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

 
We decided that the Plan does not have to pre-approve laminectomy, facetectomy and foraminotomy (unilateral 
or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess 
stenosis]), single vertebral segment; lumbar (CPT Code 63047). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not 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 the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the criteria for surgery not met. There is no clear correlation between imaging and physical 
exam showing affected nerve roots. There is no adequate documented trial of physical therapy (PT) recently. 
The surgery is not needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression 
of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral 
segment; lumbar (CPT Code 63047).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe physical therapy to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe physical therapy. You say that you are not satisfied with the in-network physical therapy you are receiving.The Plan denied your request. The Plan says there are other outpatient rehabilitation facilities available within the 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-approvethe physical therapy 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 the blood test (80053) provided on June 2, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the blood test. You say that you would like this claim reprocessed and approved 
for payment. The Plan denied your request. The Plan says prior authorization was not obtained by the facility 
or the provider; therefore, payment has been correctly denied. 
 
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 has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the blood test (80053) provided on June 2, 2020 
by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy (PT) and occupational 
therapy (OT) visits, a total of 20 of each. 
 
You asked the Plan to pre-approve the additional PT/OT visits. You say that you believe that you need all the 
therapy visits that were requested. The Plan denied your request. The Plan says on review, a total of 12 PT 
visits and 5 occupational therapy visits were approved. Additional visits beyond this are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional PT/OT visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found the enrollee does not have documented skilled 
therapy needs. Skilled services are not required to establish a maintenance program or to prevent deterioration 
of the enrollee's condition. Continuation with a home exercise program is sufficient. 
 
 
 
 
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 additional PT/OT visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional physical therapy (PT) and occupational therapy (OT) visits, a total 
of 20 of each.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Silver & Fit reimbursement from June 28, 2019 to December 1, 2019.You asked the Plan to pay forthese services. You say that youdidn't know you had 90 days to submit the claim.The Plan denied your request. The Plan says the claim was not submitted timely.The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits only when reimbursement is submitted within 90 days of the end of the calendar year.The Plan's rules for coverage of gym benefits have not been met because thePlan did not receive your reimbursement request within 90 days of the end of the calendar year.Therefore, we decided that the Plan does not have to pay forthe Silver & Fit reimbursement from June 28, 2019 to December 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. 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 follows Medicare rules. Medicare rules say that Botox is only covered for certain indications. 
 
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 Botox. Our reviewer says that the 
documentation does not support that the requested Botox is medically reasonable or necessary. Our physician 
reviewer found you have a diagnosis of Notalgia paresthetica. Notalgia paresthetica is not a condition listed 
within the applicable coverage of Botox. The drug is not otherwise FDA approved for use in this condition. 
Nor is Botox supported for use in Notalgia paresthetica within the Medicare accepted Compendia. Therefore, 
you do not meet criteria for the requested Botox. 
 
Review of the file shows that the plan uses LCD L35170 to support their denial. However, LCD L35170 is not 
valid for your (the enrollee) home state.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.
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 is likely to require 3-4 more 
weeks of acute care which would be best provided in an LTACH. The Plan denied your request. The Plan says 
the enrollee can stay for as long as is needed in the current facility. There is no reason that an LTACH would 
be better. 
 
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 the patient is a 78-year-old female who was admitted to the current acute care 
hospital status post fall and diagnosed discitis with osteomyelitis. She was treated with IV antibiotics. The 
course was complicated by dysphagia, COPD, and hypertension. Recent notes show stable vitals, but she is 
experiencing urinary retention, confusion, and weakness. She requires soft diet, PT, and supervision. 
 
The patient appears to be requiring only short term additional acute care services (less than 25 days) for 
stabilization which can be completed at the current facility. The patient does not require services at the LTACH 
that are not already available at the current 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter rental. 
 
You asked the Plan to pre-approve a power scooter rental. You say that you have a sprained ankle and are 
unable to walk to the grocery store about one mile away. The Plan denied your request. The Plan says the 
requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter rental.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the interspinous spacer procedure for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is 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 the procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the spacer is not medically needed. There is no spinal instability. Also, the spacer 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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the interspinous spacer procedure for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an admission for SNF services. 
 
You asked the Plan to pre-approve the SNF services. You say that the enrollee needs ongoing skilled therapy in 
a SNF. You say that the enrollee is not yet at MMI but believe that recovery is slowed due to ataxia. The Plan 
denied your request. The Plan says the that enrollee does not meet Medicare guidelines for services in a skilled 
nursing facility. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 the SNF services. Our reviewer says 
that daily skilled services are not medically necessary. Our physician reviewer found that based on the 
documentation provided, the enrollee does not qualify for SNF coverage. The enrollee does not have 
documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. 
 
 
 
Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the 
enrollee's condition. The enrollee's care needs at this point are custodial and, as a practical matter, can be 
provided at a lower level of care 
(ex. home, AL, LTC). 
 
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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve SNF services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc injections. 
 
You asked the Plan to pre-approve the Orthovisc injections. You say that this medication should be approved. 
The Plan denied your request. The Plan says a trial of a preferred drug is required. 
 
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 the Orthovisc injections. Our reviewer 
says that the requested drug is not considered medically necessary based on step therapy rules. Our physician 
reviewer found there is no evidence of a trial of a preferred viscosupplement agent nor any documentation that 
they would not be as effective. 
 
 
 
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 Orthovisc injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Orthovisc injections.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cyclobenzaprine HCL. 
 
You asked the Plan to pre-approve Cyclobenzaprine HCL. You say that you have limited mobility with all the 
pain you are in. The Plan denied your request. The Plan says Cyclobenzaprine to be administered at home is 
not covered under the Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Cyclobenzaprine HCL.  
 
Benefits for Cyclobenzaprine HCL may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit at a tertiary care center. 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the enrollee's treatment can be safely rendered in-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 provider at issue in this case is not a network provider with the Plan. 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 physician reviewer found radiation services can be done 
by a competent in-network provider. 
 
 
 
 
 
 
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. 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 the services. Therefore, we decided that the Plan does not have to pre-approve an office visit at a 
tertiary care center.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional OT visits. 
 
You asked the Plan to pre-approve additional OT visits. You say that the services are necessary. The Plan 
denied your request. The Plan says the services are not necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional OT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found based on the documentation provided, the health plan's denial should 
be upheld. The enrollee does not have documented OT needs. OT services are not required to establish a 
maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, as a 
practical matter, can be provided at a lower level of care (ex. restorative nursing). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional OT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 10 additional OT visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prolonged inpatient care billed for services provided on 
June 28, 2020. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the 
documentation does not support the billed 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, the CPT Code Manual definition of code 99356 is prolonged service in the inpatient or observation 
setting, requiring unit/floor time beyond the usual service; first hour (List separately in addition to code for 
inpatient Evaluation and Management service).  
 
We find that CPT code 99356 is not supported in the medical record. Based on this information, we decided 
that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for the prolonged inpatient care billed for services provided on June 28, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for MRI's and does not have to waive the 
coinsurance for an injection provided on March 23, 2020. 
 
You asked the Plan to waive the copayments for MRI's and to waive the coinsurance for an injection. You say 
that you were quoted as only owing one $110 copayment for the MRI's as they were provided on the same day. 
The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the 
correct 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 $110 
copayment for each radiological diagnostic service. Your contract with the Plan also clearly says that you must 
pay 20% coinsurance for Medicare Part B prescription drugs. 
 
You received three MRI's on March 23, 2020. Therefore, you are responsible to pay a $110 copayment per 
each MRI. The total amount you owe is: $330.  
 
You received an injection on March 23, 2020. The allowed amount is $26.25 and 20% of that is $5.25.  
 
The total amount you owe is: $335.25.   
 
 
You have been asked to pay the total amount of $335.25 for MRI's and an injection. MRI's fall within the 
outpatient diagnostic tests and therapeutic services and supplies benefit category. An injection falls within 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 copayments for 
MRI's and does not have to waive the coinsurance for an injection provided on March 23, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay 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 above 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 the enrollee has stabilized medically and is 
ready for discharge from the hospital. The enrollee does not require skilled nursing and/or skilled therapy 
services on a daily basis. The enrollee is medically stable and can receive further rehab services at a lower level 
of care.  Although further rehab services would be appropriate to improve function, as a practical matter, the 
daily skilled services can be provided at a lower level of care than a skilled nursing facility. The enrollee does 
not have any parental medication; complex wound care or nutrition given via a feeding tube. The enrollee is 
medically stable without any acute exacerbations of chronic medical problems. The enrollee's physical function 
is at or near their baseline and they can receive services at a lower level of care. Admission to a SNF for 
 
 
inpatient skilled rehab services is not medically 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.