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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not have a need for intravenous 
medications, new tube feeding, ostomy care or daily complex wound care. You are walking household 
distances with a rolling walker with contact guard assistance and is supervision for transfers. Provided records 
do not document a significant decline in your functional status compared to your recent baseline to necessitate 
daily inpatient skilled therapy services. You do not require the services on an inpatient basis, only in a skilled 
nursing facility setting. Services in the home with home health care or in a long-term care facility on a part time 
basis appear appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the positron emission tomography (PET) scan with 
concurrently acquired computed tomography (CT) scan from skull base to mid-thigh (78815). 
 
You asked the Plan to pre-approve the PET/CT scan services. You say that this service is necessary in order to 
find the extent of the disease in the enrollee. The Plan denied your request. The Plan says this service is non-
covered for the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scan services continue to remain non-
covered for initial anti-tumor treatment strategy in Medicare beneficiaries who have adenocarcinoma of the 
prostate Based on this information, we decided that Medicare rules for coverage of the PET/CT scan services 
have not been met. Therefore, we decided that the Plan does not have to pre-approve the positron emission 
tomography (PET) scan with concurrently acquired computed tomography (CT) scan from skull base to mid-
thigh (78815).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prochlorperazine for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
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 prochlorperazine for the 
enrollee.  
 Benefits for this drug 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous peripheral nerve stimulation services. 
 
You asked the Plan to pre-approve percutaneous peripheral nerve stimulation services. You say that this is 
medically necessary for the enrollee's condition. The Plan denied your request. The Plan says there are not 
enough studies to show the requested services are safe and effective. 
 
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 percutaneous peripheral nerve 
stimulation services. 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 a 54-year-old morbidly 
obese woman with bilateral knee osteoarthritis. The requested percutaneous peripheral nerve stimulation 
services would be an experimental/investigational procedure to treat knee pain.  Therefore, the request is deemed not medically reasonable or 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 percutaneous peripheral nerve stimulation services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve percutaneous peripheral nerve stimulation 
services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided from August 14, 2021, 
through September 13, 2021. 
 
You asked the Plan to pay for psychotherapy services. You say that you suffered from a major depressive 
episode, and you were hospitalized and this provider was recommended to you. You say that you were required 
to start therapy and this provider was the only one available on short notice. The Plan denied your request. The 
Plan says this provider type is not eligible in the Medicare program. 
 
The Plan must follow Medicare rules. Medicare rules say that a Marriage Family Therapist (MFT) is not 
eligible to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Marriage Family Therapist 
(MFT). Medicare says that a Marriage Family Therapist (MFT) is not eligible to participate in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for psychotherapy services provided from 
August 14, 2021, through September 13, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home infusion services. 
 
You asked the Plan to pre-approve home infusion services. You say that you have received these services in the 
past and they should be covered. The Plan denied your request. The Plan says these services are not eligible for 
payment according to Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of home infusion services have been met. 
Specifically, no medical records have been received that indicate the requested services are medically 
reasonable and necessary.  Therefore, we decided that the Plan does not have to pre-approve home infusion 
services.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the lumbar spine. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is no documentation of a failure of four weeks of conservative therapy. 
 
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 
requested MRI is medically reasonable and necessary. Our physician reviewer found you have attended 
physical therapy sessions, and have done an exercise program. The physical therapist has suggested epidural 
injections through a pain management provider. Pain management states that MRI is needed prior to injection, 
which is standard practice. You and your providers have made a good faith attempt at conservative 
management. 
 
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 
magnetic resonance imaging (MRI) of the lumbar spine.  
 
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: 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 SNF care. You say that SNF care is medically reasonable and necessary for 
the enrollee's condition. The Plan denied your request. The Plan says rules for SNF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee is a 95-year-old male with a past 
medical history of diabetes, hypertension, cardiovascular disease, vascular dementia, bilateral lower extremity 
amputations and hyperlipidemia who presented to the acute hospital on March 24, 2022, with generalized 
weakness. In this case, there is no documentation that the patient requires skilled nursing services, i.e., the 
specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and 
effectively provide medically necessary and reasonable treatment. Records do not document the need for 
intravenous medications, new tube feeding or ostomy care or daily complex wound care. While this patient 
does require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist 
are required to safely and effectively provide medically necessary and reasonable treatment. However, there is 
no documentation that daily skilled services are required. Provided records do not document a significant 
decline in the patients functional status compared to his recent baseline to necessitate daily inpatient skilled 
therapy services. Based on the medical records provided there is no documentation that the patient requires the 
services on an inpatient basis, only in a skilled nursing facility setting. Services in the home with home health 
care or in a long-term care facility on a part time basis appear appropriate in this case. 
 
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 admission to a skilled nursing facility (SNF).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on April 10, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that your 
friend called the paramedics without you knowing. You also say that you told them several times that you did 
not need the ambulance service. The Plan denied your request. The Plan says the ambulance charges are not 
covered because there was no transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 10, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on April 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a porcelain fused crown (D2752) provided by an out-of-
network provider on November 17, 2021. 
 
You asked the Plan to pay for a porcelain fused crown. You say that you would like the Plan to pay for this. 
The Plan denied your request. The Plan says D2752 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 Plans 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 a 
porcelain fused crown (D2752) provided by an out-of-network provider on November 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the total knee arthroplasty (27447) provided on October 11, 
2021. 
 
You asked the Plan to pay for the total knee arthroplasty. You say that you would like reconsideration because 
this service is payable for an assistant surgeon. The Plan denied your request. The Plan says this provider was 
not certified/eligible to be paid for this procedure. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS.  
 Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the total knee arthroplasty (27447) 
provided on October 11, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for an urgent care visit provided on October 23, 2021. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you only had a COVID-19 
rapid test at the urgent care center. You also say that there is no charge for COVID-19 testing for individuals on 
Medicare. The Plan denied your request. The Plan says that you have been charged the correct cost sharing 
amount. The Plan says no cost sharing applies to the COVID-19 test. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide medical records to show what services took place. 
Without medical records we cannot determine if additional services were provided besides a COVID-19 rapid 
test. Therefore, we are unable to determine if cost sharing applies. We decided that the Plan has to waive the 
copayment for an urgent care visit provided on October 23, 2021.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for a nuclear medicine study of the heart 
provided on October 13, 2021. 
 
You asked the Plan to reduce the coinsurance for a nuclear medicine study. You say that you were told there 
would be no extra charge. You also say you thought you would pay at least $50 not $250. 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 20% 
coinsurance for in-network radiological diagnostic services, including nuclear medicine testing.  
 
 You have been asked to pay $250.33, which is 20% of the allowed amount for a nuclear medicine study 
($1,251.64 allowed amount x 20% coinsurance = $250.33). A nuclear medicine study falls within the 
Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 reduce the coinsurance for a nuclear medicine study of the heart provided on October 13, 2021.  
 
Your complaint about the service you received by the office staff is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to 
insufficient evidence of efficacy. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee indicates that the enrollee has chronic low back pain and lumbar spinal stenosis with 
neurogenic claudication. The record indicates that the enrollee has multi-level lumbar spine disease including 
mild to severe stenosis at various levels. The record does not state that the enrollee is not indicated for 
operative intervention at no more than two levels. The elements of the coverage criteria are not satisfied.  
 
 
 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 Vertiflex device.
Appeal type: Surgery
Decision: Unfavorable

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

 
We decided that the Plan does not have to pre-approve facet joint injections.  
You asked the Plan to pre-approve facet joint injections. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because medial branch blocks are not reasonable and necessary after an anterior lumbar interbody fusion, 
which the enrollee has. 
 
The Plan follows Medicare rules. Medicare rules state that facet joint interventions are only covered for certain 
indications and are considered not reasonable and necessary when performed after anterior lumbar interbody 
fusion. 
 
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 facet joint injections. Our reviewer says 
that the enrollee does not meet the Medicare criteria for the requested facet joint injections. Our physician 
reviewer found the enrollee has had prior surgery at the requested levels and has several other probable pain 
generators. Therefore, this is not medically reasonable or 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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.