Persius/hicric huggingface dataset:
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 with your health issues you are unable to take care of yourself. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.
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. 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 were admitted for surgical revision of knee
replacement after a peri-prosthetic fracture after a fall. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: 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 requested admission to an IRF 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 in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment 
by multiple therapies, including either physical therapy or occupational therapy, and an intensive
rehabilitation therapy program. While the documentation does support a need for physical and/or occupational
therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program.

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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve one hundred and twenty (120) additional routine
transportation trips.
You asked the Plan to pre-approve additional routine transportation trips. You say that you need these addition
trips in order to get to all your medically necessary doctor appointments. The Plan denied your request. The
Plan says you have exhausted the Plan's benefit for routine transportation.
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 a maximum of forty-eight (48) one-way trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we
decided that the Plan does not have to pre-approve one hundred and twenty (120) additional routine
transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visits and the podiatry services provided on
December 3, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the office visits and the podiatry services. You say that you should be reimbursed
because you paid out-of-pocket for the services. The Plan denied your request. The Plan says no prior
authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the office visits and the podiatry services provided
on December 3, 2020 by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the duplex scan provided on May 6, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the duplex scan provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the duplex scan provided on May 6, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitoring device provided on February 2, 2021.
You asked the Plan to pay for the provided services. The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.
The record does not contain a valid physician order which support medical necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitoring device provided on February 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) scan of the shoulder (73222).

You asked the Plan to pre-approve MRI scan of the shoulder. You say that this request is medically necessary. The Plan denied your request. The Plan says the coverage criteria have not been met.

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 MRI scan of the shoulder. Our reviewer says that the request is not medically necessary and reasonable. Our physician reviewer found the enrollee is a 62 year old patient with chronic left shoulder pain and history of rheumatoid arthritis. In this case, the requested X-ray arthrogram of the left shoulder that is scheduled should be done and then the results analyzed to determine if the requested shoulder MRI is 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 MRI scan of the shoulder have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) scan of the shoulder (73222).
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 service is medically necessary. The Plan denied your request. The Plan says the service 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 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 your medical conditions are stable and you have no complex nursing or rehabilitation 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. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into an IRF is not medically necessary or reasonable. 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 pay for the intraoral X-rays (D0230 x2) provided April 19, 2021.
You asked the Plan to pay for the intraoral X-rays. You say that you would like this claim reprocessed for payment. The Plan denied your request. The Plan says the benefit maximum has been reached for dental services.
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 the intraoral X-rays when the services are medically necessary and reasonable with up to six covered every 36 months.
We looked at the file, and Medicare rules. In this case, the benefit for X-ray services has been exhausted. Based on this information, we decided that the Plan's rules for coverage of the intraoral X-rays have not been met. Therefore, we decided that the Plan does not have to pay for the intraoral X-rays (D0230 x2) provided April 19, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex device (22869).

You asked the Plan to pre-approve a Vertiflex device. You say that the service is medically necessary. The Plan
denied your request. The Plan says the service 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 a Vertiflex device. Our reviewer says
that the requested service is not considered medically reasonable and necessary in this case. Our physician
reviewer found the Vertiflex device is experimental, and more research is needed to show safety and efficacy of
the device.

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 Vertiflex device have not been met. Specifically, more research is needed to
show safety and efficacy of the device. This means the requested service is not medically necessary or
reasonable. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex device (22869).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the heart.
You asked the Plan to pre-approve CT scan. You say that having this test done will make it less likely for you to have a cardiac event. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this test is not recommended by guidelines.
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 CT scan. Our reviewer says that you do not meet the Medicare criteria for the requested CT scan. Our physician reviewer found you have no documentation of any history of hypertension, hypercholesterolemia, or other cardiac risk factors except for a family history of coronary artery disease. Cardiac CT cannot be used to identify or rule out the presence of an unstable plaque. Calcification is present much more often than significant stenosis. Most patients with coronary calcification who go on to conventional invasive catheter angiography will therefore not have significant obstructive disease. This test is 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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the heart.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a facet joint block at a third level.

You asked the Plan to pre-approve facet joint injection. You say that you have extreme back pain that prevents you from walking. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the Plan already approved 2 level and the third level is not medically necessary.

The Plan follows Medicare rules. Medicare rules state that facet joint interventions may be covered under certain circumstances. 

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 facet joint injection. Our reviewer says that you do not meet the Medicare criteria for the requested third level of facet joint injection. Our physician reviewer found Medicare rules have a utilization limit of 2 levels. This request exceeds this limit and the additional level is deemed 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 facet joint injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a facet joint block at a third level.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure.
You asked the Plan to pre-approve the Intracept procedure. You say that this request is medically necessary for
the enrollee's condition. The Plan denied your request. The Plan says the requested procedure is not medically
necessary in this case.
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 Intracept procedure. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the Intracept procedure is experimental. More research is needed to show safety and
efficacy of the Intracept procedure.
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 Intracept procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for diabetic supplies (K0553) provided April 12, 2021.
You asked the Plan to pay for the supplies. You say that these items were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery for the supplies provided in this case. The record did not
include an itemized delivery invoice. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for diabetic supplies (K0553) provided April 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for copayments for physical therapy services provided from February 4, 2021, through February 25, 2021.
You asked the Plan to reimburse you for copayments for physical therapy services under the Wellness Allowance benefit. You say that were told by a health Plan representative that you could request reimbursement for these copayments. The Plan denied your request. The Plan says copayments are not eligible for reimbursement under the Wellness Allowance benefit.
The Plan contract offers a supplemental Wellness Allowance benefit.
We looked at the file and the Plan's rules. The file shows that the Plan's Wellness Allowance benefit does not provide reimbursement for copayments. Therefore, we decided that the Plan does not have to reimburse you for copayments for physical therapy services provided from February 4, 2021, through February 25, 2021 under the Wellness Allowance benefit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam provided on April 26, 2021.
You asked the Plan to pay for the oral exam. You say that the visit was a new patient exam because you had to switch dentists. The Plan denied your request. The Plan says the claim processed correctly.
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.
We looked at the file, and Medicare rules. The file shows you last received a comprehensive oral exam on February 3, 2020. Your plan only covers this type of exam once every three years. Based on this information, we decided that the Plan's rules for coverage of the oral exam have not been met. Therefore, we decided that the Plan does not have to pay for the oral exam provided on April 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental scaling (D4346) provided on April 13, 2021.
You asked the Plan to pay for the dental scaling (D4346). You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says dental code D4346 is not a covered service under the Plan's supplemental dental 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, dental code D4346 is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental scaling (D4346) provided on April 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Cerapedics iFACTOR and Orthofix Trinity
allografts (20930).

You asked the Plan to pre-approve the Cerapedics iFACTOR and Orthofix Trinity allografts. You say that the
service is medically necessary. The Plan denied your request. The Plan says medical studies haven't proven that
the use of this product during spinal surgery is better than standard allograft products.

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 Cerapedics iFACTOR and Orthofix
Trinity allografts. Our reviewer says that the requested services are not considered medically reasonable and
necessary in this case. Our physician reviewer found the allografts iFACTOR and Trinity are experimental, and
more research is needed to show safety and efficacy of the bone grafts.

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 Cerapedics iFACTOR and Orthofix Trinity allografts have not been met.
Specifically, more research is needed to show safety and efficacy of the bone grafts. This means the requested
services are not medically necessary or reasonable. Therefore, we decided that the Plan does not have to preapprove
the Cerapedics iFACTOR and Orthofix Trinity allografts (20930).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hearing aids (V5261, V5160).
You asked the Plan to pre-approve hearing aids. You say that hearing aids could potentially ease the enrollee's communication struggles. The Plan denied your request. The Plan says hearing aids are not covered under the Medicare portion of the enrollee's benefits and completed a review under the enrollee's Medicaid benefits.
The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related services. Though hearing aids may be appropriate in this case, neither Medicare nor the Plan covers or pays for these types of items and services. Therefore, we decided that the Plan does not have to pre-approve hearing aids (V5261, V5160).