Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee is scheduled for removal of surgical hardware from a previous
ankle fracture and treatment of an overlying ulcer. The record does not document that the treating physician has a reasonable expectation of a length of stay spanning 2 or more midnights. The enrollee may be admitted for observation to make further treatment decisions. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Synvisc-One (J7325).
You asked the Plan to pre-approve Synvisc-One. You say that the requested treatment is a medical necessity
for the enrollee. The Plan denied your request. The Plan says rules for coverage for the requested drug have not
been met.
The Plan must follow Medicare rules. Medicare rules say that a repeat series of hyaluronan knee injection(s)
for patients who have responded to a prior series is considered to be reasonable and necessary when at least six
months have elapsed since the prior series of injections.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of Synvisc-One have not been met. Specifically, the case record does not support that at least six
months have elapsed since prior hyaluronan treatment. Therefore, we decided that the Plan does not have to
pre-approve treatment with Synvisc-One (J7325).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a computed tomography (CT) scan of the thorax (71250).
You asked the Plan to pre-approve a CT scan of the thorax. You say that this imaging service is medically
necessary based on the enrollee's condition. The Plan denied your request. The Plan says that the criteria for
coverage 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 a CT scan of the thorax. Our reviewer
says that the requested imaging service is medically reasonable and necessary. Our physician reviewer found
the record indicates that the enrollee has a pulmonary nodule. The record indicates that the enrollee, a former
smoker, had a screening CT of the chest July 2021. The record indicates that a planned repeat scan is being
performed at three months and requested one month in advance. The provided records indicate the medical
necessity or reasonableness, as defined by Medicare rules, of the requested service. The elements of the
coverage criteria are 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 a CT scan of the thorax have been met. Therefore, we decided that the Plan has
to pre-approve a computed tomography (CT) scan of the thorax (71250).
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for tubing (A4604), nasal mask (A7032), nasal interface (A7034), headgear (A7035), filter (A7038 and A7039) and water chamber (A7046) provided on June 14, 2021.
You asked the Plan to waive the coinsurance for the CPAP supplies. You say that you would like reconsideration because your CPAP was recalled and there is no timeframe for when you can receive a replacement. The Plan denied your request. The Plan says your claim processed appropriately, applying the correct member responsibility.
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 20% coinsurance for Durable Medical Equipment.
You have been asked to pay $83.39 for the CPAP supplies. The allowed amount for these supplies is $417.15. 20% of $417.15 is $83.39. You have been asked to pay a 20% coinsurance for the CPAP supplies. The CPAP supplies fall within the Durable Medical Equipment 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 coinsurance for tubing (A4604), nasal mask (A7032), nasal interface (A7034), headgear (A7035), filter (A7038 and A7039) and water chamber (A7046) provided on June 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 you would like an IRF admission to get more 
therapy. The Plan denied your request. The Plan says an IRF admission 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 that you do not require the intensity of services provided at an IRF. Specifically, you 
are not shown to be able to perform/tolerate fifteen hours per week of rehabilitative services. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dynamic adjustable wrist extension / flexion device, includes soft interface material (CPT code E1805) for the enrollee.
You asked the Plan to pre-approve the device. You say that a dynasplint stretching device is medically necessary. The Plan denied your request. The Plan says the information received does not meet criteria because the documentation from the enrollee's physical therapy visit, indicates that the enrollee has stiffness in their wrist and fingers caused by a stroke in December of 2020. A dynamic splinting device is not covered for the use in management of chronic (long-standing) joint stiffness.
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 device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that, "Mechanical Splinting Devices for Treatment of Joint Stiffness and Contractures," this stretching device does not meet the definition of medical necessity for use in the management of chronic contractures (no significant change in motion for a four (4) month period) for chronic joint stiffness due to stroke. The review has determined that the requested item is not medically necessary or reasonable.
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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve dynamic adjustable wrist extension / flexion device, includes soft interface material (CPT code E1805) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane injections for the enrollee.
You asked the Plan to pre-approve Durolane injections. You say that these services are medically necessary for
the enrollee. The Plan denied your request. The Plan says that there is no documentation that it has been at least
six months since the last treatment with Durolane or other viscosupplementation.
The Plan must follow Medicare rules. Medicare rules say that viscosupplementation is considered not
medically reasonable and necessary and will not be covered when a repeat series of injections is initiated prior
to six months after completion of the previous course of treatment.
We looked at the file and Medicare rules. The file indicates the enrollee received viscosupplementation therapy
on May 19, 2021, which is less than six months ago. Based on this information, we decided that Medicare rules
for coverage of Durolane injections have not been met. Therefore, we decided that the Plan does not have to
pre-approve Durolane injections for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the alveoloplasty and reconstruction of mandible or maxilla.
You asked the Plan to pre-approve the alveoloplasty and reconstruction of mandible or maxilla. You say that the facial reconstruction has to be done because of the cancer which spread to the side of your face and you need your mouth fixed. The Plan denied your request. The Plan says the request was denied correctly.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the alveoloplasty and reconstruction of mandible or maxilla when the services are medically necessary and reasonable. 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 alveoloplasty and reconstruction of mandible or maxilla. Our physician reviewer found that the services indicated are to restore the supporting structures for placement of a dental prosthesis. Our reviewer says that Medicare guidelines stipulate that these are not covered services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the alveoloplasty and reconstruction of mandible or maxilla have not been met. Therefore, we decided that the Plan does not have to pre-approve the alveoloplasty and reconstruction of mandible or maxilla.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee scooter.
You asked the Plan to pre-approve these services. You say that you need the scooter for mobility after
upcoming surgery. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a crutch substitute (E0118) is denied as not
medically necessary.
We looked at the file and Medicare rules. The requested item is a knee scooter/crutch substitute described by
procedure code E0118. This item is denied by Medicare as not medically necessary. Therefore, we decided that
the Plan does not have to pre-approve a knee scooter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an outdoor bicycle.
You asked the Plan to pre-approve an outdoor bicycle. You say that this is medically necessary for strengthening your bicep. The Plan denied your request. The Plan says this item is statutorily non-covered by Medicare.
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 pre-approve an outdoor bicycle
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Left Atrial Appendage Closure (33340) and inpatient admission.
You asked the Plan to pre-approve LAAC and inpatient admission. You say that the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that LAAC is covered when specific criteria are met, such as if there is a formal shared decision-making interaction with an independent non-interventional physician using an evidence-based decision tool. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of LAAC and inpatient admission have not been met. Specifically, there is no documentation of a shared decision-making interaction. Therefore, we decided that the Plan does not have to pre-approve Left Atrial Appendage Closure (33340) and inpatient admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the partial upper denture with cast metal framework and resin (D5213) provided on June 9, 2021.
You asked the Plan to pay for the denture. You say that your provider, who is part of the Plan's network, recommended this denture for you. You say you were not informed it would not be covered and it should be paid. The Plan denied your request. The Plan says dentures are not covered by your dental benefit. The Plan has indicated that they have opened a grievance on your behalf to investigate the in-network care complaint.
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 among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the partial upper denture with cast metal framework and resin (D5213) provided on June 9, 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
You asked the Plan to pre-approve these services. You say that the enrollee has sinus issues and needs treatment for headaches. 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 provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the enrollee needs SNF care because of her age, her dementia diagnosis, having no strength or endurance to walk alone, her unstable blood pressure, as well as the need for monitoring and administration of medications. You say that the enrollee is also dealing with incontinence from the infections that need to be treated and taken care of before she can be brought back to her assisted living facility.
The Plan denied your request. The Plan says the clinical criteria have not been met. The Plan says that the enrollee does not require daily skilled therapy services or complex daily nursing care.
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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, as a practical matter, can be provided 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiology services (G0283, 72040, 97014, 72070) associated with chiropractic care provided on April 19, 2021, to May 21, 2021.
You asked the Plan to pay for the radiology services. You say that you believe the associated X-rays were medically necessary before chiropractic care could be performed. The Plan denied your request. The Plan says these services are not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the radiology services (G0283, 72040, 97014, 72070) associated with chiropractic care provided on April 19, 2021, to May 21, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the SNF services.
You asked the Plan to pre-approve SNF services. You say that you are unable to go home and care for yourself without 24-hour care. You say that you are requesting an extension for coverage of additional days in the SNF. The Plan denied your request. The Plan says SNF services are 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 there are no required skilled nursing services identified. Our reviewer says that the documentation does not support that it is medically reasonable and necessary to provide skilled therapy services on a daily basis in a skilled nursing facility on an inpatient basis.
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 the SNF services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
You asked the Plan to pre-approve the SNF care. You say that the service is medically necessary. The Plan
denied your request. The Plan says the service 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 the SNF care. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found you have no skilled nursing needs and
you do not need skilled therapies on a daily basis in an inpatient setting.
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 SNF care have not been met. Specifically, medically necessary services can
be obtained at a lower level of care. This means admission into a SNF is not medically necessary or reasonable.
Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.