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

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of the lower extremity provided at an outpatient hospital facility on November 24, 2020.
You asked the Plan to waive the copayment for the MRI. You say that you believe the Plan underpaid this claim. The Plan denied your request. The Plan says the enrollee was 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 $275 copayment for diagnostic radiology services in an outpatient hospital setting. You have been asked to pay a $275 copayment for the MRI. The MRI falls within the diagnostic radiology services in an outpatient hospital setting 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 the magnetic resonance imaging (MRI) of the lower extremity provided at an outpatient hospital facility on November 24, 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 the services are medically necessary. The Plan 
denied your request. The Plan says coverage criteria has 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 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. 
 
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-emergent ambulance transportation.

You asked the Plan to pre-approve non-emergent ambulance transportation. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 

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 non-emergent ambulance transportation. Our reviewer says that the services are not medically necessary. Our physician reviewer found the record does not indicate that your clinical condition is such that other methods of transportation, such as stretcher van, are contraindicated. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of non-emergent ambulance transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve non-emergent ambulance transportation.
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 the enrollee continues to receive acute care services and these have not been denied. 
The medical record does not indicate that the enrollee requires services that she is not currently receiving but 
that would be available at the LTACH 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an X-ray provided on March 5, 2021. 
 
You asked the Plan to waive the copayment for an X-ray. You say that you cannot afford the charges. The Plan 
denied your request. The Plan says the claims were processed correctly and you are being charged the correct 
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 $0 
copayment for X-rays provided in a primary care physician's office or specialists office and a $50 copayment 
when provided in an outpatient hospital facility.  
 
The record shows that you received an X-ray at an outpatient hospital facility on March 5, 2021. Therefore, you 
are responsible to pay the $50 copayment.   
 
You have been asked to pay a $50 copayment for an X-ray. An X-ray 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 X-ray provided on March 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gelsyn-3 (J7328). 
 
You asked the Plan to pre-approve Gelsyn-3. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for the requested viscosupplement device. 
 
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 Gelsyn-3. Our reviewer says that 
Gelsyn-3 is not approved as step criteria have not been met. Our physician reviewer found you have not trialed 
viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the Plan, requires 
that these be trialed first. Our reviewer also found that the documentation does not outline contraindications or 
reasons these medications were not considered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gelsyn-3 (J7328).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eyeglasses to be provided by the requested out-of-network provider.
You asked the Plan to pre-approve eyeglasses to be provided by the requested out-of-network provider. The Plan denied your request. The Plan says you must get your care from network providers. Usually, the Plan will not cover care from a provider who does not work with the health Plan.
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.
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 has network providers available who can provide the eyeglasses at issue in this appeal. We found no exception that would require the Plan pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve eyeglasses to be provided by the requested out-of-network provider
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 does not meet criteria.

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 enrollee does not require an intensive, complex, multidisciplinary approach to daily therapy. While the enrollee may benefit from physical therapy and occupational therapy, rehab needs can be safely met in an alternate and low intensity setting such as a skilled nursing 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 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve right total hip arthroplasty (THA).
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 the submitted medical records state you have had conservative treatments in the form of physical therapy, steroid injections, and over the counter medications, but does not explicitly state for how long the treatments were tried and/or how long the relief was maintained.
The Plan must follow Medicare rules. Medicare rules say that THA can be covered if the LCD 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. Detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures. The noted injection and therapy were noted to be from 2019, and it is not clear how long the therapy was attended. In addition, there are no formal imaging studies provided for review to corroborate the noted pathology. You are noted to be a current every day smoker and has an elevated body mass index. There is no discussion for attempts to quit smoking prior to surgery, or formal plan for weight loss. Our physician reviewer found that your condition does not meet Medicare criteria for 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve right total hip arthroplasty (THA).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scans of the neck (70490) and of the chest (71250). 
 
You asked the Plan to pre-approve CT scans of the neck and of the chest. You say that the requested services 
are a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules 
for the requested services have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 CT scans of the neck and of the chest. 
Our reviewer says that the requested services are not medically reasonable and necessary in this case. Our 
physician reviewer found that the provided records do not discuss CT scans of the neck and chest. The 
provided records do not indicate the medical necessity or reasonableness, as defined by Medicare rules, of the 
requested services. 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 CT scans of the neck and of the chest have not been met. Therefore, we decided 
that the Plan does not have to pre-approve CT scans of the neck (70490) and of the chest (71250).
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 does not meet criteria.

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. 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation trips.
You asked the Plan to provide coverage for additional routine transportation trips. You say that you need additional rides to go to appointments and you have health issues that prevent you from walking to the bus stop. The Plan denied your request. The Plan says you have used all of the available transportation trips.
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 a maximum of 24 one-way trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a guided tissue regeneration (D4266), surgical extraction (D7210), and bone replacement graft for ridge preservation (D7953) to be rendered by an out-of-network (OON) provider.

You asked the Plan to pre-approve the guided tissue regeneration, surgical extraction, and bone replacement graft. You say that you were not happy with the in-network provider you saw. You also say that the out-of-network provider you would like to be treated by would offer you better service. The Plan denied your request. The Plan says you must use network providers to get dental services and care when there are network providers available. The Plan also says that this is not an emergency, and there are providers within your health plan network for these services.

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 requested items or services are not covered when they are received OON. Therefore, we decided that the Plan does not have to pre-approve a guided tissue regeneration (D4266), surgical extraction (D7210), and bone replacement graft for ridge preservation (D7953) to be rendered by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat Synvisc injection. 
 
You asked the Plan to pre-approve the repeat injection. You say that this is medically necessary, as you have 
suffered from severe pain in both knees for approximately ten years. The Plan denied your request. The Plan 
says the medical records did not show that six months has passed since the last injection. 
 
The Plan must follow Medicare rules. The rules say that six months must pass before a repeat hyaluronan 
treatment can take place. 
 
The last treatments were June 28, 2021, July 6, 2021, and July 13, 2021. It has not been six months since July 
13, 2021, yet. You would not be eligible until January 13, 2022. Based on this information, we decided that 
Medicare rules for coverage of the repeat injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a repeat Synvisc injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Flex-Walk system (L5981) with multiaxial ankle 
(L5968) and vacuum pump (L5781). 
 
You asked the Plan to pre-approve a Flex-Walk system with ankle and vacuum pump. You say that the 
requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says medical 
necessity rules for the requested items have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Flex-Walk system with ankle and 
vacuum pump. Our reviewer says that the requested items exceed the enrollee's medical and functional need. 
Our physician reviewer found that the documentation does not support that the enrollee requires the Flex-Walk 
system or ankle as there is no evidence that the enrollee is unable to meet functional needs with the enrollee's 
current approved foot, which includes a vacuum socket. There is also no evidence that the current foot, ankle, 
or vacuum socket, which are under warranty, require a new replacement. The medical provider notes that the 
enrollee is ambulating well with a cane and the notes indicate the enrollee is still very active. There is no 
evidence that the enrollee's needs require a vacuum socket over a standard socket for the enrollee's prosthetic 
leg. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Flex-Walk system with ankle and vacuum pump have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Flex-Walk system (L5981) with multiaxial 
ankle (L5968) and vacuum pump (L5781).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rituxan Hycela 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 a step therapy exception cannot be granted.
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 the drug. Our reviewer says that the
requested drug is not medically reasonable or necessary. Our physician reviewer found based on the medical
records provided, the enrollee has not tried and failed any of the required drugs. There is no indication that
these 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 the drug have not been met. Therefore, we decided that the Plan does not have
to pre-approve Rituxan Hycela for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that additional routine 
transportation. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, 
coverage criteria have not been met. 
 
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 a maximum of 60 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.