Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Pride Go-Go Elite Traveler 3 Wheel . 
 
You asked the Plan to pre-approve the Pride Go-Go Elite Traveler 3 Wheel. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the records do not 
show that the member has had an evaluation by a therapist or by a provider qualified to conduct a home 
evaluation of the suitability of the device requested. 
 
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 Pride Go-Go Elite Traveler 3 
Wheel. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee is not noted to have inability to utilize a lesser 
device (lightweight manual wheelchair, standard manual wheelchair, or use of a walker). 
 
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 Pride Go-Go Elite Traveler 3 Wheel have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Pride Go-Go Elite Traveler 3 Wheel .
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the spinal cord stimulator. 
 
You asked the Plan to pre-approve the spinal cord stimulator. You say that you would like reconsideration 
because this device is medically necessary. The Plan denied your request. The Plan says fibromyalgia is not a 
recognized diagnosis for this equipment to be considered 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 spinal cord stimulator. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the member does not have any indication for the spinal cord stimulator and has not 
had an adequate trial of conservative therapy. 
 
 
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 spinal cord stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the spinal cord stimulator.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve an MRI of the pelvis (72195). 
 
You asked the Plan to pre-approve the MRI. You say that you would like reconsideration because the MRI is 
the gold standard to be able to evaluate if there is bony edema to indicate acute injury. The Plan denied your 
request. The Plan says that the results of prior imaging do not show why these are not sufficient for the 
evaluation of the current clinical condition. 
 
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 MRI. Our reviewer says that the 
member has persistent pain with a need for further study to characterize its etiology. Our physician reviewer 
found the requested MRI is medically reasonable and 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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
an MRI of the pelvis (72195).  
 
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 the powered upper extremity range of motion assist 
device. 
 
You asked the Plan to pre-approve the device. You say that you would like reconsideration because the 
member has exhausted traditional rehabilitation methods and less sophisticated medical devices. The Plan 
denied your request. The Plan says this device 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 device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested services are convenience items and not necessary above standard non-powered or 
robotic orthoses. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the powered upper extremity range of motion assist device.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that the member's chance to return home and maintain 
living at home will be significantly reduced if the opportunity to participate in acute rehab is denied. The Plan 
denied your request. The Plan says that the enrollee can safely receive the services needed in other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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. 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's medical status does not currently 
require intensive physician and nursing oversight only in an IRF. The patient may benefit from multiple 
therapies such as physical and occupational therapy but the documentation does not support that the patient's 
functional status requires an intensive rehabilitation therapy program provided in an IRF. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. 
 
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 for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee would be equally served with an alternate level of care. 
 
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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled 
nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to 
safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not 
have complex wound care or other ongoing SNF level SN need. The enrollee's functional level does not require 
skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely 
and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not require 
skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a 
practical matter, this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing 
facility setting. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for observation services, an emergency room 
visit, an inpatient hospital stay, and an x-ray provided on April 24, 2020 to May 3, 2020. 
 
You asked the Plan to waive the copayments for observation services, an emergency room visit, an inpatient 
hospital stay, and an x-ray. You say that you are upset with all these copayments. The Plan denied your request. 
The Plan says the correct copayments have been applied. 
 
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 $225 
copayment for outpatient hospital observation, a $90 copayment for emergency care, a $310 copayment per day 
for days 1-2 for inpatient hospital care, and a $30 copayment for outpatient diagnostic tests/x-rays.  
 
You have been asked to pay a $225 copayment for observation services, a $90 copayment for an ER visit, a 
$310 copayment per day for days 1-2 for an inpatient hospital stay, and a $30 copayment for an x-ray. The total 
amount you are being asked to pay is $955 ($225 + $90 + $610 + (30 = $955). 
 
Observation services falls within the outpatient hospital observation benefit category. An emergency room visit 
falls within the emergency care benefit category. An inpatient hospital stay falls within the inpatient hospital 
care benefit category. An x-ray falls within the outpatient diagnostic tests/x-rays 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 observation services, an emergency room visit, an inpatient hospital 
stay, and an x-ray provided on April 24, 2020 to May 3, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 5 additional skilled nursing home health visits. 
 
You asked the Plan to pre-approve the additional skilled nursing visits. You say that you would like 
reconsideration because the member requires more teaching on the disease process and medication monitoring. 
The Plan denied your request. The Plan says the member no longer requires skilled services and ending these 
services will not cause a decline in their current status. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 skilled nursing visits. Our 
reviewer says that the additional skilled nursing services are not medically necessary. Our physician reviewer 
found the member's needs are no longer skilled and warranting skilled nursing visits. 
 
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 skilled nursing visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 5 additional skilled nursing home health visits.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT Scan of the head or brain (70450). 
 
You asked the Plan to pre-approve the CT Scan. You say that you would like reconsideration because this 
service is medically necessary. The Plan denied your request. The Plan says the CT Scan would not show the 
provider all of the details needed in order to treat the member's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CT Scan. Our reviewer says that 
there is no clinical rationale for the requested CT scan of the head/brain. Our physician reviewer found the 
requested CT Scan 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 the CT Scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a CT Scan of the head or brain (70450).
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 above. 
 
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 records do not indicate that there are significant, or complex medical/nursing issues 
that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other 
medication management, wound care, and daily therapy can be provided at a SNF. In this case, you are mostly 
moderate-minimal assist for functional transfers and activities of daily living (ADL's) and a less intensive, 
longer duration of therapy will allow for measurable gains to be attained within a reasonable, and predicted 
period. An IRF intensity is not warranted. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a facet joint injection provided on June 6, 
2019. 
 
You asked the Plan to waive the copayment for a facet joint injection. You say that you did not go under or 
receive an incision and disagree with the surgery charges. 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 $250 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
You received a facet joint injection on June 6, 2019. A facet joint injection is considered an outpatient surgical 
procedure. Therefore, you are responsible to pay the $250 copayment.  
 
You have been asked to pay a $250 copayment for a facet joint injection. A facet joint injection falls within the 
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
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 copayment for a facet joint injection provided 
on June 6, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the requested additional 
transportation is necessary. The Plan denied your request. The Plan says the requested additional transportation 
trips exceed the benefit limit. Therefore, coverage criteria has not been met. 
 
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 a maximum of 30 one-way transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips (A0120).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Superion Vertiflex surgery (22869). 
 
You asked the Plan to pre-approve Superion Vertiflex surgery. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Superion Vertiflex surgery. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found current evidence based medical guideline and peer reviewed literature do 
not fully support the spinal decompression device procedure over the gold standard of lumbar laminectomy. 
There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for 
your medical condition. FDA indications include implantation of the Superion device at one or two adjacent 
lumbar levels for moderate spinal stenosis in patients in whom operative treatment is indicated at no more than 
two levels, from L1 to L5. These indications have not been met. There is imaging evidence of severe spinal 
canal stenosis L3/4 and L4/5 and severe neuroforaminal stenosis at L3/4, L4/5, and L5/S1. FDA 
contraindications include scoliosis (Cobb angle greater than 10 degrees) and osteoporosis, and have not been 
adequately addressed in the medical records. There is imaging evidence of levoscoliosis of the lumbar spine 
with no documentation of the Cobb angle. There is no discussion indicating that a DEXA scan has 
demonstrated no osteoporosis. The Superion Vertiflex procedure would not be considered the standard of care 
for your medical condition. Therefore, this request does not meet Medicare criteria as medically reasonable and 
necessary for treatment of your medical condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Superion Vertiflex surgery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Superion Vertiflex surgery (22869).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CTA (75635). 
 
You asked the Plan to pre-approve the CTA. You say that you would like reconsideration because this scan is 
medically necessary. The Plan denied your request. The Plan says the record does not show that there are 
associated changes in symptoms, ischemia or significant arterial disease or limb threatening vascular disease. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CTA. Our reviewer says that the 
documentation does not support the medical necessity of the study in question. Our physician reviewer found 
the documentation does not demonstrate that any clinician has a plan for how to use the information. The only 
lower extremity vascular element documented in the records provided is that the member has palpable pedal 
pulses. The need for clarity with respect to management is heightened as the study in question requires rapid 
volume injection of dye in a vein and the use of potentially nephrotoxic contrast dye. 
 
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 CTA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a CTA (75635).