Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator (E0466) with accessories.
You asked the Plan to pre-approve a home ventilator with accessories. You say that the requested treatment is a medical necessity for you. The Plan denied your request. The Plan says rules for coverage for a home ventilator have not been met.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.
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 home ventilator with accessories. Our
reviewer says that the requested item is not medically reasonable and necessary in this case. Our physician
reviewer found that you have chronic obstructive pulmonary disease (COPD) and congestive heart failure
(CHF) and were recently hospitalized with an exacerbation of both conditions. There was improvement on bilevel
positive airway pressure (BiPAP). An arterial blood gas test confirmed mild carbon dioxide (CO2)
retention. Medicare does not cover a ventilator when used as BiPAP. There is no evidence of BiPAP failure in
the home 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 a home ventilator with accessories have not been met. Therefore, we decided
that the Plan does not have to pre-approve a home ventilator (E0466) with accessories.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration.
You asked the Plan to pre-approve bone marrow aspiration. You say that the requested bone marrow aspiration is medically necessary. The Plan denied your request. The Plan says the requested bone marrow aspiration 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 bone marrow aspiration. Our reviewer says that the requested bone marrow aspiration is not medically necessary. Our physician reviewer found the Plan approved posterior fusion T10-L2, removal and revision instrumentation at T10-pelvis represented by codes 22610, 22614, 22849, 20930, and 20939 and an inpatient stay. Bone marrow aspirate remains experimental for use in spinal surgery as bone graft material. More research is needed.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bone marrow aspiration have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspiration.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you received on April
22, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that this ambulance service
was needed due to difficulties following surgery, so you don't think you should have to pay the copayment. The
Plan denied your request. The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250
copayment for ambulance services.
You have been asked to pay a $250 copayment for the ambulance services. This copayment applies regardless
of the reason for the transport. 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 ambulance services you
received on April 22, 2021. Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the
appropriate Quality Improvement Organization for further review.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the documentation does not 
While he may benefit from continued physical therapy and occupational therapy with post-brain tumor 
removal, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with 
frequent physician oversight and an interdisciplinary approach to rehabilitation care. IRF admission is not 
medically necessary based on lack of need for medical supervision by PM&R physician and skilled 
rehabilitation nursing needs and current functional level. 
 
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. support the need for therapy program consisting of at least 3 hours of therapy per day at least 5 days per week.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat transforaminal epidural steroid injection (TFESI).
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 an ESI is 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain secondary to lumbar spondylosis without myelopathy and lumbar radiculopathy. He received a TFESI on February 23, 2021. There is no documentation of at least 50 percent pain relief for at least three months from the previous injection; therefore, the repeat injection is 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 repeat transforaminal epidural steroid injection (TFESI).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the osseous surgery (D4260), bone replacement graft (D4263), and guided tissue regeneration (D4267) provided on April 29, 2021.

You asked the Plan to pay for the osseous surgery, bone replacement graft, and guided tissue regeneration. You say that the surgery was necessary. The Plan denied your request. The Plan says these services are not covered benefits under your dental plan. The Plan also says that you signed treatment plan demonstrating you accepted financial responsibility for the osseous surgery.

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 pay for the osseous surgery (D4260), bone replacement graft (D4263), and guided tissue regeneration (D4267) provided on April 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan rendered on April 25, 2021.
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 procedure code 70490 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.
The provider submitted a claim for procedure codes 70490 (CT of soft tissue of neck) and 70498 (computed tomography angiography of the neck). Code 70490 is a column II code with a modifier indicator of 1 when billed with column I code 70498. Code 70490 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan rendered on April 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided on February 8, 2021.
You asked the Plan to pay for those services not related to manual manipulation of the spine. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says the Plan and Medicare only pay for services directly related to manual manipulation of the spine.
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 chiropractic services provided on February 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an eye exam.

You asked the Plan to pre-approve the exam. You say that this is medically necessary. The Plan denied your request. The Plan says there is no evidence for performing an eye exam earlier, such as a need for surgery.

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.

We looked at the file and the Plan's rules. Our reviewer found that the record indicates that you had an examination in November 2020 and are due for another examination in November 2021. You are requesting an earlier exam since you will be out-of-town. The records provided do not support the medical necessity or reasonableness of having the repeat examination at this time. The elements of the coverage rule are not satisfied Based on this information, we decided that the Plan's rules for coverage of the exam have not been met. Therefore, we decided that the Plan does not have to pre-approve an eye exam.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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 enrollee does not meet criteria for IRF admission. Our physician reviewer found the documentation does not support the need for therapy program consisting of at least 3 hours of therapy per day at least 5 days per week. While she may benefit from physical therapy and occupational therapy with post-op hip fracture, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care. IRF admission is not medically necessary based on lack of need for medical supervision by PM&R physician and skilled rehab nursing needs. 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 transit option kit for a power wheelchair.
You asked the Plan to pre-approve transit option. You say that the enrollee is looking to pursue other funding opportunities for this equipment but needs a formal decision to do so. The Plan denied your request. The Plan says the denial of authorization for this equipment is correct, because a transit option is not covered by Medicare.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home.
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a transit option kit for a power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for exercise equipment purchased on
August 13, 2020.
You asked the Plan to reimburse you for the exercise equipment. You say that the exercise equipment should be covered because during COVID-19 you were not allowed to go to the gym. The Plan denied your request. The Plan says per the temporary COVID-19 Policy, you may use your $300 Wellness Allowance towards the purchase of exercise equipment that you can use at home. Purchases made prior to October 1, 2020 do not qualify. The purchase of your exercise equipment was made prior to October 1, 2020.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan's rules for coverage of gym benefits have not been met because the exercise equipment was purchased prior to October 1, 2020. Therefore, we decided that the Plan does not have to reimburse you for exercise equipment purchased on August 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fluid flow.

You asked the Plan to pre-approve fluid flow. You say that the requested fluid flow is medically necessary. The
Plan denied your request. The Plan says the requested fluid flow 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 fluid flow. Our reviewer says that the
requested fluid flow is not medically necessary. Our physician reviewer found the enrollee is with chronic pain
syndrome, low back pain, cervicalgia, and left shoulder pain. An MRI demonstrated severe disc height loss
with anterior marrow edema at L4-5, mild degenerative disease at L3-4 and L5-S1, small disc bulges at L3-4,
L4-5, and L5-S1. There is an annular fissure are L5-S1. The provider has requested Fluid Flow, a human
amniotic flowable allograft, for the enrollee's disc tear. The documentation does not support that Fluid Flow is
medically reasonable and necessary for the enrollee in this case. The medical literature does not support the
benefit of human amniotic flowable allograft for the treatment of annular fissures.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of fluid flow have not been met. Therefore, we decided that the Plan does not have
to pre-approve fluid flow.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve an inpatient hospital admission.
You asked the Plan to pre-approve acute inpatient hospital care. You say that inpatient care is medically necessary. The Plan denied your request. The Plan says that the enrollee's needs can be met in observation care.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient services are met in this case. Our physician reviewer found the records show that at the time of admission the physician could reasonably expect that the patient's necessary hospital care would span more than two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pre-approve an inpatient hospital admission.
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 continued inpatient psychiatric services.
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says you are no longer a threat to yourself or others.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. Continued inpatient services from August 25, 2021, forward, were requested. 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 services. Our physician reviewer found that it was not expected you would improve in a reasonable period of time beyond date in question as you did not have suicidal or homicidal ideation noted. It did not appear that active treatment was taking place. You were compliant with treatment while not showing any acute threats to safety. Based upon review the records provided, you do not meet the criteria for continued acute inpatient mental health treatment beyond the date in question.
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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you on March 23, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider has opted
out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the
services provided to you on March 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the spinal cord stimulator trial to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the spinal cord stimulator trial. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there is no network deficiency for your service area for the requested service.
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 spinal cord stimulator trial to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a BiPAP device (E0471) rented on February 9 and March 9, 2021.
You asked the Plan to waive the coinsurance for a BiPAP. You say that you have already paid once for the machine at issue. The Plan denied your request. The Plan says the correct coinsurance was applied.
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 20% coinsurance for each Medicare-covered durable medical equipment item.
You have been asked to pay $49.79, or 20% of the Medicare-allowed charge of $248.96, per monthly rental for a BiPAP. A BiPAP falls within the "Durable medical equipment (DME) and related supplies" benefit category. The Plan requires rental rather than purchase of this item. 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 coinsurance for a BiPAP device (E0471) rented on February 9 and March 9, 2021.
Your complaint about receiving erroneous or incomplete information about your cost-sharing responsibility for equipment rental upon enrollment in the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.