Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health care. 
 
You asked the Plan to pre-approve inpatient mental health 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 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 mental health care. Our 
physician reviewer found based upon review the records provided, this patient does not meet the criteria for 
treatment in an acute inpatient mental health treatment beyond the date in question of October 23, 2020, 
forward and could have been treated in a lesser restrictive setting as he was not showing any suicidal or 
homicidal ideation, auditory but no visual hallucinations and was not showing any behaviors or aggression 
being cooperative and compliant while not showing any acute threats to safety. 
 
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 mental health care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient mental health care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Superion interspinous spacer (Vertiflex device). 
 
You asked the Plan to pre-approve Vertiflex device. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Vertiflex device. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee chronic low back pain. The requested spacer remains experimental. More research 
is needed to show the safety and efficacy of the device. Therefore, the enrollee does not meet criteria for the 
requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Superion interspinous spacer (Vertiflex device).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve heated chemotherapy into the abdomen (hyperthermic 
intraperitoneal chemotherapy). 
 
You asked the Plan to pre-approve hyperthermic intraperitoneal chemotherapy. 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 hyperthermic intraperitoneal chemotherapy 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 hyperthermic intraperitoneal 
chemotherapy. Our reviewer says that the documentation does not support that the requested services are 
medically reasonable or necessary. Our physician reviewer found the enrollee has metastatic colon cancer. The 
requested use does not meet the Medicare criteria for heated intra-abdominal chemotherapy. The requested use 
is not in connection with radiation therapy for the treatment of primary or metastatic cutaneous or subcutaneous 
superficial malignancies. Therefore, the enrollee does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hyperthermic intraperitoneal chemotherapy have not been met. Therefore, we 
decided that the Plan does not have to pre-approve heated chemotherapy into the abdomen (hyperthermic 
intraperitoneal chemotherapy).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 4, 2020, by an out 
of network (OON) provider. 
 
You asked the Plan to pay for cataract surgery. You say that this procedure was medically necessary, and you 
were unaware that this would not be covered because you were out-of-network. The Plan denied your request. 
The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the 
Plan and the enrollee self-directed for service. 
 
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. You sent additional records 
regarding a referral for this service, however those records show that the referral was denied by 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 medical services provided on 
February 4, 2020, by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care, each additional 30 minutes (99292) provided 
November 29, 2019. 
 
You asked the Plan to pay for critical care services. You say that please see attached medical records. The Plan 
denied your request. The Plan says the records do not support the service billed. 
 
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 99292 is critical care, each additional 30 minutes, in 
addition to the first 30-74 minutes of a critical care evaluation and management service (CPT code 99291). 
 
We find that CPT code 99292 is not supported in the medical record. Specifically, the submitted medical 
records document 45 minutes of critical care time. They do not support that an additional 30 minutes of critical 
care services was performed in addition to the first 30-74 minutes of a critical care evaluation and management 
service. Based on this information, we decided that Medicare rules for coverage of critical care services have 
not been met. Therefore, we decided that the Plan does not have to pay for critical care, each additional 30 
minutes (99292) provided November 29, 2019.
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 enrollee has severe deficits due to a complicated 
hospital course and requires intensive therapy with frequent physician oversight. The IRF criteria are clearly 
met. The Plan denied your request. The Plan says the enrollee's needs can be met in a skilled nursing facility. 
 
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 the enrollee was admitted due to possible stroke for which tPA was administered. 
This was complicated by a brain hemorrhage requiring frontal craniotomy and hemorrhage evacuation on 
10/8/2020. Course notable for respiratory failure, needing intubation, atrial fibrillation needing diltiazem, 
agitation needing IV medications, urinary retention needing Foley, aspiration pneumonia, oral candidiasis, 
thrombocytosis, anemia, leukocytosis, and increasing potassium.  
 
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 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee joint injections provided from March 9, 2020, 
through March 11, 2020 billed with CPT code 20611. 
 
You asked the Plan to pay for the knee injections. You say that these services should be paid as they were 
medically necessary and have been paid on other dates of service. The Plan denied your request. The Plan says 
the documentation does not support the use of code 20611 for the rendered services. 
 
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 20611 is Arthrocentesis, aspiration and/or injection, 
major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent 
recording and reporting. 

We find that CPT code 20611 is not supported in the medical record. Specifically, the records do not clearly 
document that a permanent recording was made and reported. Based on this information, we decided that 
Medicare rules for coverage of the knee injections have not been met. Therefore, we decided that the Plan does 
not have to pay for the knee joint injections provided from March 9, 2020, through March 11, 2020 billed with 
CPT code 20611.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is a reasonable alternative of going home with family and increased caregiver 
assistance, per the most recent therapy evaluations. 
 
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 you do not have documented skilled 
nursing needs. You do not have documented skilled therapy needs. Daily skilled services are not required to 
establish a maintenance program or to prevent deterioration of your condition. Your care needs, custodial and 
therapeutic, can, as a practical matter, be provided at a lower level of care (ex. intermittent therapy, restorative 
nursing therapy, HHS, 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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
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 medically necessary. The Plan 
denied your request. The Plan says the enrollee's needs can be met at a lower level of care. 
 
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 in this case, the complexity of the patient's nursing, medical and rehabilitation needs 
do not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete maxillary denture provided on May 28, 2020. 
 
You asked the Plan to pay for the complete maxillary denture. You say that you are upset that the Plan will not 
pay for this denture. You also say that the receptionist should have called for approval, and you can barely pay 
the bills you have. The Plan denied your request. The Plan says this service is not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
complete maxillary denture provided on May 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint injection. 
 
You asked the Plan to pre-approve sacroiliac joint injection. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve sacroiliac joint injection. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that you have a diagnosis of joint disorder. You had a SI joint injection on September 
2, 2020 that notes indicate had 50 percent improvement with pain. The requested service is only covered when 
the documentation demonstrates at least 75 percent reduction of pain for the expected duration of the anesthetic 
following and image guided contrast enhanced intra-articular SI joint injection on 2 separate occasions. The 
minimally invasive SI joint fusion notes procedure setting as outpatient does not meet the criteria for coverage 
as you did not have successful outcome from injection. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sacroiliac joint injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve sacroiliac (SI) joint injection.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve left knee surgery (Arthroplasty, knee, condyle and plateau; medial 
OR lateral compartment). 
 
You asked the Plan to pre-approve left knee surgery. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says that the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 left knee surgery. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee presents with a 5-year history of chronic right knee pain. Functional limitations are 
noted due to pain. Clinical exam findings are consistent with radiographic evidence of severe end-stage 
osteoarthritic changes in the medial compartment with associated bone-on-bone joint space narrowing, 
periarticular osteophyte formation, subchondral sclerosis, and cystic changes. The enrollee has failed to achieve 
adequate improvement with activity modification, medications, physical therapy, home exercise program, 
corticosteroid injection, and viscosupplementation injections. Current evidence based medical literature would 
support this request as safe and effective for the enrollee's severe knee osteoarthritis limited to the medial 
compartment. This enrollee has a diagnosis, condition, and/or symptoms that meet the Medicare criteria for 
unicompartmental knee arthroplasty. Therefore, this request for left knee medial compartment arthroplasty 
would be considered the standard of care, and medically reasonable and necessary for treatment of the 
enrollee's end-stage osteoarthritis. 
 
Review of the file shows that the plan uses Local Coverage Determination, LCD L36007 and L36575 to 
support their denial. However, neither of these LCDs are valid for the enrollee's home state of Montana. 
Therefore, we cannot use LCD L36007 or L36575 to substantiate our decision. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of left knee surgery have been met. Therefore, we decided that the Plan has to pre-
approve left knee surgery (Arthroplasty, knee, condyle and plateau; medial OR lateral compartment).  
 
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is not medically necessary. The Plan denied your 
request. The Plan says this is 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 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 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's 
medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee 
may benefit from multiple therapies such as physical and occupational therapy but the documentation does not 
support that the enrollee's functional status requires an 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar spine fusion for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says this surgery is not indicated. 
 
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 surgery. Our reviewer says that the 
requested surgery is not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no documentation of spinal instability, fracture, or lesion. This is not medically 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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a lumbar spine fusion for the enrollee.