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) for the enrollee.

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says needs can be met in a less intensive level of care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

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 surgical treatment of a hip fracture after a fall. Medical problems are stable. 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 supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a panniculectomy.
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 diagnosis of localized
adiposity. She underwent weight loss surgery and lost 100 pounds. She now has overhanging abdominal skin
and reports some rashes and discomfort. The exam on December 21, 2020, documented no obvious active
intertrigo. The records support that the requested panniculectomy would be entirely cosmetic in nature and is
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 panniculectomy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a walker purchased on April 19, 2020.
You asked the Plan to pay for the services. You say that this was not available in-network. The Plan denied your request. The Plan says the provider is not certified for Medicare.
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, and is also not certified to participate in Medicare. 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 a walker purchased on April 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services (99202) provided to you on September 1, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic services (99202) provided to you on September 1, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve outpatient bariatric surgery for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says that there are no rare comorbid conditions.
The Plan must follow Medicare rules. Medicare rules say that services are covered 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 the surgery. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is an adult with super obesity. The BMI is 57 kg/m2. The enrollee has two obesity-related comorbidities - sleep apnea and degenerative joint disease. The enrollee is limited in exercise secondary to ankle fracture and multiple sclerosis. 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 surgery have been met. Therefore, we decided that the Plan has to pre-approve outpatient bariatric surgery for the enrollee.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composites.

You asked the Plan to pay for the resin-based composites. You say that you cannot afford to pay for these
services. The Plan denied your request. The Plan says your calendar year maximum had been reached.

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 Plan offers a $1,000 combined
allowance for supplemental preventive and comprehensive services every year. The contract clearly says that
you are responsible for any amount over and above the allowance amount. The record shows that you met the
annual maximum benefit, and your annual maximum benefit has been exhausted. Therefore, we decided that 
the Plan does not have to pay for the resin-based composites.
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 you would like reconsideration because the IRF
admission is medically necessary. The Plan denied your request. The Plan says the records do not indicate that
there are significant, or complex medical/nursing issues that could not be addressed at a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
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 there is no documented need for intensive rehabilitation services. Medically
necessary care can be provided in a different 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).

You asked the Plan to pre-approve a Freestyle Libre CGM. You say that you need this because other monitors cause you extreme pain. The Plan denied your request. The Plan says the criteria for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the percutaneous image-guided lumbar decompression (PILD) procedure for the enrollee.

You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies have not proven that this service is helpful for treatment of the health problem.

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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the PILD procedure remains experimental for the treatment of lumbar disc herniations. More research is needed to show the safety and efficacy of the percutaneous technique. Open surgery discectomy or endoscopic discectomy remain the gold standard procedures.

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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the percutaneous image-guided lumbar decompression (PILD) procedure for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a nerve stimulator (P-Stim) for the enrollee.

You asked the Plan to pre-approve the stimulator. You say that this is medically necessary. The Plan denied your request. The Plan says this device is not covered.

The Plan must follow Medicare rules. Medicare rules say that electro-acupuncture devices are not covered by Medicare. 

The requested stimulator is considered an electro-acupuncture device. Based on this information, we decided that Medicare rules for coverage of the stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve a nerve stimulator (P-Stim) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cervical decompressor and cervical curvature corrector.
You asked the Plan to pre-approve a cervical decompressor and cervical curvature corrector. You say that you need these devices but cannot afford them. The Plan denied your request. The Plan says these devices are not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that physical therapy equipment that can be obtained without a prescription is considered to be an over-the-counter supply, is not considered DME, and is therefore ineligible for coverage. The items at issue in this appeal are acquired at stores or by internet without a prescription. Therefore, we decided that the Plan does not have to pre-approve a cervical decompressor and cervical curvature corrector.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the copayment for the sacroiliac joint injection procedure (G0260LT) performed on November 19, 2020.
You asked the Plan to waive or reduce the copayment for the injection procedure. You say that you were only expecting to pay the $40 specialist office visit copayment. The Plan denied your request. The Plan says the injection procedure that was provided is classified as a surgical procedure. Outpatient surgery is subject to a $450 copayment.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $450 copayment for outpatient surgery and services. You have been asked to pay a $450 copayment for the injection procedure. The injection procedure was provided at an outpatient hospital facility and falls within the outpatient surgery and services 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 or reduce the copayment for the sacroiliac joint injection procedure (G0260LT) performed on November 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic lightbox.
You asked the Plan to pre-approve the lightbox. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered by Medicare.
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 lightbox. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this item is not covered by Medicare in any payment system. 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 lightbox have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic lightbox.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Flow cytometry and testing (88184, 88237, 85060,
88185) provided by an OON provider.

You asked the Plan to pay for the Flow cytometry. You say that you tried to obtain prior authorization and the
services were medically necessary. The Plan denied your request. The Plan says OON criteria for coverage of
the services were not met.

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 the Flow cytometry and testing (88184, 88237,
85060, 88185) provided by an OON provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient therapeutic repetitive transcranial magnetic
stimulation (TMS) treatment.
You asked the Plan to pre-approve outpatient TMS treatment; initial, including cortical mapping, motor
threshold determination, delivery and management (90867) and Therapeutic repetitive transcranial magnetic
stimulation (TMS) treatment; subsequent delivery and management, per session (90868). You say that you
need TMS treatment. The Plan denied your request. The Plan says you have not had a trial of psychotherapy.
The Plan must follow Medicare rules. Medicare rules say that 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 outpatient TMS treatment; initial,
including cortical mapping, motor threshold determination, delivery and management (90867) and Therapeutic
repetitive transcranial magnetic stimulation (TMS) treatment; subsequent delivery and management, per
session (90868). Our reviewer says that the service is not medically necessary. Our physician reviewer found
based on the records provided, this patient does not meet the criteria for Transcranial Magnetic Stimulation
(TMS) therapy is not considered medically necessary for this patient who suffers from Major Depressive
Disorder. The patient has no diagnosis of Severe Major Depressive Disorder, but rather Chronic Major
Depressive Disorder. The patient has tried different medications but there is no documentation of the patient
showing severe depressive disorder. Therefore, we decided that the Plan does not have to pre-approve
outpatient therapeutic repetitive transcranial magnetic stimulation (TMS) treatment.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) provided on October 21, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the office visit. You say that this was a medically necessary office visit and was needed so that the enrollee could be referred to another specialist. The Plan denied your request. The Plan says they only cover out-of-network services in limited circumstances. This care was not urgent or pre-approved and could have been provided in network. In addition, the enrollee should have seen their primary care provider for a referral if necessary.
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 the office visit (99213) provided on October 21, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for punch biopsy of the skin and related
services (88305, 11104, G0463, 85652).

You asked the Plan to waive the copayment for the biopsy procedure and services. You say that you had never
been charged for a biopsy before, and you were not moved to a different room for this procedure. The Plan
denied your request. The Plan says this specific procedure code is classified as a surgical procedure. Outpatient
surgery has a $200 copayment when provided at an outpatient hospital facility.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200
copayment for outpatient surgery and services.

You have been asked to pay a $200 copayment for the biopsy procedure and services. The biopsy procedure
that was provided falls within the outpatient surgery and services 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 punch biopsy of the skin and related services (88305, 11104, G0463, 85652).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two pontics (D6242 x2) and two retainer crowns (D6752 x2).
You asked the Plan to pre-approve the pontics and retainer crowns. You say that you would like these services to be covered. The Plan denied your request. The Plan says these services are not covered.
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 two pontics (D6242 x2) and two retainer crowns (D6752 x2).