Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant at surgery services provided on September 14,
2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the service
does not meet the requirements for approval.
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1,
assistant surgeon services are not covered.
In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) code 15100. The
Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that
Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon
this information, we find that Medicare coverage criteria for the services provided have not been met.
Therefore, we decided that the Plan does not have to pay for the assistant at surgery services provided on
September 14, 2021.
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 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.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chlorpromazine.
You asked the Plan to pre-approve chlorpromazine. You say that chlorpromazine is medically necessary. The
Plan denied your request. The Plan says chlorpromazine is not covered by 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 chlorpromazine.
Benefits for chlorpromazine 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your
request. The Plan says that this is not covered under 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.
Benefits for this drug 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: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Proton Beam Therapy.
You asked the Plan to pre-approve Proton Beam Therapy. You say that Proton Beam Therapy is medically
necessary. The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage of
Proton Beam Therapy.
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 Proton Beam Therapy. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the case records did not adequately demonstrate the need for proton therapy. This is
critical in justifying the need for proton therapy in clinical scenarios (such as this case) for which
proton therapy is not standard. Proton therapy would not be furnished in accordance with accepted standards of
medical practice in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Proton Beam Therapy have not been met. Therefore, we decided that the Plan
does not have to pre-approve Proton Beam Therapy.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary for the enrollee's
condition. The Plan denied your request. The Plan says rules for SNF care have not been met.
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 daily
skilled services are not necessary. Our physician reviewer found the enrollee is an 88-year-old male with a past
medical history of coronary artery disease and chronic kidney disease who was admitted to an acute hospital on
January 11, 2022, with edema and shortness of breath related to a heart failure exacerbation. He was treated in
the hospital, improved and then transferred to a skilled nursing facility on January 26, 2022. He was re-
admitted to the acute hospital on January 30, 2022, with chest pain. At this time, he is reported to be medically
stable for discharge on outpatient medications. Based on the medical records provided, this patient does require
skilled therapy services. However, the medical records provided indicate that daily skilled services are not
required. In conclusion, this patient does not require the services on an inpatient basis, only in a skilled nursing
facility setting. Services in the home with home health care or in a long-term care facility on a part time basis
appear appropriate in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve admission to a skilled nursing facility (SNF).
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 you need IRF care. The Plan denied your request. The Plan says rules for IRF care have not been met.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 you were admitted for a fall, volume overload, chronic kidney disease, respiratory failure and coronavirus infection. 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 you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. In conclusion, 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and is currently unstable for transfer to an LTACH.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. You appear to be improving overall but still require additional short-term acute care services that can be safely administered at the current facility until more stable. You do not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that you require that are not already available and covered at the current facility. Our physician reviewer found that your condition does not meet Medicare criteria for LTACH services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for an out-of-network office visit provided on October 15, 2021.  You asked the Plan to waive the deductible for an out-of-network office visit. You say that you have seen this doctor for many years, and you did not know there was a change in network status. The Plan denied your request. The Plan says the proper deductible was applied with an out-of-network provider.   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 $1,500 deductible which is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Once you have paid your deductible, we will begin to pay our share of the costs for covered medical services and you will pay your share (your copayment or coinsurance amount) for the rest of the calendar year. The deductible does not apply to some services, including certain in-network preventive services. Prior to the date of service, you had paid $0 of the $1,500 deductible. The total amount allowed for this service was $193.29 which all of it went towards your $1,500 deductible. After the date of service there $1,306.71 ($1,500 starting deductible - $193.29 deductible paid) left for the calendar year deductible.  You have been asked to pay a $193.29 deductible for an out-of-network office visit. An out-of-network office visit falls within the What is your plan deductible 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 deductible for an out-of-network office visit provided on October 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom power wheelchair and accessories (Quantum
Q6 Edge).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says the enrollee does not need a special configuration that cannot be met by modifying a
base Group 3 power wheelchair with cushions or/and pads.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
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 services. Our reviewer says that the
requested wheelchair is not medically reasonable or necessary. Our physician reviewer found based on the
medical records provided, there is no documentation that you meet Medicare criteria for this custom power
wheelchair. The provided medical records do not clarify why a group 3 power wheelchair will not meet your
mobility needs. The requested seat lift mechanism is non-covered by Medicare as it not primarily medical in
nature. The high speed motor package is designed for outdoor speeds and not for allowing participation in
mobility related activities of daily living within the home.
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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a custom power wheelchair and accessories (Quantum Q6 Edge).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a crutch substitute (E0118).
You asked the Plan to pay for a crutch substitute. You say that you need this item. The Plan denied your
request. The Plan says this is not a covered item.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the knee scooter have not been met. Specifically, this item is not a covered benefit of Medicare or
the Plan. Therefore, we decided that the Plan does not have to pay for a crutch substitute (E0118).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network urologist.
You asked the Plan to pre-approve these services. You say that the enrollee is seeking a second opinion about his prostate cancer. The Plan denied your request. The Plan says the services are available from network providers.
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 a referral to an out-of-network urologist
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Testosterone gel 1.62% for the enrollee.
You asked the Plan to pre-approve the gel. You say that this is medically necessary to help manage
hypogonadism. The Plan denied your request. The Plan says non-injectable self-administered drugs are covered
by the pharmacy/drug 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 Testosterone gel 1.62% for
the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ablation services and leadless pacemaker insertion
(33274, 93650).
You asked the Plan to pre-approve a leadless pacemaker. You say that this is medically necessary for the
enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that leadless pacemakers will only be covered when
the enrollee is enrolled in FDA-approved studies.
We looked at the file and Medicare rules. In this case, this leadless pacemaker is not for an enrollee in an FDA-
approved study. Based on this information, we decided that Medicare rules for coverage of a leadless
pacemaker have not been met. Therefore, we decided that the Plan does not have to pre-approve ablation
services and leadless pacemaker insertion (33274, 93650).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic analysis of cochlear implant, provided on
July 12, 2021.
You asked the Plan to pay for diagnostic analysis of cochlear implant. The Plan denied your request. The Plan says there is no coverage for hearing aids or related services received from out-of-network providers.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case.
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 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 diagnostic analysis of cochlear implant, provided on
July 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One 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 the requirements are not met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the
requested drug is not medically reasonable or necessary. Our physician reviewer found the record indicates that
the enrollee has knee pain. The record does not include imaging that confirms a diagnosis of osteoarthritis. The
elements of the coverage criteria are not satisfied.
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 drug have not been met. Therefore, we decided that the Plan does not have
to pre-approve Synvisc-One for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for magnetic resonance angiography (MRA) of the head (70544) provided on September 14, 2021.  You asked the Plan to pay for MRA services. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says this claim was not billed with an appropriate modifier as required by Medicare rules.  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 70544 is a column II code to column I code 70551. 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 magnetic resonance angiography (MRA) of the head (70544) provided on September 14, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the wheelchair van transportation and mileage provided on July 2, 2021, and August 5, 2021.  You asked the Plan to pay for the wheelchair van transportation and mileage. You say that you are in a nursing home and when you have to go for a special appointment, the nursing home handles the transportation. The Plan denied your request. The Plan says you received transportation services from a non-Plan transportation coordinator.  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 routine transportation when the ride is coordinated through the Plan's transportation coordinator.   We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Non-emergent transportation is only covered when the ride is coordinated through the Plan's transportation coordinator, and the enrollee received the rides from a non-contracted provider. Therefore, we decided that the Plan does not have to pay for the wheelchair van transportation and mileage provided on July 2, 2021, and August 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on July 21, 2021.
You asked the Plan to pay for hearing aids. The Plan denied your request. The Plan says hearing aids ordered through providers other than a provider in the Plan's vendor network are not covered.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when purchased from a provider in the Plan's vendor network. We looked at the file and the Plan's rules. The file shows that the hearing aids were not purchased from a provider in the Plan's vendor network. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on July 21, 2021.