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

 
We decided that the Plan does not have to reduce the deductible and copayment for a magnetic resonance 
imaging (MRI) of the brain stem provided on August 30, 2022. 
 
You asked the Plan to reduce the deductible and copayment for the magnetic resonance imaging (MRI) of the 
brain stem. You say that your copayment should only be $250. The Plan denied your request. The Plan says 
this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $600 deductible which applies to certain items and services. Your contract with the Plan also clearly says that you must pay a $250 copayment for advanced imaging 
services at an outpatient hospital, after the deductible is met. 
 
The magnetic resonance imaging (MRI) of the brain stem falls within the advanced imaging services at an 
outpatient hospital benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract 
that there is $600 deductible which applies to certain items and services. This cost sharing is a contractual 
obligation that had not been met at the time the magnetic resonance imaging (MRI) of the brain stem was 
received on August 30, 2022.  
 
The file shows that at the time of service, you had a total of $359.78 remaining to meet the deductible. This 
amount was applied to the allowed amount of $372.23 first, and the remaining $12.45 was applied as the 
copayment amount. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to reduce the deductible and copayment for a magnetic resonance imaging 
(MRI) of the brain stem provided on August 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 22, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you would like CPT 99214 added to the current 
authorization. The Plan denied your request. The Plan says the authorization did not include CPT 99214. A 
valid authorization was not obtained for this service prior to being rendered. Please note that while out-of-
network benefits exist for this Plan, they are limited to dental services. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. 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. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on February 22, 2022, by 
an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says 
admission to the LTACH was denied as not meeting criteria, is not medically necessary, and continued acute 
hospital stay was offered, until the enrollee could discharge to a lower level of care. 
 
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 recent notes describe the enrollee as still on vent support without recent weaning 
attempts, with severe pain, percutaneous endoscopic gastrostomy leakage with consideration of surgery. The 
enrollee appears to still be somewhat unstable and should only require short term acute care services that can 
safely be provided at the current facility until more stable and appropriate for a lower level of care. The 
enrollee is receiving appropriate care at the present setting. The enrollee does not require services at the 
LTACH that are not available at the acute care hospital where they are currently receiving 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Mounjaro. 
 
You asked the Plan to pre-approve Mounjaro. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Mounjaro.  
 
Benefits for Mounjaro may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a Volara device. 
 
You asked the Plan to pre-approve Volara device. You say that the enrollee is in immediate need of this device. 
The Plan denied your request. The Plan says there is little evidence to suggest this is appropriate for the 
enrollee. 
 
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 Volara device. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is insufficient literature to support the safety and efficacy of this device in the enrollee's 
case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Volara device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve use of a Volara device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Viibryd. 
 
You asked the Plan to pre-approve Viibryd. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Viibryd.  
 
Benefits for Viibryd may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF care is medically necessary, and the enrollee 
meets full inpatient acute rehabilitation criteria. You say a lower level of care is not appropriate. The Plan 
denied your request. The Plan says that the IRF care is not medically necessary, and the enrollee's needs can be 
met at a lower level of care such as a skilled nursing facility (SNF). 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found clinical documentation shows that enrollee has complex functional deficits including neurological 
weakness and spasticity. The evaluating therapists, along with neurosurgery, all recommend intense therapy in 
an IRF setting. The clinical documentation shows that patient has an IRF compliant diagnosis and active 
comorbidities which require continued inpatient hospitalization during rehabilitation for close medical 
monitoring.  
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a physical therapy session provided on July 29, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for a physical therapy session. You say that you are appealing the denial of a 
physical therapy session because it was rendered in good faith and medically necessary. The Plan denied your 
request. The Plan says an authorization was not obtained prior to services rendered. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. 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. 
Therefore, we decided that the Plan does not have to pay for a physical therapy session provided on July 29, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a physician telephone visit provided on September 5, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a physician telephone visit. You say that you are requesting a reconsideration of 
the denied payment because you were understaffed and unable to obtain an authorization prior to services being 
rendered. The Plan denied your request. The Plan says an authorization was not obtained prior to services 
rendered. 
 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 had network providers 
available who could have provided the items/services at issue in this appeal. 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. 
Therefore, we decided that the Plan does not have to pay for a physician telephone visit provided on September 
5, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that that you have an amputated leg and needs an IRF. 
The Plan denied your request. The Plan says an IRF admission is not medically necessary, and your therapy 
needs can be provided in a lower level of care. 
 
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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) unit 
provided (as a purchase) on December 3, 2021. 
 You asked the Plan to pay for the TENS unit. You say that you have provided records to support payment for 
this item. The Plan denied your request. The Plan says the documentation you provided does not support 
medical necessity for this item. 
 
The Plan must follow Medicare rules. Medicare rules say that TENS devices for the treatment of chronic pain 
are only covered when certain criteria are met.  The patient's pain must have been present for at least 3 months 
and other treatment methods have been tried and failed.  In addition, the patient's provider must order a trial of 
the TENS device (which must be a rental) and monitor usage of the device for the first 1-2 months to determine 
that the TENS device is working. 
 
In this case, the minimal records you provided do show that the patient has chronic pain that appears to have 
been present for 3 months.  There is also evidence of other methods of pain control being tried.  However, the 
records do not show that the patient's provider ordered a trial of the TENS device and then monitored the 
patient's usage of such device for 1-2 months (as a rental) prior to a purchase of this item. In fact, the limited 
records you provided show that this purchased item was provided to the patient at only month 3 of them even 
having such pain.  There is no documentation of any required trial, and certainly no documentation of the 
required 1-2 months' rental of the TENS device prior to a purchase.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the TENS unit have not been met. Therefore, we decided that the Plan does not have to pay for the 
transcutaneous electrical nerve stimulation (TENS) unit provided (as a purchase) on December 3, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve occupational therapy services to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve therapy services. You say that you disagree with the denial of therapy 
services. The Plan denied your request. The Plan says the requested therapy services are not covered when 
received by an out-of-network provider. 
 
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 
occupational therapy services to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve occupational therapy services to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve therapy services. You say that you disagree with the denial of therapy 
services. The Plan denied your request. The Plan says the requested services are not covered when received by 
an out-of-network provider. 
 
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 
occupational therapy services to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will receive the appropriate level of care 
in the acute rehabilitation setting. The Plan denied your request. The Plan says based on Medicare guidelines 
the inpatient rehabilitation facility services you are requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  The enrollee was admitted to the hospital on November 13, 2022, for acute on chronic respiratory and heart 
failure and pneumonia. The enrollee received supplemental oxygen, diuresis, and antibiotics. She has not had a 
significant change in her baseline medical conditions or an acute change in the neurological status. The enrollee 
has had a functional decline from her baseline level of function and would likely benefit from occupational and 
physical therapies but does not require the intensity of therapies provided on acute inpatient rehabilitation. 
 
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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are blind, fell and broke your hip. You have a 
rod in your hip and need help, and you are not able to take care of yourself yet after being discharged from the 
hospital. The Plan denied your request. The Plan says criteria for admission to the Acute Inpatient 
Rehabilitation setting have not been met. Your ongoing skilled therapy and nursing needs can be provided at a 
lower level of care such as at a Skilled Nursing Facility. 
 
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 your medical problems are stable and there are no complex nursing or rehabilitation 
needs. There is no documented need for intensive rehabilitation services and medically necessary care can be 
provided in a different 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve Vertiflex. You say that this is medically necessary and considered safe and 
effective. The Plan denied your request. The Plan says this procedure is experimental/invetigational. 
 
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 Vertiflex. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertiflex procedure is experimental, more research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex procedure.