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 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. 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 does 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 you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that you 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve sanitary napkins, incontinence supplies.  You asked the Plan to pre-approve incontinence supplies. You say that you have leg edema and is taking medication that caused you to empty your bladder very often. You also have a dropped bladder. The Plan denied your request. The Plan says this item is not a covered benefit.  The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable.   While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve sanitary napkins, incontinence supplies.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric treatment.
You asked the Plan to pre-approve inpatient psychiatric treatment. 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. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric treatment. Our reviewer says that the services are not medically necessary. Our physician reviewer found based upon review of the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health
treatment beyond the date in question of December 3, 2021 forward and could have been treated in a lesser
restrictive setting. He was not showing any suicidal or homicidal ideation, auditory or visual hallucinations and
was not showing any aggressive behaviors. He was being cooperative and compliant.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient psychiatric treatment have not been met. Therefore, we decided that
the Plan does not have to pre-approve inpatient psychiatric treatment
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is insufficient evidence to determine if radiofrequency ablation of the basivertebral nerve improves health outcomes.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested procedure is experimental. More research is needed to show 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve six additional miles for a routine transportation trip.
You asked the Plan to pre-approve the additional miles. You say that this is needed to get a ride to surgery. The
Plan denied your request. The Plan says the benefit only allows for trips up to 50 miles one-way.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers routine transportation with trips up to 50 miles one-way.
We looked at your request, the records in the case file, and the rules. The requested trip is 56 miles one-way,
which exceeds the benefit limit set by the plan contract. Based on this information, we decided that the Plan's
rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not
have to pre-approve six additional miles for a routine transportation trip.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup (D2950).
You asked the Plan to pre-approve core buildup (D2950). You say that you don't have the income to cover your needs or pay for dental services. The specialist found the services were medically necessary to improve your health. The Plan denied your request. The Plan says the 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 pre-approve core buildup (D2950).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the orthopedic office visits to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the orthopedic office visit. You say that the services are medically necessary. 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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. The records provided for review do not show that the services at issue are urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve the orthopedic office visits to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
You asked the Plan to pre-approve the compression stockings. You say that the medical supplies in question
were never ordered nor approved by you. Since the items were returned unused, unopened, incorrect or not
required in the first place, you are disputing this bill in its entirety. The Plan denied your request. The Plan says
these items are not covered benefits.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are
noncovered because they do not meet the statutory definition of a surgical dressing.
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression
stockings identified with code A6530.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the office visit. You say that it is convenient to see the physician that works in the facility where you live. You say you can drive, but it is limited. 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 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 the office visit to be provided by an out-of-network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a full body Panosol 3D ultraviolet light system
You asked the Plan to pre-approve the ultraviolet light system. You say that you are requesting coverage for a home unit for the same system as the enrollee is diagnosed with T-cell lymphoma and wants to avoid the risk of exposure to COVID. The Plan denied your request. The Plan says this item is considered experimental and investigational because of insufficient evidence of its safety and effectiveness.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. We looked at this the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ultraviolet light system have not been met. Therefore, we decided that the Plan does not have to pre-approve a full body Panosol 3D ultraviolet light system
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical implant placement (D6010), custom fabricated abutment (D6057), abutment supported crown (D6058) and a radiographic/surgical implant index (D6190).
You asked the Plan to pre-approve the implant services. You say that these services are necessary and will impact the enrollee's overall well-being and sense of self-esteem. The Plan denied your request. The Plan says these services are not covered by the Plan's dental 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 a surgical implant placement (D6010), custom fabricated abutment (D6057), abutment supported crown (D6058) and a radiographic/surgical implant index (D6190).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve porcelain fused to predominantly base metal crowns (D2751) for teeth # 28, 29, and 30.
You asked the Plan to pre-approve the dental services. You say that you are in pain. You also say that you need this dental work done soon. The Plan denied your request. The Plan says crowns are not listed as covered services.
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 crowns are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve porcelain fused to predominantly base metal crowns (D2751) for teeth # 28, 29, and 30.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the cervical spine for the enrollee.
You asked the Plan to pre-approve the imaging. You say that this is medically necessary. The Plan denied your request. The Plan says there is no record of follow-up contact with the doctor after completing treatment that failed to improve symptoms.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 the imaging. Our reviewer says that the requested imaging is not medically reasonable or necessary. Our physician reviewer found there is no documentation of a recent trial of physical therapy for neck pain. There are no red flags for MRI documented. 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 imaging have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the cervical spine for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the echocardiography provided on February 27, 2021, and the positron emission tomography (PET) scan, the cardiovascular stress test, the Rb82 rubidium, and the Regadenoson injection provided on March 12, 2021.
You asked the Plan to waive the cost sharing for the echocardiography, PET scan, stress test, rubidium, and injection. You say that you had these tests two years ago with no balance. You say you cannot afford the bill. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $160 copayment for radiological diagnostic services, not including x-rays. Your contract with the Plan also clearly says that you must pay a $25 copayment for non-radiological diagnostic services. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B drugs.
You have been asked to pay a $160 copayment each for the echocardiography and the PET scan. The echocardiography and PET scan fall in the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category.
You have also been asked to pay a $25 copayment for the cardiovascular stress test. The stress test falls in the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category.
You have also been asked to pay 20% of the allowed amount for the rubidium and the Regadenoson, as follows.
Part B Drug
Allowed Amount
20% Coinsurance
rubidium
$1,041.50
$208.30
Regadenoson
$236.76
$47.35
The rubidium and Regadenoson fall in the Medicare Part B Prescription Drugs benefit category.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost sharing for the echocardiography provided on February 27, 2021, and the positron emission tomography (PET) scan, the cardiovascular stress test, the Rb82 rubidium, and the Regadenoson injection provided on March 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve total electric hospital bed (E0265).
You asked the Plan to pre-approve total electric hospital bed. You say that you had a femur fracture and had surgery done but is not completely healed. You are still using the bed and would like to continue with the authorization. The Plan denied your request. The Plan says a total electric hospital bed is not a Medicare covered benefit.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve total electric hospital bed (E0265).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental pneumatic appliance (E0667).  You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that for review of the enclosed documentation supporting medical necessity of the prescribed Flexitouch PCD. Please note the pump has been prescribed for lymphedema and is not considered drug therapy. The Plan denied your request. The Plan says the enrollee does not meet the LCD criteria for an advanced lymphedema pump as there is no failed four week trial of a basic pneumatic compression device of either E0650 or E0651.  The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.  We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental pneumatic appliance (E0667).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve coverage for special supplemental benefits.
You asked the Plan to pre-approve coverage for special supplemental benefits. The Plan denied your request.
The Plan says you do not meet the criteria established to receive the special supplemental benefits.
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for
enrollees with an eligible chronic condition.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of special supplemental benefits. have not been met. Specifically, we have confirmed that you do not
have one of the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does
not have to pre-approve coverage for special supplemental benefits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement manual adult size tilt in space wheelchair and accessories coded as E1161, E2201, E2203, E2231, E0990, L0040, L0108, E0973, E0971, E2620, E0960, E2607, E2209 and E1028.
You asked the Plan to pre-approve a replacement wheelchair. You say that due to extensive issues and the fact that many of them cannot be resolved, it was deemed that the replacement with a configuration more suited to the enrollee's seating and positioning needs. The Plan denied your request. The Plan says the current wheelchair is within the 5-year reasonable useful lifetime time frame.
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.
In this case, the current manual adult size tilt in space wheelchair was purchased in 2017 and is within the five-year reasonable useful lifetime time frame and a locally authorized repair service can make the necessary repairs so that it will meet your needs for positioning and mobility. There is no documentation that the current wheelchair is irreparably worn or damaged. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a replacement wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement manual adult size tilt in space wheelchair and accessories coded as E1161, E2201, E2203, E2231, E0990, L0040, L0108, E0973, E0971, E2620, E0960, E2607, E2209 and E1028.