Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the femoral nerve injection. 
 
You asked the Plan to pre-approve the femoral nerve injection. You say that your knees need to be cured as it is 
very severe, and you have osteoporosis. You say that you are requesting the service be approved. The Plan 
denied your request. The Plan says this type of injection is considered experimental/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 femoral nerve injection. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is an experimental/investigational procedure. 
 
  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 femoral nerve injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the femoral nerve injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the medical care during a specialist office 
visit provided on September 29, 2021, and October 5, 2021. 
 
You asked the Plan to waive the copayment for the medical care during a specialist office visit. You say that 
you should have no copayment because you have been receiving this treatment for years and never paid one. 
The Plan denied your request. The Plan says the claim processed correctly under the enrollee's specialty 
physician copayment as the treatment occurred in an office visit with the specialist. 
 
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 $25 
copayment for In-network Consultation, diagnosis, and treatment by a Specialty Care Physician. The total 
copayment amount for both visits was $50 ($25 copayment per visit x 2 visits). You have been asked to pay a $50 copayment for the medical care during a specialist office visit. The medical 
care during a specialist office visit falls within the Physician/Practitioner services, including doctors office 
visits 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 medical care during a 
specialist office visit provided on September 29, 2021, and October 5, 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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that a lower level of care will not be sufficient for the 
enrollee. The Plan denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing 
needs can be provided 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 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. The enrollee is medically stable and does not need physical medicine and rehabilitation physician close 
supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations 
of chronic medical conditions. There are no rehab nursing needs identified or documented in the record. The 
enrollee does not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per 
week with multidisciplinary approach to daily therapy in an IRF. He needs routine physical and occupation 
therapy and that can be safely provided in a skilled nursing facility. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit, blood oxygen level test, specimen handling, 
and coronavirus testing provided on October 8, 2021. 
 
You asked the Plan to pay for the coronavirus screening. You say that the services were required in order to 
travel out of the country. The Plan denied your request. The Plan says Medicare does not cover tests or 
examinations when there are no symptoms or signs of disease. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. The rules also say that routine services required by 
third parties such as business establishments are not covered by Medicare. 
 
The test at issue in this appeal, the coronavirus screening, was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for the office visit, blood oxygen level test, specimen handling, and coronavirus testing provided 
on October 8, 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 would like the IRF services covered. The Plan 
denied your request. The Plan says the records do not show the need for the intensity of an IRF or full-time 
access to a doctor or skilled rehabilitation nurse. 
 
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 that you are medically stable and do not need physical medicine and 
rehabilitation physician close supervision 3 times per week (at a minimum) for the ongoing management of any 
active or acute exacerbations of chronic medical conditions. There are no rehabilitation nursing needs identified 
or documented in the record. You do not need intensive therapies, consisting of at least 3 hours of therapy per 
day at least 5 days per week with multidisciplinary approach to daily therapy in an IRF. You need routine 
physical therapy and occupational therapy and that can be safely provided in a skilled nursing facility. An IRF 
admission is not medically necessary based on medical stability and lack of medical complexity, and lack of 
rehabilitation nursing needs. The documentation does not support the necessity for admission to an IRF. While 
you may benefit from physical therapy and occupational therapy, your rehabilitation can be safely provided at a 
lower intensity and alternate 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 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 pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF 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 did not qualify for SNF coverage on April 
19, 2022. You did not have documented skilled nursing needs. You did not have documented skilled therapy 
needs. Your care needs, custodial and intermittent, could, as a practical matter, be provided at a lower level of 
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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xiidra. 
 
You asked the Plan to pre-approve Xiidra. You say that the enrollee needs this medication. The Plan denied 
your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug 
plan. 
 
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 Xiidra.  
 
Benefits for Xiidra 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Hematology Profile Plus testing rendered on March 18, 
2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were 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 pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee has Waldenstrom 
macroglobulinemia. The limited clinical documentation does not support that the Hematology Profile Plus testing was medically reasonable and necessary. It has not been demonstrated that the testing met but did not 
exceed, the enrollee's medical need, and was at least as beneficial as an existing and available medically 
appropriate alternative. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the Hematology Profile Plus testing rendered on March 18, 2021.
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 stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. 
 
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 enrollee appears to be more stable and improving but requires only short-term 
additional acute care services that can be safely administered at the current facility such as stabilizing feeding 
and diarrhea and until appropriate for a lower level of care. The enrollee does not require services at the 
LTACH that are not already available at the current facility. There are no services at the LTACH that the 
enrollee requires that are not already available and covered at the current facility. Transfer to LTACH is not 
medically necessary as it would not be clinically advantageous. Transfer to a lower level of care may be 
considered when treatment has completed. 
 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuous glucose monitor (CGM) (K0554) and 
supplies (K0553). 
 
You asked the Plan to pre-approve the CGM and supplies. You say that the item is medically necessary. The 
Plan denied your request. The Plan says the member does not require insulin with atleast three daily injections. 
 
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 CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
continuous glucose monitor (CGM) (K0554) and supplies (K0553).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the interspinous process fixation device. 
 
You asked the Plan to pre-approve the interspinous process fixation device. You say that the enrollee failed 
conservative treatment including epidural steroid injections and physical therapy. You say that surgical 
interventions become a treatment choice when conservative treatments fail, and the denial should be 
overturned. The Plan denied your request. The Plan says the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the interspinous process fixation device. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that interspinous process fixation device fusion remains experimental. 
More research is needed to how safety and efficacy.  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 interspinous process fixation device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the interspinous process fixation device.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of SNF care from April 22, 2022, forward. 
 
You asked the Plan to pre-approve SNF care. You say that you are due to be discharged and have staples on 
your leg and toe area due to your recent amputation surgery. You state you are unable to walk more than thirty 
(30) feet with a walker, have paid and are exhausted. The Plan denied your request. The Plan says the stay is 
not medically necessary based on SNF 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 based on the medical records provided there is 
no documentation that you require 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. You do 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. There is no documentation that further daily skilled services are required. 
You are walking household distances with a wheeled walker with minimum assistance and is stand-by assist 
for transfers. Provided records do not document a significant decline in your functional status to necessitate 
daily inpatient skilled therapy services. There is no documentation that you 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 continuation of SNF care from April 22, 2022, forward.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus gene panel provided on April 20, 2021. 
 
You asked the Plan to pay for the gene panel. You say that the system connects physicians with the most up-to-
date treatment options. The Plan denied your request. The Plan says codes should not be unbundled. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the gene panel was billed with multiple codes. If a single procedure is performed, only one code 
with one unit of service may be reported for the procedure. Based on this information, we decided that 
Medicare rules for coverage of the gene panel have not been met. Therefore, we decided that the Plan does not 
have to pay for the Tempus gene panel provided on April 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transurethral waterjet ablation services. 
 
You asked the Plan to pre-approve the requested services. You say that the procedure is low risk and highly 
effective. The Plan denied your request. The Plan says you do not meet the requirements. 
 The Plan must follow Medicare rules. Medicare rules say that transurethral waterjet ablation is 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 you have benign prostatic hyperplasia and lower urinary tract symptoms. The records do 
not show that the coverage criteria have been met. Specifically, prostate volume of 30-150 cc by transrectal 
ultrasound was not provided, International Prostate Symptom Score (IPSS) was not equal to 12, a maximum 
urinary flow rate was not provided, and failure, contraindication or intolerance to at least 3 months of 
conventional medical therapy was not documented. 
 
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 transurethral waterjet ablation services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Skilled Nursing Facility services. 
 
You asked the Plan to pre-approve the Skilled Nursing Facility services. You say that the services are 
medically necessary. The Plan denied your request. The Plan says coverage criteria has 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 the Skilled Nursing Facility services. 
Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there is no 
documentation that the patient requires the services on an inpatient basis in a skilled nursing facility setting. 
Services in a long-term care facility on a part time basis are 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 the Skilled Nursing Facility services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Skilled Nursing Facility services.