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

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee does meet the requirements for an IRF 
admission and will benefit from the IRF services that cannot be accomplished at a lower level of care. The Plan 
denied your request. The Plan says the requested IRF admission does not meet the requirements for approval. 
 
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 enrollees nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the enrollee may have a need for physical therapy 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 the enrollee 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 an IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve carpal tunnel release surgery. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has carpal tunnel syndrome 
with severe, limiting symptoms. The Plan denied your request. The Plan says there is no median nerve 
compression. 
 
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 requested services. Our physician 
reviewer found that the enrollee presented with left-hand numbness. He has been noticing numbness over the 
left hand, especially over the middle, ring, and small fingers for the last 10 months. There is pain throughout 
his forearm. There is associated dull ache. There is weakness with use of the left hand. The left carpal tunnel 
exam reveals Tinels sign is positive into the middle, ring, and small fingers. The median nerve compression 
test is positive into the ring and small fingers. Light touch sensation is decreased in the median nerve 
distribution, including the middle finger. Thumb abduction strength is 4/5. However, detailed documentation is not evident regarding a trial and failure of recent, reasonable, 
comprehensive less invasive conservative care measures. Additionally, the electrodiagnostic testing was not 
clearly documented to corroborate left-sided carpal tunnel syndrome. No compelling rationale is presented, or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
requested carpal tunnel release surgery, in this case, is not indicated for the enrollees condition and 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve carpal tunnel release surgery.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after April 
2, 2023. 
 You asked the Plan to pre-approve SNF care after April 2, 2023. You say that the continued admission to a 
SNF is medically necessary. The Plan denied your request. The Plan says the continued admission to a SNF is 
not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed 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 after April 2, 2023. Our 
reviewer says that the requested SNF care is not considered medically reasonable and necessary based on 
Medicare guidelines. Our physician reviewer found you do not have daily skilled nursing needs that require the 
specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled 
therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. 
You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility 
(SNF) 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 SNF care after April 2, 2023, have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continued skilled nursing facility (SNF) care after April 2, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is ready and stable for 
transfer to LTACH. This is the best option for a full recovery. The Plan denied your request. The Plan says the 
request is not medically necessary because the enrollee is receiving the care they need in the hospital where 
they are now and there is no need to transfer to the LTACH currently. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81204 billed for date of service June 13, 
2022. 
 
You asked the Plan to pay for procedure code 81204. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says payment for code 81204 is bundled into payment for 
code 81448. 
 
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, we have confirmed that code 81204 
is a column II code to column I code 81448. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 81204 billed for date of service June 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L1 kyphoplasty. 
 
You asked the Plan to pre-approve L1 kyphoplasty. 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 percutaneous vertebroplasty and percutaneous 
vertebral augmentation (PVA or Kyphoplasty) procedures will be considered medically reasonable and 
necessary 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 L1 kyphoplasty. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no compelling rationale is 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Therefore, the requested L1 kyphoplasty, in this case, 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 L1 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L1 kyphoplasty.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Spinal Computer Assisted Intraoperative Navigational 
Procedure (61783). 
 
You asked the Plan to pre-approve a Spinal Computer Assisted Intraoperative Navigational Procedure. You say 
that the service is medically necessary. The Plan denied your request. The Plan says this service is considered 
experimental. 
 
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 Spinal Computer Assisted 
Intraoperative Navigational Procedure. Our reviewer says that the requested service is not considered medically 
reasonable and necessary in this case. Our physician reviewer found Computer assist is not needed for this case 
of spine surgery. Outcomes have not been shown to be better with computers.  
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 Spinal Computer Assisted Intraoperative Navigational Procedure have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a Spinal Computer Assisted 
Intraoperative Navigational Procedure (61783).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid provided on November 2, 2022. 
 
You asked the Plan to pay for the hearing aid. You say that you are not a contracted provider and were not told 
that the enrollee had to use a network provider. The Plan denied your request. The Plan says the service is not a 
covered benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when provided by a network provider. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network which means the 
service is not a covered benefit. Based on this information, we decided that the Plan's rules for coverage of the 
hearing aid have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aid 
provided on November 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultralightweight manual wheelchair (K0005) and 
accessories. 
 
You asked the Plan to pre-approve an ultralightweight manual wheelchair and accessories. You say that the 
item is medically necessary. The Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that an ultra-lightweight manual wheelchair ((K0005) is 
covered for a beneficiary if criteria listed in Medicare Rules section 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 an ultralightweight manual wheelchair 
and accessories. Our reviewer says that the member does not need this item. Our physician reviewer found 
there is a lack of clinical documentation, specifically the patients level of mobility, supporting the need for an 
ultralight manual wheelchair. The mobility evaluation indicates that the patient is non-ambulatory, but clinical 
documentation indicated that the patient could ambulate without difficulty. Her upper extremity motor strength 
is also noted to be 5/5 and it is not clear why she requires an ultralightweight manual wheelchair versus a 
standard or lightweight manual wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an ultralightweight manual wheelchair and accessories have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an ultralightweight manual wheelchair 
(K0005) and accessories.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the refraction provided on November 29, 2022. 
 
You asked the Plan to pay for the refraction. You say that you thought this would be covered under your 
medical benefits because you had a stroke. You say you did not get any eyeglasses. The Plan denied your 
request. The Plan says that the benefit has been exhausted. 
 
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 submit documentation showing they had previously paid for a 
refraction on April 25, 2022. Therefore, we decided that the Plan has to pay for the refraction provided on 
November 29, 2022.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the belatacept injections provided from 
June 20, 2022, to December 5, 2022. 
 
You asked the Plan to waive the coinsurance for the injections. You say that you say that you should not have 
to pay for the injections. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 Medicare Part B prescription drugs.  
 
You have been asked to pay 20% coinsurance for the belatacept injections provided from June 20, 2022, to December 5, 2022.  
 
Date of Service Item Allowed Amount 20% Coinsurance 
June 20, 2022 belatacept injection $807.02 $161.40 
July 18, 2022 belatacept injection $806.43 $161.29 
August 8, 2022 belatacept injection $806.43 $161.29 
October 10, 2022 belatacept injection $941.52 $188.30 
December 05, 2022 belatacept injection $1,287.58 $257.52 
 
These items/services fall within the Medicare Part B prescription drugs benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the coinsurance for the belatacept injections provided from June 20, 2022, to December 
5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you would like to appeal the Plan's denial. 
The Plan denied your request. The Plan says the criteria for eligibility have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cala Trio device which is an external upper limb 
stimulator used to help decrease tremors (K1018, K1019). 
 
You asked the Plan to pre-approve a Cala Trio device. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is considered experimental. 
 
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 Cala Trio device. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered experimental. 
 
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 Cala Trio device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Cala Trio device which is an external upper limb stimulator used to help decrease 
tremors (K1018, K1019).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an advanced prosthetic foot, identified by codes L5981 and L5986. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says that the 
request exceeds the enrollee's needs. 
 
The Plan follows Medicare rules. Medicare rules say that lower limb prostheses are only covered under certain 
medical 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 the requested services. Our physician 
reviewer found that the enrollee lives in assisted living and is able to walk up and down uneven ground, jog a 
few steps and is independent in activities of daily living. Per coverage criteria, the flex walk system is available 
for a level 3 (K3) walker. The enrollee walks at a K3 level. The enrollees physician has recommended the K3 
system. The Plan has not provided reasonable evidence to the contrary. Therefore, the request 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 requested services have been met. Therefore, we decided that the Plan has to 
pre-approve an advanced prosthetic foot, identified by codes L5981 and L5986.  
 
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not 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 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 you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation 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 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.