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

We decided that the Plan does not have to pre-approve MRI of the lower extremity/right knee for the enrollee.
You asked the Plan to pre-approve the MRI. You say that the services are needed at this time. The Plan denied your request. The Plan says the clinical information provided does not meet the criteria for coverage.
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 the MRI. Our reviewer says that the requested MRI is not medically reasonable or necessary. Our physician reviewer found the enrollee has known primary osteoarthritis of the right knee. X-rays dated 10/6/20 (of the right knee) have impressions of: mild degenerative changes. However, the provided medical documentation does not support any significant change in the overall clinical picture. She is noted to be "stable" based on history, physical exam and review of pertinent labs, studies and medications on the 9/3/20 exam. No follow-up exams were documented as having been provided for the right knee after the performed x-rays on 10/6/20. Furthermore, there is limited documentation of recent, reasonable and comprehensive trial and failure of conservative care modalities provided for review. Literature does not support the request for right knee MRI without prior failure of conservative treatment. Exceptional findings are not evident in this scenario to support otherwise. The request for right knee MRI 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI of the lower extremity/right knee for the enrollee.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for the COVID-19 testing provided on November 15, 2020.
You asked the Plan to pay for the COVID-19 testing. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the service is not covered.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were referred for the COVID-19 testing by a contract provider. The file does not show that the Plan provided notice that the COVID-19 testing would not be covered. No medical records or other documentation was provided by the Plan. Although the Plan states this was preventive, you were exposed to a known COVID-positive individual which does not fall within the preventive definition of the policy. Under Medicare rules, this means the COVID-19 testing is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the COVID-19 testing provided on November 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgery to place a Vertiflex Superion device (CPT Code 22869 and 22870).
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the services are 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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer is experimental. More research is needed to show safety and efficacy. 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 the surgery to place a Vertiflex Superion device (CPT Code 22869 and 22870).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued care with an out-of-network cardiologist for the enrollee.You asked the Plan to pre-approvethe continued referral. You say that the enrollee has been diagnosed with throat cancer.The Plan denied your request. The Plan says there is no diagnosis unique enough to warrant an out-of-network benefit exception.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 thatthe Plan does not have to pre-approvecontinued care with an out-of-network cardiologist for the enrollee
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric and heavy duty hospital bed (E0296, E0265, E0297, E0301).
You asked the Plan to pre-approve the total electric and heavy duty hospital bed. You say that the bed is medically necessary. The Plan denied your request. The Plan says rules for coverage are not met. A semi-electric bed was already approved.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. Heavy duty beds are covered only for enrollees over 350 pounds. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. The record shows the enrollee is less than 350 pounds. A Heavy duty bed cannot be approved. Therefore, we decided that the Plan does not have to pre-approve a total electric and heavy duty hospital bed (E0296, E0265, E0297, E0301).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on August 22, 2020 by an out of network (OON) provider.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. 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 forthe medical services provided on August 22, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the stay is medically necessary.The Plandenied your request. The Plan says the stay is not medically necessary.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 complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status does not require intensive physician or nursing supervision in an IRF. While the enrollee may benefit and participate in multiple therapies the patient's functional level does not require or appear to tolerate this therapy on an intensive rehabilitation therapy program provided in an IRF.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-approveacute IRF admission and services
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe 50mg Tramadol Tablets.You asked the Plan to pre-approveTramadol. You say that you would like reconsideration because this drug is medically necessary.The Plan denied your request. The Plan says this drug is not covered for the member's condition under Medicare Part B.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-approvethe 50mg Tramadol Tablets.Benefits for Tramadolmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadditional power wheelchair accessories (E2377, E2311, E2313) for the enrollee.You asked the Planto pre-approvethe additional accessories. You say that this is medically necessary.The Plandenied your request. The Plansaysthis 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 the additional accessories. Our reviewer says that the requested additional accessories are not considered medically reasonable and necessary in this case. Our physician reviewer found the E2377 Expandable Controller and E2313 Expandable Controller Harness are not medically necessary per Local Coverage Article: Wheelchair Options/Accessories -Policy Article (A52504). The documentation does not reveal that the enrollee requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.) The patient does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices),other 
electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee's strength and functional ability should be sufficient to control any power options through their own individual switches.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of theadditional accessories have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadditional power wheelchair accessories (E2377, E2311, E2313) for the enrollee
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued inpatient psychiatric services from December 28, 2020 onward.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. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 was admitted to the hospital on December 16, 2020 with major neurocognitive disorder, Alzheimer's type (probable), with behavioral disturbance. She presented with a plan to harm herself. She was found to be severely depressed, withdrawn, irritable and angry and continued to show on behaviors with auditory hallucinations. It is not medically necessary to provide psychiatric care at the inpatient level for the dates in question, as she is no longer showing dangerousness to self or others and is complaint with treatment. She is not showing auditory or visual hallucinations. It does not appear that active treatment is taking place. Continued inpatient 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-approvecontinued inpatient psychiatric services from December 28, 2020 onward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveCPAP device (CPT Code E0601) and heated humidifier (E0562).You asked the Plan to pre-approvethe DME. You say that you are requesting review of denial of services.The Plan denied your request. The Plan says you exhausted your benefit.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DMEhave not been met. Your plan limit for a CPAP machine is 1 every 5 years. According to the requesting provider, you received one of the devices in April 2019, with a purchase out date in May 2020. The Plan will uphold its original decision to deny for benefit maximum met.Therefore, we decided that the Plan does not have to pre-approveCPAP device (CPT Code E0601) and heated humidifier (E0562).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that LTACH care is medically necessary.The Plan denied your request. The Plan says coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee appears to be improving and requires only short term additional acute care services which can be safely completed at the current facility. The patient does not require services at the LTACH that are not already available at the current facility.We looked at this physician's review, the file, and Medicare rules. Based onthis 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-approvelong term acute care hospital (LTACH) services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had on October 1, 2020.
You asked the Plan to waive the copayment. You say that your out-of-pocket maximum was met. 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 $35 copayment for each Medicare-covered visit with a specialist. Review of the file shows that you had an office visit on October 1, 2020. You have been asked to pay a $35 copayment for the services. The visit falls within the physician 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 office visit you had on October 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate forthe panoramic x-ray (D0330), the complete upper denture (D5110), and the complete lower denture (D5120) provided on September 14, 2020.You asked the Plan to pay the in network rate forthe dental services. You say that you are being balance billed by the provider. You say that there were noother dentists in your area to perform this treatment for you. You also say that the closest dentists were in Rhode Island or Massachusetts and you had to drive back and forth several times.The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says out of network providers are allowed to balance bill members for the difference between their billed amount and the amount that the Plan paid.The Plan also says the services could have been provided in network.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, dental services that you receive out of network may cost more. Out of network providers are allowed to balance bill members for the difference between their billed amount and the amount that the Plan paid.Therefore, we decided that the Plan does not have to pay the in network rate forthe panoramic x-ray (D0330), the complete upper denture (D5110), and the complete lower denture (D5120) provided on September 14, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the prolonged evaluation and management service coded 99358 provided on August 17, 2020 and August 18, 2020.
You asked the Plan to pay for the prolonged evaluation and management service. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 99358 is prolonged evaluation and management service before and/or after direct patient care; first hour. We find that CPT code 99358 is not supported in the medical record. Specifically, the time documented does not support prolonged services on either of these dates. The documentation does not support at least 30 minutes of non-face-to-face time someplace other than the enrollee's unit/floor to support this code in addition to the E&M code that is documented. Based on this information, we decided that Medicare rules for coverage of the prolonged evaluation and management service have not been met. Therefore, we decided that the Plan does not have to pay for the prolonged evaluation and management service coded 99358 provided on August 17, 2020 and August 18, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment applied toambulance services provided on September 6, 2020.You asked the Plan to waive the copayment applied tothe ambulanceservices. You say that you do not normally have to pay for ambulance services.The Plan denied your request. The Plan says the copayment was appropriately applied to the services in dispute.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 $200 copayment for per one-way ambulance trip. You have been asked to pay a $200 copayment for the ambulance services. The ambulance services fall within the Ambulance 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 applied toambulance services provided on September 6, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvedental services to be provided by an oral surgeon.You asked the Planto pre-approvethis is medically necessary.. You say that this is medically necessary.The Plandenied your request. The Plansaysthis provider type is not covered.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. The Plan covers dental services when they are provided by a participating general dentist.The requested provider type (oral surgeon) is not covered by your dental plan. Based on this information, we decided that the Plan's rules for coverage of this is medically necessary. have not been met.Therefore, we decided that the Plandoes not haveto pre-approvedental services to be provided by an oral surgeon.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Tremfya injection, 100 mg/ml.
You asked the Plan to pre-approve Tremfya. You say that the enrollee has psoriatic arthritis and psoriasis. You
also say that the enrollee has tried and failed Enbrel, Humira, Remicade, Cosentyx, Otezla, and MTX. The Plan
denied your request. The Plan says the requested drug is considered self-administered. The Plan says selfadministered
drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the
requested drug is not covered under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 the Tremfya injection, 100
mg/ml.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a raised toilet seat for the enrollee.

You asked the Plan to pre-approve a raised toilet seat. You say that this will allow for independence and functioning to the best of the enrollee's abilities.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 raised toilet seats are not covered because they are not primarily medical in nature. 

While a raised toilet seat may be appropriate for M. Clancy, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat for the enrollee