pre-approve an occipital nerve block.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz-FX.
You asked the Plan to pre-approve the Supartz-FX. You say that you would like reconsideration because this drug is medically necessary. The Plan denied your request. The Plan says the member does not meet step therapy exception criteria.
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 the Supartz-FX. Our reviewer says that there is no evidence that the enrollee has tried and not responded the the Plan's preferred drugs, Orthovisc and Monovisc. Our physician reviewer found there is no documentation as to why these other forms of hyaluronic acid would not be expected to be 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 the Supartz-FX have not been met. Therefore, we decided that the Plan does not have to pre-approve Supartz-FX.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergent transportation provided to the enrollee on 
September 19, 2019. 
 
You asked the Plan to pay for the non-emergent transportation. You say that the claim should be paid. The Plan 
denied your request. The Plan says the clinical indicates transportation other than an ambulance (e.g. private 
car, wheelchair van, etc.) could be utilized without endangering the individual's health, whether or not such 
other transportation is actually available. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 the non-emergent transportation. Our 
physician reviewer found based on the documentation provided, it is my opinion that transportation reportedly 
provided via ambulance between the SNF and the enrollee's hemodialysis appointment was not medically 
necessary. The enrollee was not bedbound, as evidenced by her ability to walk at the SNF and in PT. The 
enrollee did not require the expertise of trained personnel or the equipment available only on an ambulance in 
order to effectuate a safe transport. Transportation could have been provided by other means (stretcher van, 
wheelchair van, private car, taxi) without endangering the enrollee's condition. A prudent layperson would not 
believe that immediate medical attention was required for someone attending a scheduled appointment. 
 
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 non-emergent transportation have not been met. Therefore, we decided that 
the Plan does not have to pay for the non-emergent transportation provided to the enrollee on September 19, 
2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that you are not feeling safe by yourself 
following your surgery. The Plan denied your request. The Plan says the guidelines for coverage have not been 
met. The Plan says that the enrollee can receive the care needed in another setting. 
 
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 the SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral 
medications, had stable vital signs, and was treated for pain with effect. The enrollee received physical therapy 
and occupational therapy in the acute hospital. The enrollee was at a supervision to contact guard/minimal 
assist level with functional mobility, including gait to 150 feet. The enrollee required varying assist with 
activities of daily living. There are no identifiable skilled nursing service needs. There are identifiable skilled 
therapy service needs, but they are not required on a daily basis. The enrollee does not meet the 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 the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physical therapy visits you had on
January 10, 2020, and January 17, 2020.
You asked the Plan to waive the copayment. You say that you did not have physical therapy services. The Plan
denied your request. The Plan says you are responsible for the copayment.
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 $20
copayment for each visit for physical therapy services.
Review of the file shows that you were provided physical therapy services on January 10, 2020, and January
17, 2020. You have been asked to pay a $20 copayment for each visit, totaling $40. The physical therapy
services fall within the outpatient rehabilitation 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 copayment for the physical therapy visits you had on January 10, 2020, and January 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bed rail, stander security pole/grab bar, mechanical lift 
for your car and hitch for the car lift purchased on April 2, 2019 through August 21, 2019. 
 
You asked the Plan to pay for the DME. You say that the durable medical equipment is medically necessary. 
The Plan denied your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The record sent by your provider indicates that you have spinal problems and arthritis and you have requested 
these items to help with your mobility and safety. The records do not indicate that the bed rail is for use with a 
covered hospital bed or that you have a hospital bed. Your records show that your bed rail is not for use with a 
covered hospital bed, Medicare does not cover grab bars and a mechanical lift and hitch for your car are 
intended for use outside the home. 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 pay for the bed rail, stander security 
pole/grab bar, mechanical lift for your car and hitch for the car lift purchased on April 2, 2019 through August 
21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a root canal for tooth #22. 
 
You asked the Plan to pre-approve the root canal treatment. You say that this treatment is necessary. The Plan 
denied your request. The Plan says the dental benefit does not cover root canal treatments. 
 
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 
root canal for tooth #22.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a new battery for a portable oxygen concentrator.
You asked the Plan to pre-approve the batteries. You say that this is medically necessary. The Plan denied your
request. The Plan says when this item is authorized, it includes the device itself, and an integrated battery or
beneficiary-replaceable battery.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered
reasonable and necessary.
Medicare does not cover replacement batteries. Therefore, we decided that the Plan does not have to preapprove
a new battery for a portable oxygen concentrator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation of the right 
knee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not covered for osteoarthritis. 
 
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 genicular nerve blocks and genicular nerve radiofrequency ablation are considered investigational and 
not medically necessary for the treatment of chronic knee pain, including, but not limited to any of the 
following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a 
treatment following knee replacement; or as a treatment for individuals who are not candidates for knee 
replacement surgery. The review has determined that the requested genicular nerve radiofrequency ablation of 
the right knee is 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 genicular nerve radiofrequency ablation of the right knee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for osteogenesis stimulator, electrical, non-invasive, spinal applications (E0748) provided on February 13, 2020.
You asked the Plan to waive the coinsurance for the DME. You say that you feel strongly that the Plan needs to bare part of this bill due to the lack of communication with you. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received a osteogenesis stimulator, electrical, non-invasive, spinal applications (E0748) provided on February 13, 2020. You are asked to pay 20% coinsurance for the DME. Your EOC states, enrollees must pay 20% coinsurance for Medicare-covered DME and related supplies. 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 osteogenesis stimulator, electrical, non-invasive, spinal applications (E0748) provided on February 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a right SI joint fusion, L4-S1 hardware removal, L3-4 TLIF procedure.
You asked the Plan to pre-approve a right SI joint fusion, L4-S1 hardware removal, L3-4 TLIF procedure. You say that the requested right SI joint fusion, L4-S1 hardware removal, L3-4 TLIF is medically necessary. The Plan denied your request. The Plan says the requested right SI joint fusion, L4-S1 hardware removal, L3-4 TLIF is 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 a right SI joint fusion, L4-S1 hardware removal, L3-4 TLIF procedure. Our reviewer says that the requested right SI joint fusion, L4-S1 hardware removal, L3-4 TLIF is not medically necessary. Our physician reviewer found the enrollee is with low back pain. The medical records document a solid fusion. There is no recent trial and failure of physical therapy. There is no documented SI joint instability. The requested SI joint fusion is not medically reasonable or 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 a right SI joint fusion, L4-S1 hardware removal, L3-4 TLIF procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a right SI joint fusion, L4-S1 hardware removal, L3-4 TLIF procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for nebulizer with compression (E0570) 
provided to the enrollee from January 9, 2020 through June 9, 2020. 
 
You asked the Plan to waive the coinsurance for the durable medical equipment (DME). You say that you are 
appealing the member's cost-share responsibility for the services the member received. The Plan denied your 
request. The Plan says the claims were processed accordingly with the member's 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that you the enrollee received nebulizer with compression (E0570) from January 9, 
2020 through June 9, 2020. The enrollee is asked to pay 20% coinsurance per date of service for the DME. The 
enrollee's EOC states, enrollees must pay 20% coinsurance for DME, oxygen/oxygen equipment and related 
supplies. This means that the enrollee has been asked to pay the correct amount based on the contract with the 
Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. 
Therefore, we decided that the Plan does not have to waive the coinsurance for nebulizer with compression 
(E0570) provided to the enrollee from January 9, 2020 through June 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network dentist. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are other dental providers who are part of the network. 
 
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 
a referral to an out-of-network dentist.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF). 
 
You asked the Plan to pre-approve SNF admission. You say that you are appealing. The Plan denied your 
request. The Plan says the denial of authorization for SNF service is correct. 
 
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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled 
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The 
enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on 
an inpatient basis in a Skilled Nursing Facility (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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a Skilled Nursing Facility (SNF).