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 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 based on the documentation provided the enrollee does not require the intensity of
services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of
rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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. Our 
physician reviewer found based on the documentation provided the enrollee appears to not be stable enough for 
transfer at this time. Acute care services can be safely administered at the current facility for the time being 
until treatment is completed and transfer to a lower level of care is more appropriate. The enrollee does not 
require services at the LTACH that are not already available at the current facility. There are no services at the 
LTACH that the enrollee requires that are not already available and covered at the current facility. 
 
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 pre-approve outpatient office visit (99204) behavioral and qualitative analysis of voice and resonance (92524) laryngeal function studies (92520) laryngoscopy, flexible or rigid telescopic, with stroboscopy (31579) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the office visit. You say that you had COVID-19 last year and was hospitalized and intubated. You have stenosis and dysfunction of the vocal cords with fatigue and can barely sleep due to lack of air and cannot carry a normal daily life routine. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 outpatient office visit (99204) behavioral and qualitative analysis of voice and resonance (92524) laryngeal function studies (92520) laryngoscopy, flexible or rigid telescopic, with stroboscopy (31579) to be provided by an out-of-network (OON) provider.
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 this procedure is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this procedure is considered experimental/investigational.
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 items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Minuteman procedure is experimental. More research is needed before coverage can be approved. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the seat lift chair provided on May 24, 2021. 
 
You asked the Plan to pay for the seat lift chair. You say that the item was medically necessary. The Plan 
denied your request. The Plan says this item does not primarily serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pay for the seat lift chair provided on May 24, 2021.
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 procedure is medically necessary 
for the enrollee's condition. The Plan denied your request. The Plan says the requested procedure is considered 
experimental/investigational. 
 
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 before coverage can 
be approved. 
 
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: 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 based on the documentation provided you do not require the intensity of services 
provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services 
and regular physician evaluation. Your care needs can be met at a lower level of 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction (92015) provided on November 17, 2021.
You asked the Plan to pay for the eye refraction. You say that you would like reconsideration because you should not owe any money for your annual eye exam. The Plan denied your request. The Plan says the services received were not for a routine eye exam but rather ongoing cataracts.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. In addition, the Plan contract says that you have a $35 copayment for Medicare covered eye exams. You have been asked to pay a $35 copayment for the Medicare covered eye exam. You have also been held responsible for the refraction services. The records indicate that the services rendered were not considered a routine eye exam because the exam was medical in nature. You have been asked to pay the correct copayment for a medical eye exam. Additionally, Medicare does not cover eye refractions. Therefore, we decided that the Plan does not have to pay for the eye refraction (92015) provided on November 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug test (G0480) rendered by the out-of-network (OON) provider on October 21, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.
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 in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the drug test (G0480) rendered by the out-of-network (OON) provider on October 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office consultation and follow-up care to be rendered 
by the out-of-network (OON) provider. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render 
the requested services. 
 
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 part of your primary care physicians network of providers. The Plan 
has network providers available who can provide the services at issue in this appeal. We found no exception 
that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to 
pre-approve an office consultation and follow-up care to be rendered by the out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp (J0881). 
 
You asked the Plan to pre-approve Aranesp. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says step therapy criteria have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Aranesp. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the Plan requires a 
trial of Retacrit or Procrit before they will approve the requested drug. In this case, the patient has not tried and 
failed the required drugs. There is no documentation provided indicating that the plans required drugs would 
likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp (J0881).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode array, epidural (63650) and incision and subcutaneous placement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling (63685).
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that this request is not medically necessary based on the guideline.
The Plan must follow Medicare rules. Medicare rules say that implantation of dorsal column or depth brain stimulators can be covered if Medicare criteria have been met. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The record indicates that you have chronic pain syndrome with a significant component being due to lumbar spine disease with radiculopathy for which surgical intervention has been recommended. The record indicates that you underwent a spinal cord stimulator trial but no documentation of objective assessment of its effect is included. Our physician reviewer found that your condition does not meet criteria for coverage of these 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 these service have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode array, epidural (63650) and incision and subcutaneous placement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling (63685).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve Injectafer. The Plan denied your request. The Plan says the enrollee has not 
met the step therapy requirements. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Injectafer. Our reviewer says that 
Injectafer is not medically reasonable and necessary in this case. Our physician reviewer found that the record 
indicates that the enrollee has iron deficiency anemia in the setting of acute blood loss and chronic kidney 
disease stage IV. The requested medication is a new start. The provided records do not indicate that the 
enrollee has tried and failed the Plan's preferred step one alternative. The record does not indicate that the 
enrollee has a contraindication to or would have an adverse effect from the Plan's preferred step one alternative. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
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 based on the documentation provided the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgery to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve a surgery. You say that you received prior services from this provider and 
would like to see them again. The Plan denied your request. The Plan says there are in-network providers 
available for this service. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a surgery to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc (J7325).
You asked the Plan to pre-approve Synvisc. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says step therapy criteria have not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Synvisc. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found the enrollee is an 82-year-old female with pain related to osteoarthritis of the left knee, diagnosis confirmed with imaging studies. The Plan requires a trial of the drugs Orthovisc or Supartz FX before they will approve the requested drug, Synvisc. Based on the medical records provided the patient has not tried and failed the required drugs. In addition, the medical records provided support that there is no indication that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the patient. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc (J7325).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound of the head and neck 
provided on September 8, 2021. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that the Plan did not pay for any 
portion of the bill. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
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 $110 
copayment for radiological diagnostic services, not including X-rays.  
 
You have been asked to pay $75.50, which is less than the $110 copayment for the ultrasound. Please note that 
any copayments or coinsurance amounts are applied before the Plan pays their share. The ultrasound falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 ultrasound of the head and neck provided on September 8, 2021.