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

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says rehab needs are not complex, and do not require an interdisciplinary approach. 
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
weakness, abdominal pain and acute kidney injury. Medical conditions are stable. There are no medical needs 
requiring inpatient admission. There are no complex nursing or rehabilitation needs. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record documents a need for physical and occupational 
therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable 
expectation that you will be able to fully participate in and benefit from the 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-approve admission to an inpatient rehabilitation facility (IRF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the hospital visit services (99223, 99233) 
provided from September 7, 2020, to September 8, 2020, by an out-of-network (OON) provider. 
 
You asked the Plan to waive the deductible for the hospital visit services. You say that you would like claim 
reprocessed. The Plan denied your request. The Plan says the clam has processed correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1500 deductible for OON services.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category OON 
services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1500 
deductible for OON services. This cost sharing is a contractual obligation that had not been met at the time the 
hospital visit services was received on September 7, 2020 to September 8, 2020. Therefore, we decided that the 
Plan does not have to waive the deductible for the hospital visit services (99223, 99233) provided from 
September 7, 2020, to September 8, 2020, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve orthovisc (J7324). 
 
You asked the Plan to pre-approve orthovisc. You say that orthovisc is medically necessary. The Plan denied 
your request. The Plan says this drug is not eligible for coverage under the Part B Medical Benefit in this case, 
as it is being dispensed by a pharmacy. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve orthovisc (J7324).  
 
Benefits for orthovisc may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PET scan of the brain for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not covered outside of clinical trials if the criteria is not met. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found the enrollee has been 
followed for complaints of memory impairment. In this case the information provided for review did not 
support that the enrollee has a differential diagnosis of fronto-temporal dementia (FTD) and Alzheimer's 
disease (AD). Rather, neither diagnosis was mentioned in the records which were provided for review with this 
case. As the requested study would not be done to differentiate between these two conditions, the proposed 
scan cannot be said to have been ordered for an indication in which Medicare covers this service. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve PET scan of the brain for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulation (TENS) 
device. 
 
You asked the Plan to pre-approve a TENS device. You say that the Plan representative told you a TENS 
device is covered. The Plan denied your request. The Plan says the medical notes state you are not in a study. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The record does not show you are in an approved clinical study. 
Based on this information, we decided that Medicare rules for coverage of a TENS device have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulation 
(TENS) device.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the physical therapy visits provided from 
October 2, 2020, to October 13, 2020. 
 
You asked the Plan to waive the copayments for the physical therapy visits. You say that you were not 
informed that the cost-sharing waiver was only until the end of September. The Plan denied your request. The 
Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for each Medicare-covered physical therapy and speech-language therapy visit.  
 
You have been asked to pay a $35 copayment for each of the physical therapy visits. ($35 x 3 visits = $105). 
The physical therapy visits 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 copayments for the physical therapy visits provided from October 2, 2020, to 
October 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 19, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented.   
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on March 19, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CT Scan of the head or brain (70450). 
 
You asked the Plan to pre-approve the CT Scan. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the requested CT Scan is not medically 
necessary. 
 
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 
there is no history or detailed physical exam or neurological exam at the time of review. Onset, recent changes 
in pattern or character of headache is not described. Our physician reviewer found there is no specific clinical 
rationale for the requested CT scan of the head/brain. The requested CT scan 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 CT Scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the CT Scan of the head or brain (70450).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says care could be received in another setting. 
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for frequent falls, congestive heart failure and a thoracic compression fracture. Medical 
conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing 
or rehabilitation needs. does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a 
need for physical and occupational therapy, it does not document a need for an intensive rehabilitation 
program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit 
from the 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-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation and endodontic 
therapy provided on September 18, 2020. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and endodontic therapy. You say 
that you contacted the Plan and were told that the Plan would cover 55% of the bill if you saw an out-of-
network provider. The Plan denied your request. The Plan says these services are 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
problem focused limited oral evaluation and endodontic therapy provided on September 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pneumatic compression device (E0652). 
 
You asked the Plan to pre-approve the pneumatic compression device. You say that you would like 
reconsideration because this device is medically necessary. The Plan denied your request. The Plan says the 
member has not tried and failed a trial with a standard compression sleeve. 
 
The Plan follows Medicare rules. Medicare rules say that A PCD coded as E0652, is covered for the treatment 
of lymphedema extending onto the chest, trunk and/or abdomen and requires a four-week trial of conservative 
therapy demonstrating failed response to treatment with and E0650 or E0651. 
 
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 pneumatic compression device. Our 
reviewer says that the member does not have lymphedema on an objective physical examination that extends 
onto the chest, trunk and/or abdomen that extends past the limits of a standard compression sleeve. Our 
physician reviewer found the record does not show that the chest, trunk and/or abdominal lymphedema has 
failed to improve with a four-week trial of regular, daily, multiple-hour home usage of the E0650 or E0651. 
 
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 pneumatic compression device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the pneumatic compression device (E0652).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve A Vertiflex device. 
 
You asked the Plan to pre-approve A Vertiflex device. 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. 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 Vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has back pain. The requested spacer device is considered experimental. 
More research is needed to show safety and efficacy of the device. 
 
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 Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve A Vertiflex device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse the out of network cost share for the cleaning (D1110) and 
the oral exam (D0120) provided on September 16, 2020. 
 
You asked the Plan to reimburse the out of network cost share for the dental services. You say that you feel that 
the brochure is inaccurate. You say that the claim was not paid according to the brochure but rather some other 
policy not mentioned in the brochure. You say that only $59 was paid toward the claim instead of $145. You 
also say that you would like to be reimburse the additional $86. The Plan denied your request. The Plan says 
the provider in this case is out of network. The Plan says that dental services that you receive out of network 
may cost more. The Plan also says that out of network providers can bill you for the difference between what 
the provider charges and what the plan paid. 
 
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. The Evidence of Coverage clearly states that you may be billed more by an out of 
network provider if the charge is greater than MAC. This is a contractual obligation you agreed to when you 
enrolled in the Plan's dental coverage. Therefore, we decided that the Plan does not have to reimburse the out 
of network cost share for the cleaning (D1110) and the oral exam (D0120) provided on September 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says care could be received in another setting. 
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for NSTEMI and had 3 vessel coronary artery bypass grafting. Medical conditions are stable. 
There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation 
needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a 
need for physical and occupational therapy, it does not document a need for an intensive rehabilitation 
program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit 
from the 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-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric services provided on February 20, 2019. 
 
You asked the Plan to pay for the psychiatric services. You say that the doctor is entitled to reimbursement. 
The Plan denied your request. The Plan says the claim was untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the psychiatric services was not filed until September 8, 2020. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the psychiatric services provided on February 20, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 2, 2018. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the claim was submitted untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the laboratory services was not filed until May 18, 2020. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the laboratory services provided on May 2, 2018.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 25, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the physician's services. 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 physician's services provided on August 25, 2020.