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

 
We decided that the Plan does not have to waive the deductible for laboratory services provided on July 20, 
2020. 
 
You asked the Plan to waive the deductible for laboratory services. You say that you were not informed that 
you would owe deductible charges for laboratory services. 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. Your 
contract with the Plan says that there is a $250 deductible for laboratory services. 
 
You received laboratory services on July 20, 2020. The record shows that you had paid $0 toward the $250 
deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $69.73.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient 
diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $250 deductible for laboratory services. This cost sharing is a 
contractual obligation that had not been met at the time laboratory services was received on July 20, 2020. 
Therefore, we decided that the Plan does not have to waive the deductible for laboratory services provided on 
July 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the member does not have clinical conditions that cannot be 
appropriately treated in the current hospital. 
 
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. There are no 
required medical services identified that are available at the LTACH, that are not available at the current health 
care setting being offered by the health plan. Our physician reviewer found that the enrollee's condition does 
not meet Medicare criteria for LTACH services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve an MRI BREAST C-+ W/CAD BI. 
 
You asked the Plan to pre-approve an MRI BREAST C-+ W/CAD BI. You say that the requested MRI 
BREAST C-+ W/CAD BI is medically necessary. The Plan denied your request. The Plan says that the 
requested MRI BREAST C-+ W/CAD BI is not medically necessary. 
 
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 BREAST C-+ W/CAD BI. Our 
reviewer says that the requested MRI BREAST C-+ W/CAD BI is medically necessary. Our physician 
reviewer found the enrollee is with a history of bilateral augmentation mammaplasty. There is concern that the 
enrollee has evidence of silicone breast implant rupture. The gold standard for evidence of silicone breast 
implant rupture is MRI evaluation. Although the enrollee states that she has implant rupture, it is unclear if this 
has been adequately confirmed from previous radiographic determination. From Medicare, the rules say that 
MRIs are covered when medically necessary and reasonable for the diagnosis or treatment of the specific 
patient involved. As the gold standard for assessment of silicone breast implant rupture is MRI evaluation, the 
requested evaluation of an MRI evaluation satisfies Medicare medically necessary criteria. 
 
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 BREAST C-+ W/CAD BI have been met. Therefore, we decided that 
the Plan has to pre-approve an MRI BREAST C-+ W/CAD BI.  
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the outpatient office visits to be provided by an out of 
network (OON) providers. 
 
You asked the Plan to pre-approve the outpatient office visits.. You say that your doctor believes this treatment 
may possibly eliminate the pain and restore the normal sexual feeling. You very much want to participate in the 
PRP treatment and ask the Plan to support you. 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. Platelet rich plasma infusion is not a recognized or viable treatment for severe back pain and loss of 
sexual feeling. 
 
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 requested provider in this case is not a network provider with the Plan. 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 these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the outpatient office visits to be provided by an out of network (OON) providers.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that the enrollee is not safe 
for discharge based on clinical presentation. The Plan denied your request. The Plan says that the enrollee is 
not acutely suicidal or homicidal, and denied auditory and visual hallucinations. 
 
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 psychiatric hospital services. 
Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary for the 
enrollee in this case. The enrollee is not shown to be a danger to herself or others. She is not showing any 
auditory or visual hallucinations and is cooperative/compliant with treatment while not showing any threats the 
safety. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for inpatient 
psychiatric hospital services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric hospital services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient skilled nursing services 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 no evidence was submitted with the appeal that clearly refutes the original rationale for 
the denial of these services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee did not have any skilled 
nursing needs. As of 11/5/2020 the enrollee did not require any skilled nursing or rehab services on a daily 
basis.  She was not expected to make measurable gains within a reasonable and predictable period of time or 
require skilled therapy to prevent deterioration with mobility or ADLs. The enrollee did not require skilled 
 
 
therapy to establish a safe and effective maintenance program. As a practical matter, the enrollee did not 
require any skilled services on an inpatient basis, at a SNF level of care as of 11/5/2020. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued inpatient skilled nursing services for the enrollee.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve transurethral destruction of prostate issue 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 the requested procedure is currently considered to be experimental and 
investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 surgery is considered medically reasonable and necessary in this case. Our physician reviewer found 
the American Urological Association (AUA) considers transurethral destruction of prostate tissue; by radio-
frequency generated water thermotherapy, also known as the Rezum procedure, to be a viable treatment of 
benign prostatic hyperplasia (BPH). Therefore, this procedure should be covered for reimbursement. The AUA 
does not consider this procedure to be investigational or experimental and, therefore, warrants coverage. 
 
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 transurethral destruction of prostate issue 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve RT300 functional electrical stimulation (FES) therapy 
system. 
 
You asked the Plan to pre-approve RT300 FES therapy system. You say that the RT300 is medically necessary 
and without it the enrollee's present and future health will be at greater risk for decline and early morbidity. The 
Plan denied your request. The Plan says the requested item is considered experimental, investigational and 
unproven. There is not enough medical proof that shows the safety and/or success of the RT300 FES therapy 
system to maintain muscle function. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of RT300 FES therapy system have not been met. Therefore, we decided that the Plan does not have 
to pre-approve RT300 functional electrical stimulation (FES) therapy system.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI of the lumbar spine. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says the doctor's notes do not show how long the back pain has lasted. 
 
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 no history of 
trauma, suspicion of infection or metastatic disease.  You have had a normal neurological exam and carries a 
diagnosis of non-specific myelopathy. No conservative treatment attempt including PT has been described. The 
medical necessity of MRI of the lumbar spine has not been established in the submitted 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 MRI of the lumbar spine.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MRI of the brain for the enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says the documentation from the CT scan of head, and a reason for the need for repeat cross-
sectional imaging of the brain has not been provided. 
 
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 and necessary. Our physician reviewer found notes from the 
enrollee's health plan indicated that the member was previously authorized to undergo CT of the head. It was 
unclear if that study was completed. Nor were any other clinical documents provider for review with this case. 
As a result, in the absence of any relevant clinical documentation, it cannot be determined that the requested 
imaging study would be reasonable and necessary for the enrollee's condition at this time 
 
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 MRI of the brain for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the hearing aids provided on May 27, 2020, by an 
out-of-network provider on May 27, 2020. 
 
You asked the Plan to reimburse you for the hearing aids. You say that you were out of state and lost your 
hearing aids. The Plan denied your request. The Plan says you did not use a network 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 reimburse you for care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items at issue in this appeal. The Plan did not pre-approve the item at issue. We 
found no exception that would require the Plan to reimburse you for these items. Therefore, we decided that the 
Plan does not have to reimburse you for the hearing aids provided on May 27, 2020, by an out-of-network 
provider on May 27, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox (J0585). 
 
You asked the Plan to pre-approve Botox. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not have a supported condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Botox. Our reviewer says that the 
criteria for coverage of Botox has not been met. Our physician reviewer found based on the Medicare-approved 
drug compendia and the medical records provided there is no documentation that supports that the Botox is 
medically reasonable and necessary for the patient for his diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox (J0585).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient hospital level of care from 11/3/20 
and forward. 
 
You asked the Plan to pre-approve continued inpatient hospital level of care from 11/3/20 and forward. You 
say that the continued inpatient hospital level of care from 11/3/20 and forward is medically necessary. The 
Plan denied your request. The Plan says the continued inpatient hospital level of care from 11/3/20 and forward 
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 continued inpatient hospital level of 
care from 11/3/20 and forward. Our reviewer says that the continued inpatient hospital level of care from 
11/3/20 and forward is not medically necessary. Our physician reviewer found the review indicates that the 
enrollee was admitted 10/26/20 after a fall. She was diagnosed with a subarachnoid hemorrhage 
(SAH)/subdural hematoma (SDH). She was evaluated by Neurosurgery. She did not have any seizures. Her 
repeat scans of her brain showed progression of the bleed. Her renal function returned to baseline. Her vital 
signs are stable. She is doing physical therapy. Her last covered day was November 2, 2020. 
 
There was no documentation provided necessitating inpatient level of care services beginning November 3, 
2020. The enrollee was not receiving nor required any inpatient diagnostic studies or therapeutic interventions. 
The review has determined that the requested continuation of inpatient hospital level of care from 11/3/20 and 
forward was not medically reasonable and necessary for the enrollee 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 continued inpatient hospital level of care from 11/3/20 and forward have not 
 
 
been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient hospital level 
of care from 11/3/20 and forward.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve biofeedback therapy. 
 
You asked the Plan to pre-approve biofeedback therapy. You say that you believe you deserve a trail and 
approval of a certain number of biofeedback sessions as you don't want to live with this chronic severe pain 
impacting your life. The Plan denied your request. The Plan says the enrollee does not meet the Medicare or the 
Plan's criteria for coverage for biofeedback therapy because biofeedback for the enrollee's condition is not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve biofeedback therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not have a diagnosis which has been shown to be effectively treated 
with biofeedback. Therefore, the request is considered not medically reasonable or 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 biofeedback therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve biofeedback therapy..