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

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services for the enrollee.You asked the Plan to pre-approvethe LTACH services. You say that these services are medically necessary.The Plan denied your request. The Plan says that the enrollee is receiving appropriate care at the current acute care facility.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. The enrollee's medical needs are beingmet in the current acute setting. The LTACH would add no additional services. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Our physician reviewer found that theenrollee's condition does not meet Medicare criteria for LTACH services.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-approvelong term acute care hospital (LTACH) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiology services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve the OON cardiology services. You say that you have been seeing these 
providers and group since your heart attack. You say that you don't want to change. You say that you already 
had appointments scheduled with these providers before enrolling with the Plan. You say that you do not want 
to go to a low class provider. The Plan denied your request. The Plan says it is not medically necessary for the 
enrollee to go to an out of network provider. The Plan says that a network gap does not exist. 
 
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 
cardiology services to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular pathology procedure provided on May 18, 
2020, by an OON provider. 
 
You asked the Plan to pay for the molecular pathology procedure. You say that you would like this claim 
reprocessed and paid according to Medicare guidelines. The Plan denied your request. The Plan says the 
service was rendered by a non-network provider. The Plan also says that another non-network provider referred 
the enrollee for services. 
 
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. 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 molecular pathology procedure provided on 
May 18, 2020, by an OON provider.
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 the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a passive partial right thumb prosthesis with silicone 
cover for the enrollee. 
 
You asked the Plan to pre-approve the prosthetic. You say that this is medically necessary. The Plan denied 
your request. The Plan says the requested prostheses and components cannot be covered as the incorrect code is 
used and the requested silicone covers are not medically needed; the notes do not show that standard custom 
covers would not be sufficient. 
 
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 prosthetic. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on the provided documentation, the prescriber did not clearly describe the requirement of 
a specialized silicone cover vs a regular cover for the requested partial thumb prosthesis. It was not clear if this 
was merely for cosmetic reasons or if it had another function. Therefore, without trial and failure of a regular 
cover or explanation of need, this request for a passive partial thumb prosthesis with silicone cover will be 
considered not medically necessary as submitted. 
 
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 prosthetic have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a passive partial right thumb prosthesis with silicone cover for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for prophylaxis of retinal detachment 
provided on June 19, 2020, and June 22, 2020. 
 
You asked the Plan to waive the copayments for prophylaxis of retinal detachment. You say that you were 
quoted as only owing a specialist copayment. 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 $100 
copayment for outpatient surgery, including services provided at hospital outpatient facilities. 
 
You received prophylaxis of retinal detachment provided on June 19, 2020, and June 22, 2020. Prophylaxis of 
retinal detachment is considered an outpatient surgical procedure. Therefore, you are responsible to pay a $100 
copayment per each service. The total amount you owe is: $200.   
 
You have been asked to pay the total copayment amount of $200 for prophylaxis of retinal detachment. 
Prophylaxis of retinal detachment falls within the outpatient surgery, including services provided at hospital 
outpatient facilities and ambulatory surgical centers 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 prophylaxis of retinal detachment provided on June 19, 2020, and June 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MyoPro, Motion G Orthotic device. 
 
You asked the Plan to pre-approve MyoPro, Motion G Orthotic device. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested item 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 MyoPro, Motion G Orthotic 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 had a stroke and has left arm hemiparesis. At this time the 
requested robotic orthosis is not proven to be more beneficial for treatment of the enrollee's medical 
condition/function of hemiparesis after stroke than any available standard therapy. The requested device is not 
the standard of care for hemiparesis after a stroke over standard treatment including treatment such as physical 
and occupational therapy, strengthening exercises, constraint induced movement therapy, Botox injections for 
spasticity. The American Heart Association/American Stroke Association discusses electromyographic 
biofeedback as used in the Myopro however there is little evidence in the literature on how well this device 
would restore muscle strength post stroke. The requested device is not reasonable and necessary for the 
diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member. A 
review of the literature reveals additional controlled studies of the MyoPro Prthosis for upper extremity 
paralysis after stroke are needed with larger enrollee groups, consistent improvements of relevant outcome 
functional measures, and long term follow up. Therefore, the enrollee does not meet criteria for the requested 
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 MyoPro, Motion G Orthotic device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve MyoPro, Motion G Orthotic device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable control system for a power wheelchair. 
 
You asked the Plan to pre-approve an expandable control system. The Plan denied your request. The Plan says 
your upper limb strength and function is adequate for the enrollee to control the power options using their own 
switches. 
 
The Plan follows Medicare rules. Medicare rules say that an expandable control system is only covered under 
certain medical indications.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an expandable control system. Our 
physician reviewer found that a wheelchair evaluation indicates that you are independent with meal prep, 
feeding, bathing, grooming, upper and lower limb dressing and toileting. Your current functional level with 
independence in meal prep, feeding, bathing, grooming, upper and lower limb dressing and toileting would be 
sufficient to control any power options through their own individual switches. Therefore, the requested system 
is not medically necessary. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable control system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an expandable control system for a power wheelchair.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray of the spine (72100) performed February 6, 2020. 
 
You asked the Plan to pay for the x-ray. You say that the service was medically necessary. The Plan denied 
your request. The Plan says the records do not support the billed services. 
 
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 72100 is Radiologic examination, spine, lumbosacral; 2 
or 3 views. 
 
We find that CPT code 72100 is not supported in the medical record. Specifically, CPT code 72082 was billed 
on the same date. The record does not show that the CPT code at issue was a separate and distinct service from 
CPT code 72082. Based on this information, we decided that Medicare rules for coverage of the x-ray have not 
been met. Therefore, we decided that the Plan does not have to pay for an x-ray of the spine (72100) performed 
February 6, 2020.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after October 18, 
2020. 
 
You asked the Plan to pre-approve SNF care. You say that the requested continuation of SNF care is medically 
necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for continued 
SNF care. 
 
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will 
stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before 
the last covered day. This notice must include a description of the enrollee's right to an appeal. 
 
We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or 
more days before October 18, 2020. The Plan must pay for SNF services until the 100-day SNF care benefit is 
exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the 
Plan has to pre-approve continued skilled nursing facility (SNF) services after October 18, 2020.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on April 13, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 13, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on April 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane (J7318). 
 
You asked the Plan to pre-approve Durolane. The Plan denied your request. The Plan says the information 
submitted does not meet the Plan's medical necessity guidelines for coverage. 
 
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 Durolane. Our reviewer says that 
Durolane does not meet coverage criteria. Our physician reviewer found based on the medical records provided 
the enrollee has not tried and failed the required drug(s). Our reviewer also found that there is no indication that 
the Plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durolane (J7318).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Oxycodone-Acetaminophen. 
 
You asked the Plan to pre-approve Oxycodone-Acetaminophen. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says Oxycodone-Acetaminophen is not covered 
under the enrollee's Medicare Part B 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 Oxycodone-
Acetaminophen.  
 
Benefits for Oxycodone-Acetaminophen 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 16, 2020 by an 
OON provider. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the services 
were rendered in a non-participating facility. The Plan also says that the enrollee was referred by a non-
participating provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 
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 for the laboratory services provided on May 16, 2020 
by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided by you on May 26, 2020.You asked the Plan to pay forthe ambulance services. You say that you were following the COVID executive order for treatment in place.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on May 26, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services provided by you on May 26, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the CT scan provided on June 8, 2020. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you were advised to get a CT scan 
since you fainted and hit your head. You say that you are appealing the charge since they are Covid-19 related. 
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 $200 
copayment for covered diagnostic radiology services in a provider's office or freestanding radiology center.  
 
You have been asked to pay $139.80, which is less than the standard $200 copayment for the CT scan. The CT 
scan 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 the CT scan provided on June 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on June 22, 2020 and June 24, 
2020. 
 
You asked the Plan to pay for 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 June 22, 2020 and June 24, 
2020.