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 at the present time, medical care is ongoing, and the amount of therapy is appropriate to meet your needs.
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 do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does not currently require intensive physician and nursing oversight only in an IRF. You may benefit from multiple therapies such as physical and occupational therapy but the documentation does not support that your functional status requires or can tolerate 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-approve admission to an inpatient rehabilitation facility (IRF).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane.
You asked the Plan to pre-approve Durolane. The Plan denied your request. The Plan says the enrollee has not
had previous treatment, contraindication, or intolerance to Orthovisc and Monovisc.
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 physician reviewer
found that the enrollee has pain related to osteoarthritis of both knees, confirmed with imaging studies. He has
failed conservative treatment. He has had a prior adverse reaction to Synvisc. The Plan requires a trial of
Monovisc and Orthovisc before they will approve the requested drug. Based on the medical records, the
enrollee has not tried and failed the required drug. There is no indication that the plan's required drugs would
likely be less effective, or likely have adverse effects for the patient.
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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that the enrollee needs the supplies due to multiple medical conditions. The Plan denied your request. The Plan says the service is not a covered benefit under the enrollee's benefit plan.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on March 9, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider on March 9, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for autonomic nervous system function testing (95923) provided
on February 19, 2019.
You asked the Plan to pay for autonomic nervous system function testing. You say that the billed procedure
matches the service provided. The Plan denied your request. The Plan says the documentation is insufficient to
corroborate this service.
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 95923 is testing of autonomic nervous system function;
sudomotor, including 1 or more of the following: quantitative sudomotor axon reflex test (QSART), silastic
sweat imprint, thermoregulatory sweat test, and changes in sympathetic skin potential.
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 autonomic nervous system function testing.
Our reviewer says that the billing of CPT 95923 is not supported. Our physician reviewer found tre is no
evidence that autonomic nervous system function was tested via QSART, silastic sweat imprint,
thermoregulatory test or sympathetic skin potential changes.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of autonomic nervous system function testing have not been met. Therefore, we
decided that the Plan does not have to pay for autonomic nervous system function testing (95923) provided on
February 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.
You asked the Plan to pre-approve a home ventilator, any type, used with non-invasive interface (E0466). You say that the enrollee meets criteria for a home ventilator. The Plan denied your request. The Plan says the medical records did not support the medical necessity required to approve the request for home ventilator with non-invasive interfaces.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 home ventilator, any type, used with non-invasive interface (E0466). Our reviewer says that the home ventilator is not medically necessary. Our physician reviewer found coverage criteria for a home ventilator are not met. This enrollee has severe COPD with chronic hypercarbic respiratory failure. The enrollee may qualify for, and benefit from, BiPAP. Certain BiPAP devices are capable of providing the AVAPS-AE mode of support that is ordered. Medicare does not cover a home ventilator when used as BiPAP. There is no documented failure of BiPAP. A home ventilator is not medically necessary, and the denial is upheld. 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 home ventilator, any type, used with non-invasive interface (E0466) have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for power wheelchair, group 2 standard, captains chair, patient weight capacity up to and including 300 pounds (K0823) and wheelchair accessory, manual swingaway, retractable or removable mounting hardware for joystick, other control interface or positioning accessory (E1028) provided on December 18, 2019. 
 
You asked the Plan to waive the coinsurance for the DME. You say that no one told you it would be a rental. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 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 the DME on December 18, 2019. You are asked to pay 20% coinsurance for the DME. 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 power wheelchair, group 2 standard, captains chair, patient weight capacity up to and including 300 pounds (K0823) and wheelchair accessory, manual swingaway, retractable or removable mounting hardware for joystick, other control interface or positioning accessory (E1028) provided on December 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on December 30, 2019, and
December 31, 2019.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were
billed without the appropriate modifier.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code and when necessary be followed by the
appropriate modifier. Medicare rules also state that to be recognized as a waived test, some CLIA waived tests
have unique HCPCS procedure codes and must have a QW modifier included with the HCPCS code.
In this case, the requested codes are listed on the CLIA edit list for 2019 as codes that require the QW modifier
be applied to the claim for payment under Medicare guidelines. Review of the claim submitted does not show a
QW modifier associated with the billed codes. Based on this information, we decided that Medicare rules for
coverage the lab services have not been met.
Therefore, we decided that the Plan does not have to pay for the lab services provided on December 30, 2019,
and December 31, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on December 28, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you do not feel the copayment is fair due to arriving at the hospital later in the day. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 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 inpatient hospital care on December 28, 2019. You are asked to pay a $285 copayment for inpatient hospital care. 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 inpatient hospital care provided on December 28, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve the crowns for tooth #'s 8 and 9.
You asked the Plan to pre-approve the crowns for tooth #'s 8 and 9. You say that the teeth are severely worn
out due to multiple failed restoration attempts. The Plan denied your request. The Plan says that the services are
not medically necessary.
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 the crowns
for tooth #'s 8 and 9 when the services are medically necessary and reasonable.
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 crowns for tooth #'s 8 and 9. Our
reviewer says that the criteria for coverage has been met. Our physician reviewer found that tooth #'s 8 and 9
have severe incisal breakdown and previous restorations have not held up. Our physician reviewer also found
the crowns are medically reasonable and necessary to restore tooth #'s 8 and 9 to normal function and to
prevent further breakdown.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the crowns for tooth #'s 8 and 9 have been met. Therefore, we decided that the
Plan has to pre-approve the crowns for tooth #'s 8 and 9.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan
denied your request. The Plan says that the enrollee does not have complex medical care that requires physician
oversight three times per week.
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 the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient
stay with an interdisciplinary approach to rehabilitation care. The patient's medical status does not currently
require intensive physician and nursing oversight only in an IRF. The patient may benefit from multiple
therapies such as physical and occupational therapy but the documentation from therapy does not support that
the patient's functional status, with limitations in therapy due to fatigue, requires or can tolerate an intensive
rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for retainer crown - porcelain/ceramic (D6740 x 2) and pontic -
porcelain/ceramic (D6245) provided on January 6, 2020.
You asked the Plan to pay for the dental services. You say that the services were medically necessary. The Plan
denied your request. The Plan says the services are not a covered benefit under the plan.
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. The services are not listed in your EOC as a covered benefit; therefore,
the services are not covered. Therefore, we decided that the Plan does not have to pay for retainer crown -
porcelain/ceramic (D6740 x 2) and pontic - porcelain/ceramic (D6245) provided on January 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 18, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the outpatient visit (99214). You say that you would like reconsideration because the services rendered were medically necessary. The Plan denied your request. The Plan says the out-of-network provider rendered non urgent/non-emergent services to the member without authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. 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 medical services provided on February 18, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incision and subcutaneous placement of spinal
neurostimulator for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says there is no documentation of a successful trial of stimulation.
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 the criteria is not met. There is no diagnosis of failed back surgery. There is no documentation of a trial
completion.
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 incision and subcutaneous placement of spinal neurostimulator for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone marrow aspiration provided on May 9, 2017.
You asked the Plan to pay for the bone marrow aspiration. The Plan denied your request. The Plan says this is
an experimental service.
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 pay for the bone marrow aspiration. Our reviewer
says that the requested services are not considered medically reasonable and necessary in this case. Our
physician reviewer found that bone marrow aspiration remains experimental in cases of spine surgery. Recent
literature shows it is not more effective than iliac crest bone graft.
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 bone marrow aspiration have not been met. Therefore, we decided that the
Plan does not have to pay for the bone marrow aspiration provided on May 9, 2017.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve drive-through Procrit injections.
You asked the Plan to pre-approve drive-through injections. The Plan denied your request. The Plan says this 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 drive-through injections. Our reviewer
says that the requested services are not considered medically reasonable and necessary in this case. Our
physician reviewer found that the Plan has taken every precaution to ensure patient safety for any clinic visits.
Social distancing and stringent sanitization of all facilities is strictly adhered to. The enrollee is not homebound
or receiving any Home Health services. There is no indication for the enrollee to receive Procrit injections on a
drive through basis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of drive-through injections have not been met. Therefore, we decided that the Plan
does not have to pre-approve drive-through Procrit injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a health club membership (S9970).
You asked the Plan to pre-approve a health club membership. You say that the services are necessary. The Plan
denied your request. The Plan says the requested service is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not cover gym benefits.
The services at issue in this appeal are gym benefits. Therefore, we decided that the Plan does not have to preapprove
a health club membership (S9970).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy, core buildup, post and core, crown, and partial denture.
You asked the Plan to pre-approve the dental services. You say that the dental work will be covered as a medical benefit. The Plan denied your request. The Plan says the requested services are not a covered benefit.
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. Although the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve endodontic therapy, core buildup, post and core, crown, and partial denture.