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

 
We decided that the Plan does not have to pre-approve a cryoablation of the nose, Clarifix procedure (30999). 
 
You asked the Plan to pre-approve the Clarifix procedure. You say that the service is medically necessary. The 
Plan denied your request. The Plan says this service is considered experimental. 
 
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 Clarifix procedure. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is insufficient literature to support the safety and efficacy of the requested service for your 
condition.  The record provided does not establish the medical necessity and reasonableness, as defined by 
Medicare rules, of the requested service. 
 
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 Clarifix procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a cryoablation of the nose, Clarifix procedure (30999).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 28, 2022, to 
September 26, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the claim has not been billed 
with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from August 28, 2022, to 
September 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on January 
17, 2022. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged 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 $150 
copayment for outpatient surgery/Medicare-covered ambulatory surgical center visit.  
 
You have been asked to pay a $150 copayment for an outpatient surgery. This item/service falls within the 
outpatient surgery/Medicare-covered ambulatory surgical center visit benefit category. 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 an outpatient surgery provided on January 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 31, 2022. 
 
You asked the Plan to pay for an office visit. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on October 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vertiflex placement surgery. 
 
You asked the Plan to pre-approve a vertiflex placement surgery. You say that the service is medically 
necessary. The Plan denied your request. The Plan says this service is considered experimental. 
 
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 placement surgery. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found this service is considered experimental. 
 
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 placement surgery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a vertiflex placement surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5225), and mandibular 
partial denture (D5226). 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee lost the lower and upper 
partial. The Plan denied your request. The Plan says the benefit for the requested services has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the benefit for the  maxillary partial denture was exhausted on date of service February 20, 2021, and the  
mandibular partial denture on April 20, 2021. Therefore, we decided that the Plan does not have to pre-approve 
a maxillary partial denture (D5225), and mandibular partial denture (D5226).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you would like reconsideration because the services 
are medically necessary. The Plan denied your request. The Plan says a SNF admission is not medically 
necessary. and your needs can be met in another setting. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for interrogation device evaluation provided on August 29, 
2022. 
 
You asked the Plan to pay for interrogation device evaluation. You say that the records attached support the 
services provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for interrogation device 
evaluation provided on August 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Standard Wheelchair (K0001). 
 
You asked the Plan to pre-approve a Standard Wheelchair. You say that the item is medically necessary. The 
Plan denied your request. The Plan says there is no indication that a home assessment has been done or that the 
member or caregiver has sufficient arm strength to move it. 
 
The Plan follows Medicare rules. Medicare rules say that a standard wheelchair may be covered when the 
documentation indicates the beneficiarys home provides adequate access between rooms, maneuvering space, 
and surfaces for use of the manual wheelchair that is provided and the enrollee or caregive have adequate strength to move the wheelchair. 
 
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 Standard Wheelchair. Our reviewer 
says that the member does not need this item. Our physician reviewer found the patients home must be 
accessible for the requested manual wheelchair and he or a caregiver must demonstrate an ability to use it. This 
information is not provided in the documentation. 
 
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 Standard Wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Standard Wheelchair (K0001).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary, and you 
would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the 
requested IRF admission 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 that the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program.  While the enrollee may have a need for physical therapy and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
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 an IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the minuteman procedure. 
 
You asked the Plan to pre-approve the minuteman procedure. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the service is considered experimental. 
 
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 minuteman procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found fusion indications within guidelines/literature for (existing or potential intraoperative) 
instability have not been documented and/or met in this case. In addition, there are multiple alternate pain 
generators plausibly significantly contributing to the clinical condition that have not been fully documented as 
having been excluded and/or ruled out. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. 
 
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 minuteman procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the minuteman procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SSBCI benefits. 
 
You asked the Plan to pre-approve the SSBCI benefits. You say that you believe you are eligible for the SSBCI 
benefits. The Plan denied your request. The Plan says you do not meet the criteria to be eligible for SSBCI 
benefits. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. We looked at the file and Medicare rules. The Plan requested medical records from your provider but did not 
receive any, and without medical records we cannot determine whether you meet the criteria for the SSBCI 
benefits. Based on this information, we decided that there is insufficient information in the record to determine 
if Medicare rules for coverage of SSBCI benefits have been met. Therefore, we decided that the Plan does not 
have to pre-approve SSBCI benefits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy visit provided on October 06, 2022. 
 
You asked the Plan to pay for psychotherapy visit. You say that the records attached support the services 
provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for psychotherapy visit 
provided on October 06, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Lite diabetic test strips.  
You asked the Plan to pre-approve Freestyle Lite test strips. You say that the requested brand of test strips is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MA Plans may specify brands and manufacturers 
as preferred and charge lower cost-sharing for the preferred brands or may limit DME to only those preferred 
brands and manufacturers. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Freestyle Lite test strips have not been met. Specifically, the requested item is a non-preferred 
brand. The case record does not contain medical documentation to support the medical necessity of the 
requested item. Therefore, we decided that the Plan does not have to pre-approve Freestyle Lite diabetic test 
strips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 21, 2022. 
 
You asked the Plan to pay for an office visit. You say that there was an authorization obtained. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on October 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator.. You say that the item is medically necessary. The Plan 
denied your request. The Plan says there is no evidence of failure of a standard Bi-Pap and the specific 
requested device will only be used in a bi-level PAP mode, this can be achieved with a different type of device. 
 
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. Our reviewer says 
that the member does not need this item. Our physician reviewer found his patient has been hospitalized twice 
in the last few months, most recently with COVID pneumonia. There is a history of COPD on home oxygen, 
severe obesity, obstructive sleep apnea, and lung cancer in remission. It appears the patient was prescribed a 
home ventilator following the hospitalization in December and has it at home. There is no documentation of use of the device at home. An arterial blood gas during the admission in December was consistent with severe 
acute on chronic hypercarbic respiratory failure. There are no pulmonary function tests to confirm COPD and 
assess severity. This patient may benefit from BiPAP with AVAPS during sleep as an outpatient. There is no 
documentation that this has been tried and failed. Medicare does not cover a home ventilator when used at 
settings that can be provided with BiPAP. 
 
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. have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mandibular partial denture (D5214). 
 
You asked the Plan to pre-approve dental services. You say that you are unable to eat or chew so it is important 
to have the dentures approved. The Plan denied your request. The Plan says this service is not covered under 
your Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Mandibular partial denture 
(D5214) is not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D5214 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve mandibular 
partial denture (D5214).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan 
denied your request. The Plan says the requested IRF admission 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 that the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee 
may have a need for physical therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
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 an IRF admission and services.