Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF 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 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 daily 
skilled services are not necessary. Our physician reviewer found based on the medical records provided daily 
skilled services are not required. You do not require the services on an inpatient basis, in a skilled nursing 
facility setting. Services in a long-term care facility on a part time basis appear appropriate in this case. 
 
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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Superion interspinous spacer for the enrollee. 
 
You asked the Plan to pre-approve the spacer. You say that this is medically necessary. The Plan denied your 
request. The Plan says this 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 the spacer. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the device is experimental. More research is needed to show safety and efficacy of the device. There is 
no spinal instability. The hardware is not 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 spacer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Superion interspinous spacer for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on July 18, 2020. 
 
You asked the Plan to reimburse you for the hearing aids. The Plan denied your request. The Plan says you 
must see the Plan's hearing aid provider to use the hearing aid benefit. 
 
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.  
 
We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by the Plan's 
hearing aid provider. 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 July 18, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF services after December 31, 2020. 
 
You asked the Plan to pre-approve continuation of SNF services. The Plan denied your request. The Plan says 
the enrollee has returned to her prior baseline level of function and does not have skilled nursing needs. 
 
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 continuation of SNF services. Our 
reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that the 
enrollee did not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled 
professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a 
SNF beyond the last covered date. The enrollee did not have complex wound care, IV antibiotics or other 
ongoing SNF level skilled nursing needs beyond the last covered date. The enrollee's functional level did not 
require the skilled therapy services with the specialized skill, knowledge and judgment of a qualified 
therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF beyond the 
last covered date. The enrollee did not require ongoing skilled nursing or skilled therapy services (or a 
combination of these services) on a "daily basis" in a SNF. As a practical matter, the enrollee does not require 
the necessary services on an inpatient basis, in a skilled nursing facility setting beyond the last covered date. 
 
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 continuation of SNF services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve continuation of SNF services after December 31, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says  a review of 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 the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the device is experimental. More research is needed to show safety and efficacy. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for breast biopsy services (CPT 19081) provided to the enrollee 
on June 30, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the place of service is inappropriate for this procedure. 
 
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 19081 is "Biopsy, breast, with placement of breast 
localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when 
performed, percutaneous; first lesion, including stereotactic guidance." 
 
We asked our coding 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 coding reviewer found the 
documentation submitted was reviewed, and the services do not meet the criteria. The documentation did not 
include a place of service to verify if an incorrect Place of Service was reported. 
 
We looked at this coder'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 for breast biopsy services (CPT 19081) provided to the enrollee on June 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient mental health care after January 7, 
2021. 
 
You asked the Plan to pre-approve inpatient mental health care. You say that you are appealing. The Plan 
denied your request. The Plan says the denial of authorization for continued inpatient mental health care as of 
January 8, 2021 is correct. 
 
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 mental health care. Our 
reviewer says that you do not meet the Medicare criteria for inpatient mental health care as of January 8, 2021. 
Our physician reviewer found based upon the records provided it was not expected that you would improve in a 
reasonable period of time for the admission in question as you did not have suicidal or homicidal ideation noted 
and denied any auditory or visual hallucinations. You were oriented and showing fair insight while being 
compliant with treatment and not showing any acute threats to safety. It does not appeal medically reasonable 
and necessary to have psychiatric care provided at the acute inpatient level of care rather than a lower level of 
care. It does not appear that active treatment was taking place beyond January 7, 2021. It does appear that the 
records were supervised and evaluated by a physician. 
 
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 mental health care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continued inpatient mental health care after January 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a standing frame (E0641 or E0642). 
 
You asked the Plan to pre-approve a standing frame. You say that there is a need for this item The Plan denied 
your request. The Plan says this item is not a covered benefit. 
 
The Plan will cover durable medical equipment for use in your home (or another location used as your home as 
defined by Medicare) in accord with our durable medical equipment formulary and Medicare guidelines. 
Durable medical equipment for home use is an item that is intended for repeated use, primarily and customarily 
used to serve a medical purpose, generally not useful to a person who is not ill or injured, and appropriate for 
use in the home.  Coverage is limited to the standard item of equipment that adequately meets member?s 
medical needs.  Comfort, convenience, or luxury equipment or features are not covered.   
 
 
Standing frame is not considered reasonable and necessary, this item is not covered by Health Plan or Original 
Medicare. Therefore, we decided that the Plan does not have to pre-approve a standing frame (E0641 or 
E0642).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee appears to not be stable 
enough for transfer. Completion of oxygen weaning is needed prior to transfer which will likely take less than 
25 days. The enrollee does not require services at the LTACH that are not already available at the current 
facility. There are no services at the LTACH that are not already available and covered at the current facility. 
Therefore, this request for LTACH services will be considered not medically necessary. Transfer may be 
considered at a later date when treatment has completed and the enrollee is more stable. The Plan denied your 
request. The Plan says the stay is not medically necessary. 
 
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.  
 
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 admission to a long term acute care hospital (LTACH) for the enrollee.
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 enrollee meets the full criteria for IRF care. The 
Plan denied your request. The Plan says the denial of authorization for IRF service is correct. 
 
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 
does not require multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the record documents a need for physical and occupational therapy, the 
record does not show a need for an intensive rehabilitation program. There is not a reasonable expectation that 
the 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lidocaine/prilocaine cream. 
 
You asked the Plan to pre-approve lidocaine/prilocaine cream. You say that the enrollee needs this medication. 
The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's 
prescription drug plan. 
 
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 lidocaine/prilocaine cream.  
 
Benefits for lidocaine/prilocaine cream 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Easy Step Bathtub-to-Shower Conversion and Grab Bar 
provided on May 27, 2020, and June 5, 2020. 
 
You asked the Plan to pay for the Easy Step Bathtub-to Shower Conversion and Grab Bar. You say that you 
would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the 
items are not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The items at issue in this appeal do not serve a purpose that is primarily medical in nature. These items are 
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 pay for the Easy Step Bathtub-to-Shower Conversion and Grab Bar 
provided on May 27, 2020, and June 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that 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 and COVID 19 pneumonia. Medical conditions are stable. There are no 
medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for 
physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There 
is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve personal care assistance services. 
 
You asked the Plan to pre-approve the personal care assistance services. You say that you have fallen various 
times, and this would help you get the services you need. You say that you are at risk when left alone. The Plan 
denied your request. The Plan says the consumer directed personal assistance program is not a covered benefit 
under your contract. The Plan says that these services may be covered under your Medicaid benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that custodial care is not a Medicare covered benefit.  
 
We looked at the file and Medicare rules. The services you are requesting are custodial in nature. Based on this 
information, we decided that Medicare rules for coverage of the personal care assistance services have not been 
met. Therefore, we decided that the Plan does not have to pre-approve personal care assistance services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from July 
15, 2020, to July 17, 2020. 
 
You asked the Plan waive the co-payment for inpatient hospital care. You say that the enrollee did not leave the 
hospital so there should not be separate charges. The Plan denied your request. The Plan says the co-payment 
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). The enrollee's contract with the plan clearly says that the enrollee 
must pay a $250 co-payment per day for days 1-7 of inpatient hospital care.   
 
The enrollee has been asked to pay a $250 co-payment per day for 2 days of inpatient hospital care. The 
services at issue fall within the inpatient hospital 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. Therefore, we decided that the Plan does not have waive the co-
payment for to waive the copayment for inpatient hospital care provided from July 15, 2020, to July 17, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the brain (70551). 
You asked the Plan to pre-approve an MRI of the brain. You say that the services are necessary. The Plan 
denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of the brain. Our reviewer says 
that the services are medically necessary. Our physician reviewer found the MRI of the brain makes sense to 
not only evaluate the brain but also to determine the appearance of the paranasal sinuses which will be included 
in the field of view. The other qualifying factor for a brain MRI is the persistent dizziness you are experiencing. 
The mastoid bones, a common origin for such a symptom will also be included in the field of view. For all 
these reasons MRI of the brain is indicated. 
 
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 MRI of the brain have been met. Therefore, we decided that the Plan has to 
pre-approve a magnetic resonance imaging (MRI) of the brain (70551).