Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you have plantar fasciitis flares and insoles 
provides extra support because you work on your feet for 3 plus hours. The Plan denied your request. The Plan 
says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the three additional extractions (D7210 x3) provided on 
December 28, 2021. 
 
You asked the Plan to pay for the additional extractions. You say that you would like to appeal these services. 
The Plan denied your request. The Plan says you met your maximum benefit on this date of service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan offers a $1,000 annual dental 
benefit maximum, less the cost-sharing you pay. The contract says that after your annual maximum benefit 
maximum has been met, you are responsible for the full charges of any additional dental services. The record 
shows that you met the annual maximum benefit while processing this claim for the December 28, 2021 date of 
service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not 
have to pay for the three additional extractions (D7210 x3) provided on December 28, 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 are medically stable and do not need PM&R physician close supervision 3 times 
per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical 
conditions. You do not require 3 hours a day five days a week of IRF therapies with interdisciplinary 
management. Your rehab needs can be provided in an alternate and low intensity setting such as in 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee did not have any parental 
medications, complex wound care or nutrition given via a feeding tube. The enrollee received skilled care and 
improved; however, his functional improvement had plateaued by 5/13/22 and he did not require any further 
inpatient skilled rehab services. The enrollees function was at or near his new baseline level of function and he 
could be discharged to a lower level of care for further services. As of 5/13/22, the enrollee required custodial 
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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator trial. 
 
You asked the Plan to pre-approve a spinal cord stimulator trial. You say that this service is medically 
necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that a spinal cord stimulator trial can be covered only for 
patients who have undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to 
implantation. Such screening must include a psychological evaluation.  
 
The file does not show that a psychological evaluation has been conducted in conjunction with this request for 
a spinal cord stimulator trial. Therefore, we decided that the Plan does not have to pre-approve a spinal cord 
stimulator trial.
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 appears to be improving and should only require short-term additional 
acute care services that can be completed at the current facility until more appropriate for a lower level of care. 
There are no services at the LTACH that the enrollee requires that are not already available and covered at the 
current facility. Transfer to LTACH is not medically necessary as it would not be clinically advantageous at 
this time. Completion of care at the current facility is 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5258) provided on January 24, 2022 by an 
out-of-network provider. 
 
You asked the Plan to pay for the hearing aids. You say that you were not aware how the Plan worked because 
no one told you. The Plan denied your request. The Plan says the hearing aids were not purchased through the 
Plans vendor. The Plan also says that the reimbursement request submitted indicates that you did not receive 
hearing aid that were a Plan approved hearing aid brand. 
 
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 plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you use the Plan's hearing aid vendor and receive the Plan approved hearing aid brand 
to receive hearing aid benefits.  
 
We looked at the file and the Plan's rules. The record shows that you received these hearing aids from a 
provider who is not plan approved. Based on this information, we decided that the Plan's rules for coverage of 
the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing 
aids (V5258) provided on January 24, 2022 by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT provided on December 14, 2021. 
 
You asked the Plan to waive the copayment for a CT. You say that you weren't advised ahead of time that you 
would have to pay that big of an amount. The Plan denied your request. The Plan says you have been charged 
the correct copayment 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 $225 
copayment for in-network advanced imaging service (not including x-rays).  
 You have been asked to pay $127.94, which is less that the $225 copayment for a CT. The CT 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 a computed tomography (CT) scan provided on December 14, 2021.
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 you appear to be more stable and improving and should only require short-term 
additional acute care services, including additional weaning, that can be completed at the current facility until 
more appropriate for a lower level of care. There are no services at the LTACH that you require that are not 
already available and covered at the current facility. Transfer to LTACH is not medically necessary as it would 
not be clinically advantageous at this time. Completion of care at the current facility is 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intermittent limb compression device (E0673, E0651). 
 
You asked the Plan to pay for intermittent limb compression device. You say that the services were medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. Therefore, we decided that the Plan does not have to pay for an intermittent limb compression 
device (E0673, E0651).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device and related supplies to 
be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that the enrollee needs the pump at home to avoid 
hospital stays. The Plan denied your request. The Plan says there are in-network providers able to provide 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 at issue in this appeal. We found no exception that would require the Plan 
to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve a 
pneumatic compression device and related supplies to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the breast ultrasound (76642) provided on 
May 18, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 one screening mammogram every 12 months for women age 40 
and older is covered. If you receive a separate additional non-preventive evaluation and/or service, a 
copayment will apply. The copayment amount depends on the provider type or place of service. Additionally, 
you must pay a $40 copayment per provider, per date of service for routine radiology services such as 
ultrasounds. 
 
You have been asked to pay a $40 copayment for the radiology service provided. The record shows that you 
had a mammogram on this day, in which an abnormality was found that needed further investigation. You then 
received an ultrasound as well and a copayment was applied to this service. The Plan contract states that one 
screening mammogram is covered per year; however, if you receive a separate additional non-preventive 
evaluation and/or service, a copayment will apply. 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 breast ultrasound (76642) provided on May 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you are unable to walk more than 15 minutes 
without pain. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Epogen for the enrollee. 
 
You asked the Plan to pre-approve Epogen. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is no indication the step therapy drugs would likely be less effective, and/or 
cause adverse effects for the member. 
 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 Epogen. Our reviewer says that Epogen 
is not medically reasonable and necessary. There is no indication that the patient has tried and failed the 
required Retacrit or Procrit. There is no indication that the Plan's required drugs would likely be less effective 
and/or likely have adverse effects for the patient. Our physician reviewer found that the enrollee's condition 
does not meet step therapy criteria for Epogen. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Epogen have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Epogen for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair glide. 
 
You asked the Plan to pre-approve a stair glide. You say that you also have back stairs which are wider for 
installation. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair glide.
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 LTACH services are medically 
necessary as the care and services required by the enrollee exceeds the clinical capabilities of all lower levels of 
care in her geographical location. The Plan denied your request. The Plan says the enrollee is receiving 
appropriate inpatient care at the current hospital and she is not medically stable to be moved to a LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not already 
available 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transcatheter aortic valve replacement (TAVR) 
procedure. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee's symptoms are progressing 
quickly. The Plan denied your request. The Plan says the request does not meet the requirements for approval. 
 
The Plan follows Medicare rules. Medicare rules say that a transcatheter aortic valve replacement is only 
covered under certain medical indications.  
 
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 requested services. Our physician 
reviewer found that the enrollee has aortic stenosis and dyspnea. The cardiac catheterization and 
echocardiogram show severe aortic stenosis. The cardiologist indicated that TAVR be performed, while the 
cardiac surgeon indicated that she would be a candidate for either TAVR or surgical AVR. The guidelines 
indicate that the cardiologist and cardiac surgeon are required to provide care as a team in establishing the 
mutually agreed upon clinical strategy. As a result, at this time the coverage criteria for the requested TAVR 
would not be considered met. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a transcatheter aortic valve replacement (TAVR) procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Platelet Rich Plasma (PRP) treatments. 
 
You asked the Plan to pre-approve PRP treatments. You say that PRP has worked for you when other 
prescribed treatments have not helped. You say that you have suffered for more than seven years, and more 
than a dozen plan doctors have not been able to help you. You say that your pain is the result of a plan surgeon 
who damaged you. The Plan denied your request. The Plan says PRP treatment is considered experimental and 
is not currently the standard of care. 
 
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 PRP treatments. Our reviewer says that 
PRP treatments are not considered medically reasonable and necessary in this case. Our physician reviewer 
found Platelet Rich Plasma (PRP) treatment is considered experimental and is not currently the standard of care 
for treatment of male sexual dysfunction. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PRP treatments have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Platelet Rich Plasma (PRP) treatments.