Persius/hicric huggingface dataset:
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 is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on review of the available records, you do not meet criteria for an IRF
admission. There is no documentation of any nursing needs. Documentation does not support the need for a therapy program consisting of at least 3 hours of therapy per day at least 5 days per week. While you may benefit from physical therapy, and occupational therapy, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care. Your rehabilitation needs can be easily met at a less intense and alternate level of 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Reblozyl.
You asked the Plan to pre-approve Reblozyl. You say that the enrollee has been having side effects with Retacrit. The Plan denied your request. The Plan says the enrollee has not received an erythropoiesis stimulating agent and blood transfusions.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Reblozyl. Our physician reviewer found that the requested use of Reblozyl is not FDA-approved for the enrollee's diagnosis. The clinical note show that the enrollee is not benefiting and not tolerating Erythropoietin. The requested use of the drug is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The requested use is not listed as not indicated, not supported or not recommended in any of the compendia. The documentation does not support that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Reblozyl have not been met. Therefore, we decided that the Plan does not have to pre-approve Reblozyl.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on November 30, 2020, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the drug testing. You say that 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. The record shows 
there was no referring provider. Therefore, we decided that the Plan does not have to pay for the drug testing 
provided on November 30, 2020, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D7411).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the requested services are not listed as a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve dental services (D7411).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on March 27, 2020.
You asked the Plan to pay for the physical therapy services. You say that providers are required to pay non-contracted providers at the preferred provider rate when services are not available in the service area. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. The Plan says the code is not appropriate for the service billed.
The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on March 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the automatic external defibrillator provided on March 23, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the automatic external defibrillator. You say that the service is medically necessary, and you could not have reasonably known a prior authorization was required. 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. Therefore, we decided that the Plan does not have to pay for the automatic external defibrillator provided on March 23, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve the RFA. You say that you would like reconsideration because the member 
had two procedures on their right side and one on their left. You also say that this request is for a second 
procedure on the left side. The Plan denied your request. The Plan says the member already had three 
radiofrequency sessions in the cervical spine region in the past 12 months. 
 
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 RFA. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the physician decided to break up the RFA performed into Right side, and then Left side instead 
of doing bilateral RFA at each session.  The request for a fourth session exceeds utilization criteria and 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 the RFA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the radiofrequency ablation (RFA).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PET scan to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve the PET scan. You say that the out-of-network provider is one of the 
advanced leaders in their field and they should have the special PET scan. The Plan denied your request. The 
Plan says the provider is out-of-network. 
 
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 specialized PET scan 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 the PET scan to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on September 22, 2020.
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation submitted does not support the Place of Service (POS) code billed on this claim.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The documentation shows that the sample for this testing was taken in a nursing facility setting, therefore the POS code 11 - indicating an office setting - is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on September 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and panoramic
x-ray (D0330) provided on June 3, 2021, by an OON provider.
You asked the Plan to pay for the comprehensive oral evaluation and panoramic x-ray. You say that you
believe these services should be covered. The Plan denied your request. The Plan says services performed by
an OON provider are not covered because your healthcare plan does not have OON benefits. The Plan also says
that you did not contact the Plan prior to this date of service to verify benefits and provider eligibility.
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, you are responsible for 100% of the
cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay
for the comprehensive oral evaluation (D0150) and panoramic x-ray (D0330) provided on June 3, 2021, by an
OON provider.
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 is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there is no need for physician supervision 3 times per week (at a minimum) for the 
ongoing management of any active or acute exacerbations of chronic medical conditions. Based upon the 
enrollee's current high level of function with supervision for mobility, the enrollee does not require an 
intensive, complex, multidisciplinary approach to daily therapy. Documentation does not support the need for 
therapy program consisting of at least 3 hours of therapy per day at least 5 days per week with an 
interdisciplinary approach to rehabilitation care. There are no documented skilled nursing needs. While the 
enrollee may benefit from physical therapy and occupational therapy, his rehabilitation needs can be safely met 
in an alternate and lower intensity 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite (D2393) provided on July 20, 
2020. 
 
You asked the Plan to pay for the resin-based composite. You say that you are pretty sure that when you called 
in last year you were told that $200 worth of dental work was covered. The Plan denied your request. The Plan 
says this service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the resin-
based composite (D2393) provided on July 20, 2020
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 service is medically necessary. The Plan denied 
your request. The Plan says the service is not medically necessary.
 
The Plan must follow Medicare rules. The rules say that 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 conditions are stable and you have no complex nursing or rehabilitation 
needs. While the documentation does support a need for physical and/or occupational therapy, there is no 
documented need for an intensive, multi-disciplinary rehabilitation program. 
 
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. Specifically, medically necessary services can be 
obtained at a lower level of care. This means admission into an IRF is not medically necessary or reasonable. 
Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) 
admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interlaminar stabilization device (Vertiflex).
You asked the Plan to pre-approve Vertiflex procedure. You say that this is the most appropriate treatment for the enrollee. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because guidelines do not support the use of this procedure.
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 procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show its safety and efficacy. 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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an interlaminar stabilization device (Vertiflex).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve balloon dilation of the left Eustachian tube. 
 
You asked the Plan to pre-approve balloon dilation of the left Eustachian tube. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the requested 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 balloon dilation of the left Eustachian 
tube. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has a history of left-sided Eustachian tube 
dysfunction and serous otitis media. The enrollee has required several ear tubes on the left, which have 
extruded. The enrollee has persistent middle ear fluid on that side. The enrollee has left-sided sensorineural 
hearing loss. It is documented that the enrollee in this case has been treated with several ear tubes on the left. 
Documentation of medical management of the enrollee's Eustachian tube dysfunction is lacking. The 
documentation is insufficient to demonstrate that balloon dilation of the left Eustachian tube is medically 
reasonable and necessary for the enrollee in this 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 balloon dilation of the left Eustachian tube have not been met. Therefore, we 
decided that the Plan does not have to pre-approve balloon dilation of the left Eustachian tube.
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 is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 
 
Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the documentation does support a need for physical and/or occupational 
therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 
 
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: 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 service is medically necessary. The Plan denied 
your request. The Plan says the service is not medically necessary. The Plan must follow Medicare rules. The rules say that 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 conditions are stable and you have no complex nursing or rehabilitation 
needs. While the documentation does support a need for physical and/or occupational therapy, there is no 
documented need for an intensive, multi-disciplinary rehabilitation program. 
 
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. Specifically, medically necessary services can be 
obtained at a lower level of care. This means admission into an IRF is not medically necessary or reasonable. 
Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) 
admission and services.