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

We decided that the Plan does not have to pre-approve MRI, brain (including brain stem); without contrast
material, followed by contrast material(s) and further sequences (CPT code 70553) to be performed by a
tertiary provider.

You asked the Plan to pre-approve the MRI. You say that given the enrollee's complex neurological condition
with previous meningioma, this warrants an evaluation at a Level 4 Epilepsy Center with Neuroradiology
evaluation of MRI. The Plan denied your request. The Plan says the enrollee can be approved for care at
tertiary facilities only when diagnostic testing cannot be performed locally. The Plan states the enrollee has
local facilities where the MRI can be performed. Unfortunately, this request cannot be approved at this time by
this provider, but the enrollee will be approved to receive the services by an in-network non-tertiary provider.

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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.

The provider at issue in this case is not a network provider with the Plan. 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 MRI. Our physician reviewer found a request for evaluation at a Level 4
Epilepsy Center with Neuroradiology evaluation of MRI was made. MRI could be effectively performed with a
local covered imaging group and sent over to the neuroradiologist for a second opinion read without any
reduction in quality of care. The records do not support the MRI needing to be completed by the tertiary level
provider as requested.

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 MRI have not been met.

The Plan has network providers available who can provide the items/services at issue in this appeal. We found
no exception that would require the Plan to pre-approve the MRI. Therefore, we decided that the Plan does not
have to pre-approve MRI, brain (including brain stem); without contrast material, followed by contrast
material(s) and further sequences (CPT code 70553) to be performed by a tertiary provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation mileage.

You asked the Plan to pre-approve the additional mileage. You say that this is medically necessary. The Plan
denied your request. The Plan says this request will exceed the mileage benefit limit.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers routine transportation up to 50 miles one-way each trip.

We looked at your request, the records in the case file, and the rules. Your requested trip is 70.2 miles, which
exceeds the mileage limit. Based on this information, we decided that the Plan's rules for coverage of routine
transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve additional
routine transportation mileage.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF care from April 30, 2021, forward.

You asked the Plan to pre-approve SNF 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 Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 there are identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of SNF care from April 30, 2021, forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an air purifier.

You asked the Plan to pre-approve the purifier. You say that this is medically necessary. The Plan denied your request. The Plan says this is for convenience purposes.

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 an air purifier.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Tandem slim insulin infusion pump (E0787).

You asked the Plan to pre-approve the pump. You say that this is medically necessary. The Plan denied your request. The Plan says no clinical documentation or information was received in order to substantiate the medical necessity of this request.

The Plan must follow Medicare rules. Medicare rules say that E0787 is not a covered code.

No records to review were provided. Additionally, E0787 is statutorily not covered by Medicare at this point. Based on this information, we decided that Medicare rules for coverage of the pump have not been met. Therefore, we decided that the Plan does not have to pre-approve a Tandem slim insulin infusion pump (E0787).
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 IRF admission is medically necessary. The Plan
denied your request. The Plan says the enrollee's needs can be met at a different 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 based on the medical records provided the complexity of your nursing, medical and
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to
rehabilitation care. You may require skilled physical therapy and occupational therapy but based on the
medical records provided It is not clear you would be able to fully benefit and/or participate in an IRF 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 continuous glucose monitor for the enrollee.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the monitor. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee requires frequent adjustment of insulin dosing on the basis or 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 Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer placement (22870, 22869).

You asked the Plan to pre-approve the spacer placement. You say that the services were medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

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 placement. 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 spacer placement have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer placement (22870, 22869).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve replacement dentures.

You asked the Plan to pre-approve the replacement dentures. You say that you want to return your current dentures and have new dentures approved for coverage. The Plan denied your request. The Plan says there are no medical conditions documented which would put you at risk if you do not have this additional dental benefit provided outside of your regular benefits.

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 replacement of removable and fixed prostheses is covered only if the existing prostheses were inserted at least 60 months prior to the replacement. The record shows that you received dentures in February 2021, and your dentures benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve replacement dentures.
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 lumbar spinal stenosis with neurogenic claudication. The requested Superion spacer is not supported over the gold standard of lumbar laminectomy. The services are experimental in nature and 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the eyeglasses provided December 5, 2019, up to the $500 eyewear benefit allowance.

You asked the Plan to pay for the eyeglasses. You say that your previous pair of eyeglasses were not done correctly therefore you needed to obtain a new pair of eyeglasses and they should be covered by the Plan. The Plan denied your request. The Plan says that your $500 allowance was already applied to a previous claim and therefore no reimbursement is due for these eyeglasses.

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 eyewear up to a $500 benefit allowance.

We looked at the file and the Plan's rules. In this case the Plan has failed to provide documentation verifying that the $500 eyewear allowance has already been applied to a previous claim. Since the record does not show that you have exhausted the eyewear allowance, we decided that the Plan has to pay for the eyeglasses provided December 5, 2019, up to the $500 eyewear benefit allowance.

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: 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 IRF care is medically necessary. The Plan denied
your request. The Plan says rules for IRF care have not been met.

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 member is a 73-year-old female with a medical history including valvular heart
disease, chronic lung disease, hypertension and chronic kidney disease who was admitted to the hospital after a
mechanical fall at home. The member does not require treatment by multiple therapies, including either
physical therapy or occupational therapy, at an intensive rehabilitation therapy program. The member continues
to have a need for skilled therapy with ongoing safety concerns and a potential for functional improvement
however, the documentation does not support that she would meet criteria for admission to an acute inpatient
rehabilitation facility. There is no indication that the member would require skilled rehabilitation in an IRF,
participating in rehab services 15 hours a week, under the supervision of a physician with at least 3 visits
weekly to regain or maintain her functional status. The member is ambulating up to 12 feet with minimal
assistance. She is medically stable and can receive services 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D2950) 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 dental services (D2950) for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 home health physical therapy visits.

You asked the Plan to pre-approve 6 home health physical therapy visits. 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 home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

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 6 home health physical therapy visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found the documentation does not support that the coverage criteria for 6 additional home health visits were met 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 6 home health physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 6 home health physical therapy visits.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a whole body MRI.

You asked the Plan to pre-approve the MRI. You say that this is medically necessary due to a recent fall. The Plan denied your request. The Plan says this is not a service that can be obtained without a physician's order or an approved referral.

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 the MRI. Our reviewer says that the requested MRI is not medically reasonable or necessary. Our physician reviewer found there is a plan for physical therapy that has not been started yet. All MRI exams require a written order from the physician. The exam must be appropriate for clinical symptoms. The medical necessity for total body MRI has not been established in the records.

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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve a whole body MRI.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says there are no medical records.

The Plan must follow Medicare rules. Medicare rules say that medical records are required for payment of DME items.

No medical records were provided for review. Based on this information, we decided that Medicare rules for coverage of the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Epidural injections.

You asked the Plan to pre-approve Epidural injections. 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 follows Medicare rules. Medicare rules say that Epidural injections are 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 Epidural injections. Our reviewer says
that the services are not medically necessary. Our physician reviewer found in this case; you are a new patient
at pain management. You did have chiropractic care. There is no documentation that outpatient medical
management has been attempted or would not be tolerated. The documentation does not indicate significant
functional loss. The elements of the coverage determination are not satisfied. The requested service cannot be
recommended.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Epidural injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Epidural injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D9250) 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 dental services (D9250) for the enrollee.