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

We decided that the Plan does not have to pre-approve a low air loss mattress for the enrollee.
You asked the Plan to pre-approve the mattress. You say that this is medically necessary. The Plan denied your request. The Plan says the rental is not approved at this time.
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 mattress. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided, there is no documentation that the enrollee has had multiple stage II pressure ulcers located on the trunk or pelvis, which have been treated in a comprehensive program or large or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis or a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the past 60 days to qualify for the requested low air loss mattress. 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 mattress have not been met. Therefore, we decided that the Plan does not have to pre-approve a low air loss mattress for the enrollee
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve radiofrequency ablation to the SI joint.  You asked the Plan to pre-approve radiofrequency ablation to the SI joint. You say that the requested radiofrequency ablation to the SI joint is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested radiofrequency ablation to the SI joint.  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 radiofrequency ablation to the SI joint. Our reviewer says that the enrollee does not meet criteria for the requested radiofrequency ablation to the SI joint. Our physician reviewer found radiofrequency ablation of the lateral sacral branches is considered experimental because of the wide variation in efficacy reported in the literature. Therefore, the request is considered not 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 radiofrequency ablation to the SI joint have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation to the SI joint.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a bone growth stimulator (E0747).  You asked the Plan to pre-approve the bone growth stimulator. You say that the device is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.  The Plan follows Medicare rules. Medicare rules say that non-union of long bone fracture is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the electrical osteogenic stimulator.  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 bone growth stimulator. Our reviewer says that the requested bone growth stimulator is not medically necessary. Our physician reviewer found follow-up radiographs on December 7, 2021 indicate very scant increased opacity consistent with possible early callus formation. The record does not indicate that fracture healing has ceased for 3 or more months.  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 bone growth stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve a bone growth stimulator (E0747).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a right total hip replacement.
You asked the Plan to pre-approve a right total hip replacement. You say that the requested right total hip
replacement is medically necessary. The Plan denied your request. The Plan says the requested right total hip
replacement is not medically 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 a right total hip replacement. Our
reviewer says that the requested right total hip replacement is not medically necessary. Our physician reviewer
found the enrollee was being treated for unilateral primary osteoarthritis, right hip, and right hip pain. She
presented with right hip discomfort for 3 months. Her pain is located on the lateral aspect of the hip and
radiates into the groin, and into the lower back. She is unable to walk for long periods due to her pain, along
with ascending stairs. Height is 64 inches, weight 163 pounds, and body mass index is 27.98 kg/m2. Exam of
the right hip reveals tenderness of the sacroiliac joint. There is pain with motion of the hip. Limb lengths are
equal. Flexion is greater than 95, abduction 30-45, adduction 30-45, internal rotation 0, and external rotation
45. X-rays demonstrated severe bone-on-bone joint space narrowing.
However, detailed documentation is not evident regarding trial and failure of recent, reasonable and
comprehensive less invasive conservative care measures. She has not had evident documentation of having
trialed and failed formal physical therapy and/or any injection therapy prior to the request for surgery.
Additionally, detailed documentation is not evident regarding severity of pain to the right hip and significant
limitations in activities. There is no compelling rationale presented or extenuating circumstances noted to
support the medical necessity of this request as an exception. Therefore, the request for right total hip
replacement is not 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 a right total hip replacement have not been met. Therefore, we decided that the
Plan does not have to pre-approve a right total hip replacement.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided on May 27, 2021.
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says the
admission did not meet inpatient criteria, meets observation status.
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 pay for 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 that the record did not show that at the time of inpatient admission the admitting
physician reasonably expected that the patient's necessary hospital care (including earlier emergency room
and/or observation care) would span two midnights.
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 pay for the acute inpatient hospital care provided on May 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for diagnostic radiology services (78452)
provided on August 11, 2021.
You asked the Plan to waive the copayment for the diagnostic radiology services. You say that the services
should be covered as they were a part of your stress test. The Plan denied your request. The Plan says the costsharing
is separate and applied 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 $75
copayment for Outpatient diagnostic tests and therapeutic services and supplies.
You have been asked to pay a $75 copayment for the diagnostic radiology services. Diagnostic radiology
services fall 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 diagnostic radiology services (78452) provided on August
11, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a duplex scan provided on October 5, 2021.
You asked the Plan to waive the copayment for a duplex scan. You say that you have already paid the
copayment for the service provided. The Plan denied your request. The Plan says only part of the copayment
has been paid and the proper copayment was applied.
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 $40
copayment for each In-network Medicare-covered standard x-rays and ultrasounds. With $35 of the $40
copayment already paid only $5 ($40 copayment - $35 already paid) is left of the copayment.
You have been asked to pay a $5 copayment for a duplex scan. The duplex scan 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 duplex scan provided on October 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary visit provided on March 22, 2021, by an outof-
network (OON) provider.
You asked the Plan to pay for the domiciliary visit. You say that the provider relies on facility staff to verify
eligibility and obtain the proper authorization. You say the service was medically necessary. The Plan denied
your request. The Plan says no prior authorization was obtained.
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 did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we
decided that the Plan does not have to pay for the domiciliary visit provided on March 22, 2021, by an out-ofnetwork
(OON) provider
Appeal type: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Injectafer.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the step therapy requirement is not met.  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has unspecified iron deficiency anemia. It is documented that he is not tolerating an oral iron replacement secondary to gastrointestinal upset. He has not tried and failed the Plan's required drugs, Venofer and Infed. The records do not show that the required drugs would be contraindicated or less effective; therefore, Injectafer is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Injectafer.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography scan (74177) provided on July 13,
2021.
You asked the Plan to pay for a computed tomography scan. You say that this is supported in the records. The
Plan denied your request. The Plan says this is not separately payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 74177
is a column II code to column I code 74175. This claim has not been billed with an appropriate modifier to
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we
decided that the Plan does not have to pay for a computed tomography scan (74177) provided on July 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture (D5213).
You asked the Plan to pre-approve a partial denture. You say that you had tooth # 9 pulled. You also say that you need a new partial upper denture. The Plan denied your request. The Plan says 1 partial upper denture is covered per plan year. The Plan also says that the frequency limit has been reached.
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 and partial upper denture is listed as covered, the frequency limit has been reached. The record shows that the Plan paid for a partial upper denture that you received on March 4, 2020. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5213).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prosthetic leg with electronic knee with advanced foot
and ankle features.
You asked the Plan to pre-approve these services. 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. 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the records indicate the enrollee
requires two Lofstrand crutches presently and will continue to require one Lofstrand crutch with the new
requested prosthesis for his mobility. The use of Lofstrand crutches is not consistent with a K3 level of
ambulation to justify necessity of the requested prosthetic leg with electronic knee with advanced foot and
ankle features.
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 a prosthetic leg with electronic knee with advanced foot and ankle features
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by the requested out-of-network provider.
You asked the Plan to pre-approve physical therapy services to be provided by the requested out-of-network provider. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the Plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the Plan.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical therapy services to be provided by the requested out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an osteogenesis stimulator (E0748) provided on August 16, 2021.
You asked the Plan to waive the coinsurance for the osteogenesis stimulator. You say that the services should be covered as you were informed your copayment would be $800. The Plan denied your request. The Plan says the coinsurance applied correctly based on the services 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 you must pay a 20% coinsurance for Durable medical equipment (DME) and related supplies.
You have been asked to pay a 20% coinsurance for an osteogenesis stimulator ($4,529.04 x 20% = $905.81). Osteogenesis stimulators fall within the Durable medical equipment (DME) and related 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 coinsurance for an osteogenesis stimulator (E0748) provided on August 16, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on
October 20, 2020.
You asked the Plan to waive the copayment for the ER visit. You say that the enrollee was taken to the wrong
hospital. The Plan denied your request. The Plan says the enrollee has been charged the correct cost sharing
amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay a $90 copayment for each emergency room visit.
The enrollee has been asked to pay a $90 copayment for the ER visit. ER visits fall within the Emergency Care
benefit category.
This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This
cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we
decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on
October 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the magnetic resonance angiography testing provided on September 14, 2021.  You asked the Plan to pay for the services provided. You say that the records support the procedure was performed by the provider. The Plan denied your request. The Plan says a modifier was not billed to represent the services as separate/distinct. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.  The file shows that CPT code 70544 was billed along with code 70551. We find that CPT code 70544 may be eligible for payment when billed with this code pair. The claim information does not show that the code at issue was billed with a modifier suitable for payment. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the magnetic resonance angiography testing provided on September 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Gel mattress (E0185).
You asked the Plan to pre-approve a Gel mattress (E0185). You say that the requested Gel mattress (E0185) is
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the
requested Gel mattress (E0185).
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 Gel mattress (E0185). Our reviewer
says that the enrollee does not meet criteria for the requested Gel mattress (E0185). Our physician reviewer
found the criteria for a gel mattress (E0185) have not been met per Local Coverage Determination (LCD) -
Pressure Reducing Support Surfaces - Group 1 (L33830). There is no evidence in the documentation that the
enrollee is completely immobile. There is no evidence that the enrollee cannot make changes in body position
significant enough to alleviate pressure, or that the enrollee has any stage pressure ulcer on the trunk or pelvis.
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 Gel mattress (E0185) have not been met. Therefore, we decided that the Plan
does not have to pre-approve a Gel mattress (E0185).