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

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553, K0554). 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose 
monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor (K0553, K0554).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro robotic orthosis (L8702). 
 
You asked the Plan to pre-approve a MyoPro orthosis. You say that the requested item is a medical necessity 
for the enrollee. The Plan denied your request. The Plan says medical necessity rules for coverage of the 
requested item have 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 a MyoPro orthosis. Our reviewer says 
that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the MyoPro orthosis is not known to be effective, based on scientific evidence, 
professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not 
in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro 
orthosis will improve the long-term outcomes for the enrollee, improve hemiparetic arm function, or be safe for 
long term use. There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a MyoPro orthosis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a MyoPro robotic orthosis (L8702).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the injection, collagenase, clostridium 
histolyticum (J0775) provided on December 29, 2021. 
 
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to 
the service provided. 
 
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 20% 
coinsurance for Part B drugs that are administered by an in-network provider.  
 
You have been asked to pay $810.36 (Plan allowed amount of $4,051.80 x 20% coinsurance) for the Medicare 
Part B drug injection provided.   
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 coinsurance for the injection, collagenase, clostridium histolyticum (J0775) 
provided on December 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral L5 medial branch blocks. 
 
You asked the Plan to pre-approve bilateral L5 medial branch blocks. You say that this service is medically 
necessary. The Plan denied your request. The Plan says the patient does not meet criteria for this service. 
 
The Plan follows Medicare rules. Medicare rules say that medial branch blocks are only covered when patients 
meet all of the criteria from the local coverage determination.  
 
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 bilateral L5 medial branch blocks. Our 
reviewer says that the requested medial branch blocks are not medically necessary. Our physician reviewer 
found the documentation does not support that the patient's symptoms are purely facet-related.  The patient has a history of radicular symptoms and a diagnosis of low back pain with radiculopathy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bilateral L5 medial branch blocks have not been met. Therefore, we decided 
that the Plan does not have to pre-approve bilateral L5 medial branch blocks.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve, 
including all imaging guidance 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the Intracept procedure is experimental. More research is 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 thermal destruction of intraosseous basivertebral nerve, including all imaging guidance
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyaluronan or derivative, Monovisc, for intra-articular 
injection. 
 
You asked the Plan to pre-approve Hyaluronan or derivative, Monovisc, for intra-articular injection. You say 
that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been 
established. Therefore, coverage criteria have 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 Hyaluronan or derivative, Monovisc, 
for intra-articular injection. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found in this case, records do not show failure of 
the steroid injection or that you experienced improvement in pain and functional capacity following the 
previous series of injections. The records did not indicate the response to these injections. The review has 
determined that the services at issue are not 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 Hyaluronan or derivative, Monovisc, for intra-articular injection have not been met. Therefore, we decided that the Plan does not have to pre-approve Hyaluronan or derivative, Monovisc, for 
intra-articular injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet injections. 
 
You asked the Plan to pre-approve facet injections. 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 follows Medicare rules. Medicare rules say that therapeutic facet joint procedures are considered 
medically reasonable and necessary when specific criteria are met. 
 
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 injections. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found in this case, the enrollee has 
radiculopathy. The review has determined that the enrollee does not meet the coverage criteria detailed in the 
LCD. 
 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on 
April 11, 2021 to April 14, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you cannot afford these 
charges. The Plan denied your request. The Plan says the copayment amount charged is correct. 
 
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 $295 
copayment per day, days 1 to 5 for inpatient hospital care.  
 
 
 
 You have been asked to pay a total of $885 for 3 days of inpatient hospital care (3 x $295). An inpatient 
hospital stay falls within the Inpatient Hospital Care 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 the inpatient hospital stay provided on April 11, 2021 to April 14, 2021.
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 this should be covered. The Plan denied your 
request. The Plan says needs can be met at a lower level of care such as a skilled nursing facility (SNF). 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  You were admitted for sepsis and a urinary tract infection and was discharged home. There is ongoing 
weakness. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that you will be able to 
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a surgical procedure (62321) performed on 
January 20, 2022. 
 
You asked the Plan to waive the copayment for the surgical procedure. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
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 $275 
copayment for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
 
  You have been asked to pay a $275 copayment for the surgical procedure. 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 surgical procedure (62321) performed on January 20, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care after October 14, 2021. 
 
You asked the Plan to pay for the SNF care. You say that you believe these services should be covered. The 
Plan denied your request. The Plan says SNF care as of October 14, 2021, was 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 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 pay for the SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found as of October 14, 2021, the member did not 
require any skilled nursing or rehab services on a daily basis. She was not expected to make measurable gains 
within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with 
mobility or activities of daily living. The member did not require skilled therapy to establish a safe and 
effective maintenance program. As a practical matter, the member did not require any skilled services on an 
inpatient basis, at a SNF level of care as of October 14, 2021. The member did not have any parental 
medications, complex wound care or nutrition given via a feeding tube. The member received skilled care and 
improved; however, her functional improvement had plateaued by 10/14/21 and she did not require any further 
inpatient skilled rehab services. The members function was at or near her prior level of function and she could 
be discharged to a lower level of care for further 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 the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) care after October 14, 2021.
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 you feel that this level of care is necessary. The Plan 
denied your request. The Plan says criteria for IRF are not met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the patient was admitted for a stroke. Medical problems are stable. There are no 
complex nursing or rehabilitation needs.  While the patient has a need for physical and/or occupational therapy, there is no documentation of a need for 
an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for admission to a skilled nursing facility (SNF) for the enrollee. 
 
You asked the Plan to pay for the admission. You say that the enrollee is unsafe to go home, because there is 
no family near. The Plan denied your request. The Plan says needs can be met at a lower 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 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 pay for the admission. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found based on the medical records provided 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. The records do not document the need for intravenous medications, new tube feeding 
or ostomy care or daily complex wound 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 the admission have not been met. Therefore, we decided that the Plan does not 
have to pay for admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total knee replacement (27447). 
 
You asked the Plan to pre-approve the total knee replacement. You say that the knee replacement procedure is 
medically necessary. The Plan denied your request. The Plan says coverage rules have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Total Knee Arthroplasty (TKA) is considered 
reasonable and necessary for individuals with Advanced joint disease and unsuccessful non-surgical medical 
management, when appropriate and attempted for a minimum of 3 months. 
 
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 total knee replacement. Our 
reviewer says that this procedure is not medically necessary. Our physician reviewer found the records 
provided do not document a failed trial of less invasive conservative treatments. Additionally, the exam does 
not reasonably reveal functional limitations to support the need for surgical intervention. 
 
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 total knee replacement have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a total knee replacement (27447).
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 you believe that the IRF level of care is necessary. 
The Plan denied your request. The Plan says your records do not show that you need therapy 3 hours a day 5 
days per week, nor do you need an intensive multidisciplinary team for your 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 in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 Our physician reviewer found the complexity of the members nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
member does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program.  
 
The member continues to have a need for skilled therapy with ongoing safety concerns and a potential for 
functional improvement however, the documentation doesnt support that he would meet criteria for admission 
to an acute inpatient rehabilitation facility.  There is no indication that the member would require skilled 
rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a physician 
with at least 3 visits weekly to regain or maintain his functional status.  
 
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.