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

We decided that the Plan does not have to pay for lab services (88172, 88341, 88173, 88344) provided April
16, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says the claim was previously paid.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code 88172, 88341, 88173, & 88344 is not supported in the medical record. Specifically,
documentation shows these services were already paid under claim number 820201250241011. Based on this
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we
decided that the Plan does not have to pay for lab services (88172, 88341, 88173, 88344) provided April 16,
2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Superion interspinous spacer (22869, 22870).
You asked the Plan to pre-approve a Superion interspinous spacer. 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. 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 a Superion interspinous spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer 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 a Superion interspinous spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve a Superion interspinous spacer (22869, 22870).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe continuation of inpatient psych services provided after February 9, 2021.You asked the Plan to pre-approvecontinuation of inpatient psych services. You say that this service is medically necessary.The Plan denied your request. The Plan says the enrollee no longer meets criteria for inpatient psych care.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 continuation of inpatient psych services. Our reviewer says that the services requested do not meet medical necessity. Our physician reviewer found based upon the records provided, this patient does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of February 9, 2021, and could have been treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to safety.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continuation of inpatient psych services have not been met.Therefore, we decided that the Plan does not have to pre-approvethe continuation of inpatient psych services provided after February 9, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 1 standard power operated vehicle (K0800).
You asked the Plan to pre-approve a group 1 standard power operated vehicle. You say that the item is 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 a power mobility device is covered when specific criteria is 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 a group 1 standard power operated vehicle. Our reviewer says that the item is not medically necessary. Our physician reviewer found the documentation indicates that this enrollee has a personal mobility deficit but it is not clear that this deficit impairs participation in MRADLs in the home or why the enrollee's mobility deficit cannot be helped effectively by a walker or manual wheelchair in the home. The documentation does not reveal a detailed home assessment indicating that the enrollee can safely maneuver the wheelchair in the home. The documentation does not reveal that the enrollee will significant improve MRADL performance in the home due to this requested power operated vehicle. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a group 1 standard power operated vehicle have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 1 standard power operated vehicle (K0800).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trintellix.
You asked the Plan to pre-approve Trintellix. You say that the medication is not medically necessary. The Plan
denied your request. The Plan says your plan does not have a Medicare Part D benefit or a separate pharmacy
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.
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 Trintellix.
Benefits for Trintellix 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 pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested items are not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient admission for the approved total shoulder 
arthroplasty (23472). 
 
You asked the Plan to pre-approve inpatient admission for the approved total shoulder arthroplasty (23472). 
You say that the requested inpatient admission for the approved total shoulder arthroplasty (23472) is 
medically necessary. The Plan denied your request. The Plan says the requested inpatient admission for the 
approved total shoulder arthroplasty (23472) 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 inpatient admission for the approved 
total shoulder arthroplasty (23472). Our reviewer says that the requested inpatient admission for the approved 
total shoulder arthroplasty (23472) is not medically necessary. Our physician reviewer found this enrollee cites 
right shoulder pain that is aching, throbbing, constant and moderate. Aggravating factors include lifting, 
carrying, pushing/pulling, squeezing, throwing, range of motion, and nighttime. Exam demonstrates pain with 
motion. There is tenderness of the AC joint and across chest. Impingement 1&2 are positive. O'Brien's is 
positive. 
 
Current evidence based medical literature supports the approved right total shoulder arthroplasty being 
performed as an outpatient procedure. This is due to the lack of documented co-morbidities within this 
enrollee's clinical records. The requested admission for the approved total shoulder arthroplasty (23472) is 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 inpatient admission for the approved total shoulder arthroplasty (23472) have 
not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient admission for the 
approved total shoulder arthroplasty (23472).
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 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 IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the medical records provided the complexity of the enrollee's nursing, 
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. There is no documentation that the enrollee requires the intensive rehabilitation 
therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears 
to be 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 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. 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 LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found you do not require services at the LTACH that are not available at the acute care
hospital where you are currently receiving care. There are no services available at the LTACH that you require
that are not available at the health care setting being offered by the health plan. The requested LTACH services
are not medically necessary, reasonable, and appropriate for your diagnosis and condition and able to be
furnished safely and effectively only on an inpatient basis.
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.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve COOLIEF radiofrequency ablation (RFA) of your facet 
joint (64635). 
 
You asked the Plan to pre-approve COOLIEF RFA of your facet joint. 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 non-thermal RF modalities for facet joint denervation 
including chemical denervation (alcohol, phenol, etc.), laser therapy, cryotherapy, as well as pulsed RF 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 COOLIEF RFA of your facet joint. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found cooled and pulsed 
RFA are specifically excluded as acceptable methods. 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 COOLIEF RFA of your facet joint have not been met. Therefore, we decided 
that the Plan does not have to pre-approve COOLIEF radiofrequency ablation (RFA) of your facet joint 
(64635).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit.
You asked the Plan to pre-approve Retacrit. 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 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 Retacrit. Our reviewer says that the medication is not medically necessary. Our physician reviewer found as the enrollee does not have a low enough blood count to meet criteria for Retacrit treatment, this medication will be considered not medically necessary at this time. The documentation does suggest that the Retacrit would be safe and effective for the enrollee, however, the benefit is less the higher the blood count is. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periapical x-rays, the limited oral evaluation, the post and 
core in addition to crown and the clinical crown lengthening provided on October 2, 2020. 
 
You asked the Plan to pay for these services. You say that payment should be made for these services. The Plan 
denied your request. The Plan says that the benefit for periapical x-rays was exceeded. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The Plan covers one periapical 
x-rays per calendar year.  
 
We looked at the file and Medicare rules. The file indicates the Plan has already covered one periapical x-ray 
on this date of service. The Plan is not required to cover more than one per calendar year. The limited oral 
evaluation, the post and core in addition to crown and the clinical crown lengthening are not covered under this 
benefit. Based on this information, we decided that the Plan's rules for coverage of these services have not been 
met. Therefore, we decided that the Plan does not have to pay for the periapical x-rays, the limited oral 
evaluation, the post and core in addition to crown and the clinical crown lengthening provided on October 2, 
2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy rendered on May 27, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be 
covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The 
Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. 
 
We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare 
and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does 
not have to pay for the home infusion therapy rendered on May 27, 2020.  
 
Benefits for these services 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment forradiologic examination, knee; 3 views (CPT Code 73562) provided on August 13, 2020.You asked the Plan to reduce the copayment forthe x-ray. You say that your copayment should be $20 and not $41.05.The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received a radiologic examination, knee; 3 views (CPT Code 73562) provided on August 13, 2020. At the time of services rendered you had not met your $750 deductible; therefore, you have been asked to pay $41.05 for the services to apply to your deductible. Your 2020 EOC states, "The deductible is $750. This is the amount you have to pay out-of-pocket before the plan will pay their share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost for most of your covered services. Once you have paid your deductible, the plan will begin to pay their share of the costs for covered medical services and you will pay your share (your copayment or coinsurance amount) for the rest of the calendar year." 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 reduce the copayment forradiologic examination, knee; 3 views (CPT Code 73562) provided on August 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Erivedge. 
 
You asked the Plan to pre-approve Erivedge. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Erivedge.  
 
Benefits for Erivedge 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRFadmission and services.You asked the Plan to pre-approveIRF 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 requestedIRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the documentation provided, the health plan's denial should be upheld. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.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-approveacute IRF admission and services
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services for the enrollee.You asked the Plan to pre-approvethe LTACH services. You say that these services are medically necessary.The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute setting.The Plan must follow Medicare rules. Therules 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. The patient appears to be improving sufficiently to need only short-term additional acute care services which can safely be received at the current facility. The patient does not require services at the LTACH that are already available at the current facility. 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-approvelong term acute care hospital (LTACH) services for the enrollee.