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 IRF care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for coverage of IRF care.

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 there are no complex nursing or rehabilitation needs.

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 has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that this 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 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 periodontal scaling and root planing (D4342) provided on
May 20, 2021.
You asked the Plan to pay for the scaling and planing. You say that the periodontal scaling and root planing
(D4342) is not on your original dental treatment plan, and you did not approve this charge. The Plan denied
your request. The Plan says the calendar year maximum has been met. The Plan also says that it was confirmed
that you received the services which the provider billed the Plan for this date of service.
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 Plan offers a $1,000 combined
allowance for supplemental preventive and comprehensive dental services every year. The contract says that
you are responsible for any amount over and above the allowance amount. The record shows that you met the
annual maximum benefit while processing this claim for the May 20, 2021 date of service and your annual
maximum benefit has been exhausted. The record shows that you did receive these services even though you
may not have approved the charges beforehand. Therefore, we decided that the Plan does not have to pay for
the periodontal scaling and root planing (D4342) provided on May 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.

You asked the Plan to pre-approve a shower chair. You say that the requested item is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says the requested item is not a covered benefit because 
the item is not primarily medical in nature.

The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature. 

While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve prosthetic equipment to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve prosthetic equipment. You say that it is necessary for the enrollee to be approved to visit the provider closer to the enrollee's home. The Plan denied your request. The Plan says that they have an in-network provider that can provide the services in question.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. In this case, the Plan has denied coverage to the OON provider based on the Plan's contracted provider being a suitable provider. However, no address has been given for this in-network provider. Without an address, it is impossible to evaluate this claim for accessibility issues regarding whether the Plan's contracted provider is available within a reasonable distance and travel time from the enrollee's home. Therefore, we decided that the Plan has to pre-approve prosthetic equipment to be provided by an out-of-network (OON) provider.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the knee orthosis (CPT code L1843).

You asked the Plan to pre-approve the knee orthosis. You say that you would not be able function or be able to walk without the knee brace. The Plan denied your request. The Plan says your request is not medically necessary because your records show you do not have recent injury or surgery or objective evidence of instability.

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 knee orthosis. Our physician reviewer found there is no documentation of recent injury to or a surgical procedure on the knee(s). The documentation does not support that you have knee instability documented by examination of you with objective description of joint laxity. LCD L33318 states that coverage will be denied if only pain or a subjective description of joint instability is documented. 

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 knee orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve the knee orthosis (CPT code L1843).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220) provided September 20, 2021, limited oral evaluation - problem focused (D0140) provided September 21, 2021, and the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) provided September 23, 2021.

You asked the Plan to pay for the intraoral x-ray, limited oral exam and tooth extraction. You say that you urgently needed treatment and there weren't any network providers available. The Plan denied your request. The Plan says the cost of the x-ray was correctly assessed as you were still in your deductible. The services on September 21, 2021, and September 23, 2021, were provided out-of-network and therefore are not covered.

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 certain dental services when provided by a participating provider. Cost sharing applies after the $100 annual deductible is met. 

We looked at the file and Medicare rules. The Plan provided documentation showing that you are responsible for the full allowed amount ($18.32) for the intraoral x-ray and this cost was applied to your deductible which had not been met at the time of the service. The limited oral exam and tooth extraction were provided by an out-of-network provider. 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 intraoral - periapical first radiographic image (D0220) provided September 20, 2021, limited oral evaluation - problem focused (D0140) provided September 21, 2021, and the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) provided September 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Humira.
You asked the Plan to pre-approve Humira. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not covered under the enrollee's medical benefit.
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 Humira.
Benefits for Humira 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: 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 an eye exam. You say that you need to see this doctor to have the procedure.
The Plan denied your request. The Plan says the requested services exceed your benefit limit.
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. The Plan covers eye exams once per year.
We looked at the file and the Plan's rules. The Plan covers eye exams once per year. Review of the file shows
that you previously received an eye exam on November 29, 2021. Based on this information, we decided that
the Plan's rules for coverage of an eye exam have not been met. Therefore, we decided that the Plan does not
have to pre-approve an eye exam.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sixteen (16) additional PT visits.
You asked the Plan to pre-approve sixteen (16) additional PT visits. You say that you need additional visits as you are still having constant pain that affects your back and you are unable to sit or stand in a comfortable position. The Plan denied your request. The Plan says additional PT visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.
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 sixteen (16) additional PT visits. Our
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration
of the enrollee's condition. Our physician reviewer found based on review of the limited available records, you
do not meet Medicare coverage criteria for the requested additional physical therapy visits beyond the number
received so far. The details of your PT treatments do not support the medical necessity for the therapy sessions.
The documentation does not support, and it is not medically necessary for coverage for additional therapy visit
for a chronic back pain. The requested therapy is not generally accepted as specific and effective therapy for
your condition. The records do not demonstrate that the unique skills of a professional therapist are required to
provide treatment safely and effectively, that the services can be safely and effectively performed only by a
therapist, or for physical therapy and occupational therapy, by or under the supervision of a therapist. The
requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of
a qualified therapist required to establish, design and/or deliver a program to maintain your current condition or
to prevent or slow further deterioration.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of sixteen (16) additional PT visits have not been met. Therefore, we decided that
the Plan does not have to pre-approve sixteen (16) additional PT visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on
February 24, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
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 services at issue in this appeal. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for the services provided by an out-of-network provider on February
24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuous passive motion exercise device (E0936).

You asked the Plan to pre-approve the continuous passive motion exercise device. You say that the item is 
medically necessary. The Plan denied your request. The Plan says you have not received a total knee 
replacement.

The Plan must follow Medicare rules. Medicare rules say that continuous passive motion devices are devices 
covered for patients who have received a total knee replacement. To qualify for coverage, use of the device 
must commence within 2 days following surgery. In addition, coverage is limited to that portion of the 3-week 
period following surgery during which the device is used in the patient's home. There is insufficient evidence 
to justify coverage of these devices for longer periods of time or for other applications

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the continuous passive motion exercise device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the continuous passive motion exercise device (E0936).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis 5 mg tablet.
You asked the Plan to pre-approve Eliquis. You say that the enrollee needs this medication. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.
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 Eliquis 5 mg tablet.
Benefits for Eliquis 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 pay for computed tomography (CT) of the head without dye billed with code 70450 for date of service July 16, 2021.
You asked the Plan to pay for code 70450. You say that the records attached support that the procedure in dispute was performed. You say that the claim was denied in error and should be reprocessed for payment. The Plan denied your request. The Plan says payment for the code in dispute is bundled into another service billed on the same day by the same provider.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for computed tomography (CT) of the head without dye billed with code 70450 for date of service July 16, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses provided on July 22, 2021.
You asked the Plan to pay for the eyeglasses. The Plan denied your request. The Plan says you must purchase eyewear from a provider in the vision vendor network.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when obtained from a provider in the Plan's vision vendor network. We looked at the file and the Plan's rules. The file shows that the eyeglasses were not obtained from a provider
in the Plan's vision vendor network. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses provided on July 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Sanexas treatment and injections provided on May 4, 2020
by an out-of-network (OON) provider.
You asked the Plan to pay for the OON treatment/injections. You say that this is a medically necessary
treatment which should be reimbursed. The Plan denied your request. The Plan says the services were provided
OON without authorization being requested.
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 Sanexas treatment and injections provided on May
4, 2020 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eyeglasses.
You asked the Plan to pre-approve eyeglasses. The Plan denied your request. The Plan says the records show
you will be eligible for new eyeglasses in July 2022.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan
covers these services every two years.
We looked at the file and the Plan's rules. The file shows that you will be eligible for coverage of new
eyeglasses in July 2022. Based on this information, we decided that the Plan's rules for coverage of eyeglasses
have not been met. Therefore, we decided that the Plan does not have to pre-approve eyeglasses.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis tablets 5mg for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says Eliquis is a self-administered drug.
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 Eliquis tablets 5mg for the
enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure (22899, C9752, C9753).
You asked the Plan to pre-approve an Intracept procedure. You say that this has been proven to be safe and
effective. The Plan denied your request. The Plan says this is 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 an Intracept procedure. Our reviewer
says that the requested 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 it is safe
and effective.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve an Intracept procedure (22899, C9752, C9753).
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 IRF care is medically necessary. The Plan denied
your request. The Plan says you do not meet Medicare criteria for coverage of IRF care.
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 you do not require treatment by multiple therapies, including either physical therapy
or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical
and/or occupational therapy, there is no documentation of a need for an intensive 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.
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.