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 mental health facility.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied
your request. The Plan says there must be an imminent danger to self or others.
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 the admission. Our reviewer says that
the requested admission is not medically reasonable or necessary. Our physician reviewer found it did not
appear that the requested admission is reasonably expected to improve the enrollee's condition or for the
purpose of diagnosis. You are not shown to be a danger to yourself or others. You have no auditory or visual
hallucinations. You are noted to be cooperative and compliant with treatment while not showing any aggressive
behaviors.
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 admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve admission to an inpatient mental health facility.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.

You asked the Plan to pre-approve the admission. You say that this is medically necessary.The Plan denied your request. The Plan says no daily skilled needs are noted.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the admission have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF) for the enrollee
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea FreeStyle Libre 2 reader for the enrollee.You asked the Planto pre-approvethe monitor. You say that this is medically necessary.The Plandenied your request. The Plansaysthe requested product was determined not to be reasonable and 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 monitor. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has not been using insulin multiple times (3 or more) a day. The enrollee'streatment does require frequent adjustment on the basis of testing results.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 monitor have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea FreeStyle Libre 2 reader for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecore buildup for tooth 3.You asked the Plan to pre-approvecore buildup. 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 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.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvecore buildup for tooth 3.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services (80307) provided on August 10, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says these services were not emergent or pre-authorized. There were network
providers available.
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 service 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 lab services (80307) provided on August 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea shower chair.You asked the Plan to pre-approvea shower chair. You say that you are in pain and unable to walk or fully stand up.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approvea shower chair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forcritical care services provided to the enrollee on March 12, 2020.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says the records do not support the service billed.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 99291 is "Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74minutes."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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the medical records provided do not include sufficient documentation to corroborate that a Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes was performed on the enrollee. This service cannot be verified andis not eligible for reimbursement.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 pay forcritical care services provided to the enrollee on March 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for and pay for an eye examination and
refraction provided on August 10, 2020.
You asked the Plan to waive the copayment for and pay for eye exam and refraction. You say that you were
unaware that this would not be paid. The Plan denied your request. The Plan says the copayment amount you
are being charged is correct, and the denial of payment for this refraction is correct because this provider does
not participate in the Plan routine vision network.
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 $35
copayment for each Medicare-covered vision care visit. Medicare generally does not cover routine vision and
eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare
coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when
performed by a Plan preferred routine vision provider.
You have been asked to pay $35 copayment for eye exam. Eye exam falls within the Vision Care 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. The refraction
performed is not covered by the Plan because this provider is not a Plan preferred provider for routine vision
services. Therefore, we decided that the Plan does not have to waive the copayment for and pay for an eye
examination and refraction provided on August 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveXiidra eye drops.You asked the Plan to pre-approveXiidra eye drops. You say that you want the enrollee treated with this drug.The Plan denied your request. The Plan says this drug 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-approveXiidra eye drops.Benefits for Xiidra eye dropsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveXiidra Dro 5%.You asked the Plan to pre-approveXiidra. You say that the enrollee suffers from severe dry eye with low tear volume and break up time.The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered 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 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-approveXiidra Dro 5%
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on June 29, 2020.
You asked the Plan to reimburse you for the hearing aids. The Plan denied your request. The Plan says you
must use the Plan's hearing aid provider.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for
hearing aids only when provided by the Plan's hearing aid provider.
We looked at the file and the Plan's rules. The provider in this case is not a network hearing aid provider with
the Plan. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not
been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on
June 29, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a coronary computed tomography angiography (CCTA)
with quantitative calcium scoring.
You asked the Plan to pre-approve these 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. Medicare rules say that CCTA is covered when specific criteria are met.
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 based on the records, the enrollee has
increased coronary risk. In this setting, a screening CCTA with calcium scoring is not recommended and has
not been shown to improve cardiac outcome incremental to that achievable based on treatment guided by
standard clinical risk profiling and basic lipid analysis alone. The 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-approve a coronary computed tomography angiography (CCTA) with quantitative calcium scoring.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approvecomputed tomography (CT) scans of the chest and abdomen.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says that the services are 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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer foundthe enrollee is status post resection of esophageal cancer. The request is for surveillance CT scans at six month intervals due to rapid growth of this type of cancer and need for early detection of recurrence. The CT scans are reasonable and medically necessary for this indication.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 been met.Therefore, we decided that the Plan has to pre-approvecomputed tomography (CT) scans of the chest and abdomen
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approves killed nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary.The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage of SNF care.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that SNF care is medically necessary at this time. Our physician reviewer found the patient did require skilled nursing services as she required nursing a change in medical status and required the start of antibiotics and steroid medications. A skilled nurse is required to ensure that the patient is stabilized and evaluate her condition on her medications.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric admission.
You asked the Plan to pre-approve inpatient psychiatric admission. You say that the enrollee remains a patient
at your facility and has not been discharged as of this date due to continued need of psychiatric services until
stabilized. The Plan denied your request. The Plan says the enrollee does not meet medical necessity criteria for
acute inpatient level of care.
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 inpatient psych admission. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found based upon review the records provided, this enrollee did not require
inpatient mental health treatment beyond the dates in question as he was not a danger to himself or others and
did not have any auditory or visual hallucinations.. It did not appear that active treatment was taking place
beyond the date in question. It did not appear that the services for the dates in question were reasonably
expected or medically necessary to improve the patient's condition or for the purpose of diagnosis. Based upon
review the records provided, this patient does not meet the criteria for treatment in an acute inpatient mental
health treatment beyond the date in question of November 30, 2020 forward and could have been treated in a
lesser restrictive setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient psych admission have not been met. Therefore, we decided that the
Plan does not have to pre-approve inpatient psychiatric admission.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
You asked the Plan to pre-approve these 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. 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has a history of back pain.
The requested Vertiflex Superion spacer is considered experimental in nature, as more research is needed to
show safety and efficacy. The 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-approve a Vertiflex Superion spacer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a right middle finger prosthesis 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 the requested prosthesis cannot be covered.
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 requested device does not appear to be furnished in a setting appropriate to the enrollee's medical
needs and condition, and it also appears to exceed the enrollee's needs. The physician note and vendor note
indicate that the enrollee would benefit from a Partial Point Design prosthesis. A description of this device
indicates that the device has steel construction permitting 100lb load carrying capacity for wider ADLs
including heavy duty tasks. The evaluation notes he is seated most of the day, on permanent disability, does not
play a sport and needs it for toileting, zipping zippers, buttoning, handling soap, cash, credit card, cell phone,
opening jars, holding small items, and tying shoes. The documentation does not support a heavy-duty need.
Furthermore, the vendor's actual prescription is for a right naked finger which conflicts with the notes that
discuss a Partial Point Finger needed.
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 a right middle finger prosthesis for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization
device for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The
Plan denied your request. The Plan says that the current medical literature indicates that this service is
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 these services. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. The spacer is
experimental. More research is needed to show safety and efficacy of the procedure. Our physician reviewer
found that the enrollee's condition does not meet Medicare criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve the insertion of a Superion interspinous stabilization device for the enrollee.