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

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you were not able to tolerate therapy, but now you 
can. The Plan denied your request. The Plan says this request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that 
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. Our physician 
reviewer also found that 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 acute IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the cooled radiofrequency ablation surgery (64633, 64634). 
 
You asked the Plan to pre-approve the cooled radiofrequency ablation surgery. You say that these services are 
medically necessary. The Plan denied your request. The Plan says the requested surgery is not medically 
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 cooled radiofrequency ablation 
surgery. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that the patient meets criteria for thermal radio frequency 
ablation (RFA) treatment. Cooled RFA treatment however is still experimental. More research is needed to 
show safety and efficacy of cooled RFA treatment. Cooled RFA treatment 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 cooled radiofrequency ablation surgery have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the cooled radiofrequency ablation surgery (64633, 64634).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnifying glass. 
 
You asked the Plan to pre-approve the item. You say that the cost of this is expensive and you can't afford it. 
The Plan denied your request. The Plan says this is not considered durable medical equipment. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a magnifying glass.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system and a power anterior 
reach/tilt system. 
 
You asked the Plan to pre-approve the items. You say that this is medically necessary. The Plan denied your 
request. The Plan says these items do not serve a primarily medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation system and a power anterior reach/tilt system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown on tooth #20 (D2751). 
 
You asked the Plan to pre-approve the crown. You say that this is medically necessary. The Plan denied your 
request. The Plan says this benefit has been exhausted. 
 
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 crowns once 
every sixty months (five years). 
 
A crown on the same tooth was last received on September 6, 2019. Based on this information, we decided that 
the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown on tooth #20 (D2751).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for respiratory failure, congestive heart failure and encephalopathy. 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 acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed. 
 
You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your 
request. The Plan says the clinical information does not show that criteria has been met. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 bed. Our reviewer says that the 
requested bed is not medically reasonable or necessary. Our physician reviewer found the documentation does 
not clearly reveal your condition has failed positioning of the bed in ways not feasible in an ordinary bed or 
why positioning of the bed in other ways is not feasible. The documentation does not support a need for an 
immediate or frequent change in body position is needed or a need for special attachments that cannot be fixed 
on an ordinary bed. The request for a semi-electric hospital bed 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 the bed have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a semi-electric hospital bed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF care provided to the enrollee from February 12, 
2021, to February 19, 2021. 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the documentation provided, the health plan's denial should be upheld. 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. The enrollee's care 
needs can be met at a lower level of 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 IRF care provided to the enrollee from February 12, 2021, to February 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you strongly recommend the LTACH 
level of care for this enrollee in order to sustain a safe and sustainable discharge. You also say that the enrollee 
does meet the LTACH admission criteria. The Plan denied your request. The Plan says your request for 
approval of admission to a LTACH does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving and requires only short term additional acute 
care services which can be safely completed at the current facility. Our reviewer found that there are no 
services at the LTACH that the enrollee requires that are not already available and covered at the current 
facility. Our physician reviewer also found that transfer to a lower level of care may be considered when 
appropriate and when treatment had completed. 
 
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-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve denture relining services (D5730 and D5731) 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 this is 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-approve 
denture relining services (D5730 and D5731) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve viscosupplementation of the knee with Hyalgan solution. 
 
You asked the Plan to pre-approve Hyalgan. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of authorization for this service is correct, because there is no 
evidence of trial/failure to intractable articular steroids. 
 
The Plan follows Medicare rules. Medicare rules say that viscosupplementation therapy with drugs such as 
Hyalgan is only covered under certain clinical conditions. 
 
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 Hyalgan. Our reviewer says that the 
enrollee does not meet the Medicare criteria for use of Hyalgan. Our physician reviewer found the X-Rays do 
not show severe degenerative joint disease and there is no documentation of injection with intraarticular 
steroids.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve viscosupplementation of the knee with Hyalgan solution.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve homemaker services. 
 
You asked the Plan to pre-approve homemaker services.. You say that the enrollee was diagnosed with 
dementia in 2019. You say that the enrollee is no longer capable of administering her own medications. You 
say that getting the enrollee into an assisted living community but it has been delayed due to Covid-19. You 
also say that a home health aide was hired to keep her from wandering or doing any harm to herself while her 
daughter and son were working. The Plan denied your request. The Plan says homemaker services for which 
the sole purpose is to enable a member to continue residing at home, such as assisting with meals and 
cleaning, are specifically excluded from coverage. The Plan says that the requested services are not covered by 
Medicare or offered as a supplemental benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that custodial care is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of homemaker services. have not been met. Therefore, we decided that the Plan does not have to pre-
approve homemaker services.
Appeal type: Other
Decision: Favorable

 
We decided that the Plan has to pre-approve Car-T Therapy with Yescarta (CPT Code: 0538T, Q2041, 0537T, 
0539T) 
 
You asked the Plan to pre-approve the services. You say that the enrollee will die if they do not get the 
treatment. The Plan denied your request. The Plan says that there is no evidence in the peer reviewed literature 
to support use of CAR-T in HIV and a history of hepatitis B. The Plan states off label use must be supported in 
one or more compendia in the published peer ?reviewed literature and the use must not be listed as 
unsupported, not indicated, or not recommended in any of the compendia. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 physician reviewer 
found there is no listed exclusion for HIV and HBV just that enrollees should be screened and monitored for 
this. The enrollee is on treatment for both and studies show that enrollees with these infections can tolerate 
treatment. Testing for HIV and HBV is indicated but not stated as a contraindication for treatment. The 
documentation supports that the requested drug is safe and effective and otherwise reasonable and necessary 
for this 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 the services have been met. Therefore, we decided that the Plan has to pre-
approve Car-T Therapy with Yescarta (CPT Code: 0538T, Q2041, 0537T, 0539T)  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an MRI provided on June 11, 2020. 
 
You asked the Plan to waive the copayment for an MRI. You say that you met the MOOP amount for the year 
and should not be responsible for the charges. 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 that the MOOP amount for 2020 
is $1,000. Your contract with the Plan also clearly says that you must pay a $150 copayment for each 
radiological diagnostic service. 
 
You received an MRI on June 11, 2020. The record shows that you had only paid $880 toward the $1,000 
MOOP amount prior to receiving the services. Therefore, you are responsible to pay the remaining MOOP 
amount balance of $120, which is less than the $150 copayment.   
 
You have been asked to pay $120 for an MRI. An MRI 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 
an MRI provided on June 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient office visit (99212) arthrocentesis, aspiration 
and/or injection (20610) provided on September 2, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that practiced transitioned to SPA for credentialing. 
Please consider payment of this claim of this claim as services rendered and time spent caring for this patient 
during transitional period. The Plan denied your request. The Plan says enrollee's must receive their medical 
services from an in-network provider with the exception being urgent or emergent services. Non-emergent 
services with non-contracted providers require prior authorization before services being rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for outpatient office visit (99212) arthrocentesis, 
aspiration and/or injection (20610) provided on September 2, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services (A0425, A0427) provided on 
October 8, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says these services are not covered. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patient?s health. The Plan follows the same rules.  
 
We looked at the file and Medicare rules. The file indicates that the transportation was not for an emergency. 
Based on this information, we decided that Medicare rules for coverage of the ambulance services have not 
been met. Therefore, we decided that the Plan does not have to pay for the ambulance services (A0425, A0427) 
provided on October 8, 2020.