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 you need this to regain independence. The Plan
denied your request. The Plan says this 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 records provided, you do not require treatment by multiple therapies and
an intensive rehabilitation therapy program. While you need physical 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids provided on April 8, 2021.
You asked the Plan to pay for the hearing aids. You say that your information states hearing aids have $500
benefit every 36 months. You say that your information did not mention having to purchase from a plan vendor
and the denial should be reversed. The Plan denied your request. The Plan says hearing aids ordered through
providers other the Plan's hearing aid vendor 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 they are received from the Plan's hearing aid vendor.
We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of the hearing aids have not been met. Specifically, the hearing aids were not purchased form the
Plan's hearing aid vendor. Therefore, we decided that the Plan does not have to pay for the hearing aids
provided on April 8, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Electric Stimulation Therapy and Sanexas device.
You asked the Plan to pre-approve the Electric Stimulation Therapy and Sanexas device.. You say that you
would like reconsideration because the requested therapy is medically necessary. The Plan denied your request.
The Plan says the member's condition does not meet medical necessity criteria.
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 Electric Stimulation Therapy and
Sanexas device. Our reviewer says that the requested items/services are not considered medically reasonable
and necessary in this case. Our physician reviewer found the available medical records do not document disuse
atrophy or a spinal cord injury which are requirements for its coverage as detailed in the National Coverage
Determination (NCD) for Neuromuscular Electrical Stimulation (NMES) (160.12), Indications and Limitations
of Coverage.
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 Electric Stimulation Therapy and Sanexas device. have not been met.
Therefore, we decided that the Plan does not have to pre-approve Electric Stimulation Therapy and Sanexas
device.
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 this is medically necessary. The Plan denied your
request. The Plan says an intensive rehabilitation program is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
You were admitted for congestive heart failure and atrial fibrillation. Medical problems are stable. There are no
complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical
record supports a need for physical 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 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 Methotrexate tablets.
You asked the Plan to pre-approve Methotrexate tablets. You say that the enrollee has good control of his
symptoms on this medication. The Plan denied your request. The Plan says coverage of this medication is the
responsibility of the enrollee's prescription drug plan.
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.
Benefits for Methotrexate tablets 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an advanced knee, foot, ankle, and protective covering
for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says a request for a K3 foot and microprocessor knee does not meet Medicare criteria as
reasonable and necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the available documentation is insufficient to support that the enrollee in this case is a K3 ambulator.
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 an advanced knee, foot, ankle, and protective covering for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the
enrollee.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan
denied your request. The Plan says that the enrollee no longer requires skilled services and the continuation of
SNF is not medically necessary.
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 services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not
meet Medicare criteria for continued SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional accessories for a prosthetic leg (L5590,
L5910) for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says these items cannot be covered.
The Plan must follow Medicare rules. Medicare rules say that L5990 is not considered reasonable or necessary.
The rules also say that equipment which the beneficiary owns or is a capped rental item may be replaced in
cases of loss or irreparable damage.
L5590 is statutorily not covered in this case. Additionally, the enrollee's current prosthetic socket includes
L5910. There is no evidence that the current prosthesis is damaged beyond repair or lost, so a new L5910
cannot be approved. 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 additional accessories for
a prosthetic leg (L5590, L5910) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the dental services provided on May 6, 2021.
You asked the Plan to pay more for the dental services. You say that you were not aware the dental provider
was out-of-network. You say that you would not have seen this provider if you knew you would incur these
charges. The Plan denied your request. The Plan says the claim reprocessed to pay the $1,000 allowance and
you are responsible for the remaining amount.
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, you also have a maximum benefit of
$1,000 for dental services every calendar year. The Plan paid $1,000 toward the dental services received on
May 6, 2021, which exhausted your benefit. You are responsible for the remaining amount over the $1,000
maximum. Therefore, we decided that the Plan does not have to pay more for the dental services provided on
May 6, 2021
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional right side epidural injections for the enrollee.
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 left side can be approved, but the right side cannot.
The Plan must follow Medicare rules. Medicare rules say that it is not considered medically reasonable and
necessary to perform transforaminal epidural steroid injections are more than two nerve root levels during the
same session. The rules say that no more than two injections should be performed at a single setting.
The plan has already approved two levels on the left side for this sessions. Additional services cannot be
approved. 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 additional right side epidural injections
for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied
your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due
to insufficient evidence of efficacy.
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 procedure. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found this procedure is experimental. More research is needed to show safety and efficacy.
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 procedure have not been met. Therefore, we decided that the Plan does not
have to pre-approve the Intracept procedure for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vyndamax.
You asked the Plan to pre-approve Vyndamax. You say that this is medically necessary. The Plan denied your
request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.
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.
Benefits for Vyndamax 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 waive the copayment for otolaryngology visit you had on April 26,
2021.
You asked the Plan to waive the copayment for the otolaryngology visit. You say that you had to go to this
office for the same service twice. You do not feel as if you should have to pay twice. The Plan denied your
request. The Plan says you were charged this copayment 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 $30
copayment per visit for specialist services.
You have been asked to pay a $30 copayment per visit for the otolaryngology visit. The specialist visit
copayment applies each time you go to the office, regardless of the reason. 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 otolaryngology visit you had on April 26, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on
July 4, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that you were at another ER but the
magnetic resonance imaging (MRI) machine was down. You had to be sent to another ER and were charged a
separate copayment. The Plan denied your request. The Plan says you were charged this copayment 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 $90
copayment per visit for emergency room services.
You have been asked to pay a $90 copayment per visit for the ER visit. This is a per-visit copayment and it
applies each time you go to the ER, regardless of the reason. 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 the emergency room (ER) visit you had on July 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve vasectomy for the enrollee.
You asked the Plan to pre-approve the vasectomy. You say that this is medically necessary. The Plan denied
your request. The Plan says the requested service is not covered by Medicare or the health plan.
The Plan must follow Medicare rules. Medicare rules say that vasectomy is not covered if the primary
indication is sterilization.
The requested procedure is elective and meant for sterilization. It cannot be approved. Based on this
information, we decided that Medicare rules for coverage of the vasectomy have not been met. Therefore, we
decided that the Plan does not have to pre-approve vasectomy for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

e decided that the Plan does not have to pre-approve an out-of-network pulmonary disease consult.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your
request. The Plan says the requested provider is out-of-network.
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
an out-of-network pulmonary disease consult.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on July 19, 2021.
You asked the Plan to pay for the services. You say that The Plan denied your request. The Plan says the
services are not authorized because screening testing is not a Medicare benefit.
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 pay for the services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found these services are not authorized because screening testing is not a Medicare benefit. The review has
determined that the services at issue in this case medically reasonable or necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pay for laboratory services provided to the enrollee on July 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pulmicort nebulizer suspension.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says this is for a Part D use only.
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 Pulmicort nebulizer
suspension.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost sharing for the Injectafer injection you received on October 20,
2020.
You asked the Plan to reduce the cost sharing for the Injectafer injection. You say that you were told that you would only
have to pay $65 for this injection. The Plan denied your request. The Plan says you were charged this coinsurance
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 20% coinsurance
for Medicare Part B drugs.
You have been asked to pay 20% coinsurance for the Injectafer injection. The Injectafer injection falls within the
Medicare Part B drugs benefit category. This coinsurance applies regardless of what verbal estimates you may have been
given. 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 reduce the cost sharing for the Injectafer injection you received on October 20, 2020.
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 disagree with the denial. The Plan denied your
request. The Plan says the services are 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 medically necessary. Our physician reviewer found the records show that you were
admitted to the hospital for elective hip replacement surgery. You are now medically stable with 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. 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.