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 does not meet criteria.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the enrollee does not require treatment by multiple therapies, including either
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive
rehabilitation therapy program provided in an IRF.
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 the complexity of the patient's nursing, medical and rehabilitation needs do not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
The patient does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, and an intensive rehabilitation therapy 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 long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee will benefit from being closely monitored. The Plan denied your request. The Plan says the enrollee does not have multiple medical conditions which needs complex medical management.
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 physician reviewer found that the enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a complete upper denture (D5110) and a partial lower denture (D5214) to be provided by an out of network provider.
You asked the Plan to pre-approve dentures. You say that the requested provider is in network. You also say that they were just credentialed. The Plan denied your request. The Plan says that the provider in this case is not in network.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of dentures have been met. Specifically, the file indicates that the requested provider is in network. Therefore, we decided that the Plan has to pre-approve a complete upper denture (D5110) and a partial lower denture (D5214) to be provided by an out of network provider.
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 Accu-Chek Aviva Plus diabetic test strips. 
 
You asked the Plan to pre-approve the non-preferred Accu-Chek brand test strips. You say that it is felt that the 
non-preferred brand should be allowed. The Plan denied your request. The Plan says there was no medical 
reason given that the preferred brands could not meet the enrollee's needs. 
 
The Plan must follow Medicare rules. Medicare rules say that Plans are allowed to impose restrictions to 
certain brands of medical equipment as long as all medically necessary brands are covered.  
 
In this case, there is no medical documentation or statement from the prescriber to support that the non-
preferred brand is medically necessary and that the preferred brand cannot be used. Therefore, we decided that 
the Plan does not have to pre-approve Accu-Chek Aviva Plus diabetic test strips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital services provided July 12, 2020.
You asked the Plan to pay for the outpatient hospital services. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says the claim was received after the timely filing limitation.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the outpatient hospital services was not filed until September 13, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the outpatient hospital services provided July 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) device 
purchased on July 20, 2021. 
 
You asked the Plan to pay for the CPAP device. You say that you would like reconsideration because your 
physician recommended this provider to you the last time you purchased CPAP equipment. The Plan denied 
your request. The Plan says this equipment must be rented monthly. The Plan must follow Medicare rules. Medicare rules say that for capped rental items of Durable Medical 
Equipment (DME), A/B MACs (HHH) and DME MACs pay the fee schedule amounts on a monthly rental 
basis not to exceed a period of continuous use of 15 months. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the CPAP device have not been met. Specifically, the requested CPAP device is considered a 
capped rental item. The record shows that this equipment was purchased while the Plan contract states that this 
equipment must be rented. Therefore, we decided that the Plan does not have to pay for the continuous positive 
airway pressure (CPAP) device purchased on July 20, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care after February 24, 
2022. 
 
You asked the Plan to pre-approve SNF care after February 24, 2022. You say that the requested continued 
admission to a SNF is medically necessary. The Plan denied your request. The Plan says the requested 
continued admission to a SNF is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care after February 24, 2022. Our 
reviewer says that the enrollee does not meet the Medicare criteria for continued SNF care. Our physician 
reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) 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 SNF care after February 24, 2022, have not been met. Therefore, we decided 
that the Plan does not have to pre-approve skilled nursing facility (SNF) care after February 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services provided to the enrollee on September 15, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says this code is included in the payment for another code.
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 71259 is a column II code to column I code 71275. This claim has not been billed with an appropriate modifier to bypass the edit. Modifier -26 is not an appropriate modifier to bypass this 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 radiology services provided to the enrollee on September 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital services provided on May 24, 2021.
You asked the Plan to pay for the outpatient hospital services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the codes billed on this claim have a status indicator of N.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT codes Q9966, 62290, J0744 and J2250 are not supported in the record. Specifically, per the Outpatient Prospective Payment System, these codes all have a status indicator of N. This means that the payment for these codes is packaged into the APC payment for outpatient services. Based on this information, we decided that Medicare rules for coverage of the outpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient hospital services provided on May 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services can be safely received in other settings, for example: a skilled nursing 
facility, home with home health services or home with outpatient therapy. 
 
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 review has determined that 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 does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable 
expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa (J7323). 
 
You asked the Plan to pre-approve Euflexxa. You say that you would like this request to be reconsidered 
because you are doing everything possible to avoid surgery. The Plan denied your request. The Plan says this 
request does not meet the Plan's Part B step therapy criteria for Euflexxa (J7323). 
 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 Euflexxa. Our reviewer says that 
Euflexxa is not medically reasonable and necessary. Our physician reviewer found the Plan requires a trial of 
drug Orthovisc or Supartz FX before they will approve the requested drug. Our reviewer found that in this case, 
you have not tried and failed the required drug(s). Our physician reviewer also found that there is no 
documentation provided indicating that the Plans required drug(s) would likely be less effective and/or likely 
have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa (J7323).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an auricular nerve stimulator. 
 
You asked the Plan to pre-approve an auricular nerve stimulator. You say that this device is medically 
necessary for your condition. The Plan denied your request. The Plan says the criteria for coverage have not 
been met. 
 The Plan must follow Medicare rules. Medicare rules say that payment may be made for implanted peripheral 
nerve stimulators in which electrodes are surgically placed under the skin around a nerve. The rules also say 
that acupuncture is only covered when provided for low back pain when furnished by a licensed acupuncturist. 
 
We looked at the file and Medicare rules. We find that this device does not meet the Medicare definition for an 
implanted nerve stimulator because the device involves needles inserted around the nerves and not electrodes 
being surgically implanted. The Food and Drug Administration (FDA) clearances for devices of this type are as 
electroacupuncture devices. Since acupuncture is not covered by Medicare for any condition when rendered 
through a device rather than by a licensed practitioner, we find that Medicare coverage criteria for this auricular 
stimulator have not been met. Based on this information, we decided that Medicare rules for coverage of an 
auricular nerve stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve 
an auricular nerve stimulator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses (V2020, V2784, V2750) purchased on 
November 30, 2020. 
 
 
 You asked the Plan to pay for the eyeglasses. You say that the language of your contract states that you should 
pay a $50 copayment for eyeglasses or contact lenses after cataract surgery. You say the Plan should pay for 
these services and you should have a $50 copayment. You also say that you did not have cataract surgery. The 
Plan denied your request. The Plan says routine prescription eyewear is not covered by your plan. You 
indicated that you have not had cataract surgery, and therefore are not eligible to receive eyewear post cataract 
surgery. Routine eyewear for people who have not had cataract surgery are not covered by Medicare or your 
plan. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers eyewear only when they are provided following cataract surgery. Routine eyewear is 
not covered by the Plan or by Original Medicare. 
 
Documentation indicates that you have not had cataract surgery. Though the Plan offers a vision benefit in 
excess of Medicare coverage, routine eyewear is not covered by this benefit. Therefore, we decided that the 
Plan does not have to pay for the eyeglasses (V2020, V2784, V2750) purchased on November 30, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no required skilled nursing services identified. It is not medically reasonable and necessary to provide skilled therapy services on a daily basis on an inpatient basis. You do 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on September 5, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says an edit exists between CPT 71045 and 36556. 
 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 71045 
is a column II code to column I code 36556. This claim has not been billed with an appropriate modifier to 
bypass the edit. Modifier -26 is not appropriate for this case. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for imaging services 
provided to the enrollee on September 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no evidence that the enrollee requires services that are not currently available. 
As LTACHs and acute care hospitals (ACHs) are licensed to provide the same level of care, there is no 
advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such 
time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for 
any ongoing long term care needs. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.