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

We decided that the Plan does not have to pre-approve inpatient hospital care for the right total hip arthroplasty
(CPT code 27130).
You asked the Plan to pre-approve acute inpatient hospital care. You say that you are in pain due to bone
deterioration. You state you are unable to walk without excruciating pain, you need the surgery to help you to
walk, and to get your quality of life back to be able to take care of yourself. The Plan denied your request. The
Plan says the surgery is approved at outpatient. The Plan states the inpatient hospital care is not 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 documentation indicates that you are medically stable. There is no
specific documentation indicating medical necessity for admission after the elective procedure. The procedure
is not the inpatient only list. The review has determined that the record does not show that the admitting
physician reasonably expects that your necessary hospital care will 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 pre-approve inpatient hospital care for the right total hip arthroplasty (CPT code 27130)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the wound care provided from June 21,
2021, to July 21, 2021.
You asked the Plan to waive the copayments for the wound care. You say that you say you are being charged
$295 each visit The Plan denied your request. The Plan says you have been asked to pay 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). Your contract with the Plan clearly says that you must pay a $295
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including
but not limited to hospital or other facility charges and physician or surgical charges.
You have been asked to pay a total of $1,308.69 for the wound care. The wound care falls within the
"Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory
Surgical Centers" benefit category. See chart below.
Date of Service Service Allowed Amount Copayment Member Liability
June 21, 2021 Skin removal $315.23 $295.00 $295.00
June 28, 2021 Skin removal $477.78 $295.00 $295.00
July 12, 2021 Skin removal $315.23 $295.00 $295.00
July 19, 2021 Application of
wound care
compression system
$128.69 $295.00 $128.69
July 21, 2021 Skin removal $315.23 $295.00 $295.00
Total $1,308.69
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 copayments for the wound care provided from June 21, 2021, to July 21,
2021
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF from
December 11, 2021 and forward is medically necessary. The Plan denied your request. The Plan says the
enrollee does not meet criteria for SNF admission from December 11, 2021 and forward.
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 admission to a SNF. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled
nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely
and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not
reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. The enrollee
has stable vital signs and is breathing comfortably on room air with no evidence of oxygen desaturation. The
enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and
judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable
treatment in a SNF. The enrollee does not require skilled nursing or skilled therapy services (or a combination
of these services) on a daily basis in a SNF. As a practical matter, this enrollee does not require the necessary
services on an inpatient basis, in a skilled nursing facility 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 admission to a SNF have not been met. Therefore, we decided that the Plan
does not have to pre-approve admission to a skilled nursing facility (SNF)
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Coflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there is not enough evidence to show that this procedure is helpful.
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. More research is needed to show safety and efficacy. High failure rates have been reported with similar devices. 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 the Coflex device for the enrollee
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan.
You asked the Plan to pre-approve CT scan. You say that you are appealing with supporting records. The Plan
denied your request. The Plan says the denial of authorization for this test is correct, because follow-up
imaging for a radiopaque stone is only indicated for an individual who is symptomatic and has not passed the
stone.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are
medically necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve CT scan. Our reviewer says that the
enrollee does not meet the Medicare criteria for the requested CT scan. Our physician reviewer found follow-
up computed tomography (CT) scan is not necessary because the original stone was radiopaque and follow-up
kidney, ureters, and bladder (KUB) radiograph would be adequate instead of a CT scan.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of CT scan have not been met. Therefore, we decided that the Plan does not have
to pre-approve a computed tomography (CT) scan.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the transcutaneous electrical modulation pain reprocessing
(0278T) you received on July 21, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is an experimental
service.
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 pay for the services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found that the record indicates that the requested service is requested for polyneuropathy. There is insufficient
literature to support the use of the requested service for the enrollee's condition. The record provided does not
establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service.
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 services have not been met. Therefore, we decided that the Plan does not
have to pay for the transcutaneous electrical modulation pain reprocessing (0278T) you received on July 21,
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 pre-diabetic and have leg 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: 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 SNF services. The Plan denied your request. The Plan says your needs can
be met with intermittent therapy.
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 physician reviewer
found that your current level of function is at a supervision assist level for eating, independent with oral care,
standby assist for sitting and scooting, and contact guard assist for transfers. You do not require skilled nursing
or therapy services to provide medically necessary treatment in a SNF on a daily 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 skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure.
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 an Intracept procedure. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the Intracept procedure is experimental. More research is needed to show safety and
efficacy of the intracept procedure for low back pain.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve an Intracept procedure.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the excision of excessive skin.
You asked the Plan to pre-approve the excision of excessive skin. You say that the requested procedure is
medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage have
not been met.
The Plan follows Medicare rules. Medicare rules say that panniculectomy is medically necessary when the
panniculus hangs below the level of the pubis, and the medical records document that the panniculus causes
chronic intertrigo (dermatitis occurring on opposed surfaces of the skin, skin irritation, infection or chafing)
that consistently recurs over 3 months while receiving appropriate medical therapy, or remains refractory to
appropriate medical therapy over a period of 3 months.
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 excision of excessive skin. Our
reviewer says that the requested procedure is not medically reasonable and necessary. Our physician reviewer
found you are a 64-year-old woman with a diagnosis of Localized adiposity. The enrollee has a history of
morbid obesity, and previously underwent a laparoscopic sleeve gastrectomy which resulted in weight loss. It is
documented that the enrollee has not had any history of blisters or skin infections, and that she has not needed
to use any special powders or creams for skin irritation. The enrollee's panus covers the top part of the pubis
area. Panniculectomy, or the removal of excessive skin, is considered medically necessary when the panniculus
hangs below the level of the pubis, and the medical records document that the panniculus causes chronic
intertrigo that consistently recurs over 3 months while receiving appropriate medical therapy, or remains
refractory to appropriate medical therapy over a period of 3 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 excision of excessive skin have not been met. Therefore, we decided that the
Plan does not have to pre-approve the excision of excessive skin.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the flex-walk system or equal (L5981).
You asked the Plan to pre-approve the flex-walk system or equal. You say that the item is medically necessary.
The Plan denied your request. The Plan says the request for a K3 prosthesis exceeds the member's need and
does not meet the Medicare criteria of reasonable and necessary.
The Plan follows Medicare rules. Medicare rules say that the records must document the beneficiary's current
functional capabilities and his/her expected functional potential, including an explanation for the difference, if
that is the case. It is recognized, within the functional classification hierarchy, that bilateral amputees often
cannot be strictly bound by functional level classifications.
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 flex-walk system or equal. Our
reviewer says that this item is not medically necessary. Our physician reviewer found the requested item
exceeds the patient's medical need as the medical progress note documentation does not support that this
patient is a level K3 ambulator.
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 flex-walk system or equal have not been met. Therefore, we decided that the
Plan does not have to pre-approve the flex-walk system or equal (L5981).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interstitial continuous glucose monitor (A9277,
A9276).
You asked the Plan to pre-approve an interstitial continuous glucose monitor. You say that the requested items
will give you a much better quality of life. The Plan denied your request. The Plan says the requested items are
not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that CGM devices that do not meet the definition of a
therapeutic CGM as defined in CMS Ruling 1682R will be denied as non-covered (no benefit).
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of an interstitial continuous glucose monitor have not been met. Specifically, the requested CGM
device does not meet the definition of a therapeutic CGM. Non-Therapeutic CGMs are not covered by
Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve an interstitial
continuous glucose monitor (A9277, A9276).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the inpatient evaluation and management (EM) service provided by a
pain management specialist on July 17, 2021.
You asked the Plan to pay for the inpatient pain management EM services. You say that this is not subject to a
global period and was billed for medically necessary services provided to the patient. The Plan denied your
request. The Plan says that providers of the same specialty from the same billing group are considered the same
physician. In this case, another pain management doctor provided anesthesia during a procedure on the same
date. This EM service is not separately payable and is included in payment for the anesthesia provided.
The Plan must follow Medicare rules. Medicare rules say that anesthesia care is paid based on the time spent.
This time begin at the preoperative examination and ends when the anesthesiologist transfers the patient to
postoperative care.
In this case, the records show that the physician who provided anesthesia care transferred to patient to
postoperative care at 10:30AM. This means that payment for the anesthesia service is only for services
provided up until that time. The record shows that the appealing physician evaluated the patient for pain control
between 1 and 2PM later that day. This is not part of postoperative anesthesia recovery care. We find that this
is a separately payable service according to Medicare anesthesia billing rules. Therefore, we decided that the
Plan has to pay for the inpatient evaluation and management (EM) service provided by a pain management
specialist on July 17, 2021.
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 pre-approve a portable oxygen concentrator battery for the enrollee.
You asked the Plan to pre-approve a portable oxygen concentrator battery. You say that the enrollee needs a
battery that lasts longer. The Plan denied your request. The Plan says that an extra battery pack is not covered
under Medicare.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered
reasonable and necessary.
The file shows that the enrollee has a portable oxygen concentrator battery. a portable oxygen concentrator
battery serves the same purpose as a portable oxygen concentrator battery. Therefore, we decided that the Plan
does not have to pre-approve a portable oxygen concentrator battery for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oral appliance to be rendered by the out-of-network
(OON) provider.
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's
denial. The Plan denied your request. The Plan says there are in-network providers available to render the
requested item.
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 item at issue in this appeal. We found no exception that would require the Plan
to pre-approve this item. Therefore, we decided that the Plan does not have to pre-approve an oral appliance to
be rendered by the out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gel footplate covers, an expandable controller upgrade
with harness, and electronic connection.
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 covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose. The rules say that an expandable controller is covered to operate specific electronic systems.
The requested gel footplate covers do not serve a purpose that is primarily medical in nature. The requested
expandable controller with harness and electronic connection are already included in the approved power
wheelchair. Therefore, we decided that the Plan does not have to pre-approve gel footplate covers, an
expandable controller upgrade with harness, and electronic connection.