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

 
We decided that the Plan does not have to pre-approve the insertion of an interlaminar/interspinous process 
stabilization/distraction device for the enrollee. 
 
You asked the Plan to pre-approve the device. 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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found these interlaminar spacer devices are 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the insertion of an interlaminar/interspinous process stabilization/distraction device for the 
enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for massage therapy. 
 
You asked the Plan to provide coverage for massage therapy. You say that you have severe arthritis in your 
joints making it very difficult for you to move and do normal home care. You say you have a bi-weekly 
chiropractic adjustment and weekly therapeutic massages by the masseuse at the chiropractic center that allows 
you to be able to move and care for yourself and your family with less pain and difficulty. The Plan denied 
your request. The Plan says massage therapy is not covered by Medicare and excluded on your Plan. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to provide coverage for massage therapy.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine 
without contrast to be rendered by the out-of-network (OON) provider. 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says there are in-network providers available to render the 
requested service. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the service at issue in this appeal.  We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the 
Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine without contrast to 
be rendered by the out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Special Supplemental Benefits for Chronically Ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI. You say that you would like the Plan to reconsider their denial. The 
Plan denied your request. The Plan says you do not meet criteria as you do not have a need for intensive case 
management. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI have not been met. Specifically, the file shows that you do not have a need for intensive 
case management. Therefore, we decided that the Plan does not have to pre-approve Special Supplemental 
Benefits for Chronically Ill (SSBCI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cochlear device (L8614). 
 
You asked the Plan to pre-approve Cochlear device (L8614). You say that the requested Cochlear device 
(L8614) is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria 
for the requested Cochlear device (L8614). 
 
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 Cochlear device (L8614). Our reviewer 
says that the enrollee does not meet criteria for the requested Cochlear device (L8614). Our physician reviewer 
found the record indicates that the enrollee has unilateral sensorineural hearing loss. The record does not 
indicate that the enrollee is enrolled in a FDA-approved category B investigational device exemption clinical 
trial as defined at 42 CFR 405.201, a trial under the Centers for Medicare & Medicaid (CMS) Clinical Trial 
Policy as defined at section 310.1 of the National Coverage Determinations Manual, or a prospective, 
controlled comparative trial approved by CMS as consistent with the evidentiary requirements for National 
Coverage Analyses and meeting specific quality standards. The elements of the coverage criteria are not 
satisfied.  The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Cochlear device (L8614) have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Cochlear device (L8614).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for magnetic resonance imaging (MRI) of the spine and 
brain stem provided on September 3, 2021, and November 8, 2021. 
 
You asked the Plan to waive the coinsurance for the MRI's. The Plan denied your request. The Plan says that 
the correct coinsurance was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay $0 for each advanced imaging service, such as MRI's.  
 
The Plan says you must pay a 20% coinsurance for the MRI's. Based on the Plan contract, however, you cannot 
be asked to pay more than $0 for the MRI's. Therefore, we decided that the Plan has to waive the coinsurance 
for magnetic resonance imaging (MRI) of the spine and brain stem provided on September 3, 2021, and 
November 8, 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occupational therapy evaluation for driver's license 
(97166) provided January 20, 2022. 
 
You asked the Plan to pay for the occupational therapy evaluation for driver's license. You say that this service 
was required for your driver's license renewal. The Plan denied your request. The Plan says this service is not 
covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. Driving assessments provided under an occupational therapy plan of care are covered only when there 
is a reasonable expectation that the patients ability to drive will be restored or improved. The need for the 
assessment must be related to the presence of, or recovery from, a specific injury or illness. 
 
We looked at the file and Medicare rules. The occupational therapy evaluation for your drivers license renewal 
was not performed in relation to a specific injury or illness to restore your ability to drive. Based on this 
information, we decided that Medicare rules for coverage of the occupational therapy evaluation for driver's license have not been met in this case. Therefore, we decided that the Plan does not have to pay for the 
occupational therapy evaluation for driver's license (97166) provided January 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on September 17, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that your receptionist did not know you were out-of-
network. The Plan denied your request. The Plan says the services were provided out-of-network and were not 
approved in advance. 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit provided on September 17, 2021 by 
an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from June 
11, 2020, to June 17, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider has reported inpatient hospital services with the incorrect DRG.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 388 (G.I. OBSTRUCTION WITH MCC). 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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found the 
review indicates that the he member was admitted to the hospital with epigastric abdominal pain without any 
radiation due to partial small bowel obstruction. Although the physician documented acute pancreatitis due to a 
mildly elevated lipase of 100, the following day the lipase levels were 71, 48 and the member did not have 
persistent, severe epigastric pain. The abdominal pain resolved as the partial small bowel obstruction resolved. 
Listing of acute pancreatitis in the medical record was not supported by the documentation. In summary, 
K85.90 (acute pancreatitis without necrosis or infection, unspecified) was not substantiated as a valid 
diagnosis. DRG 389: OBSTRUCTION WITH CC is the appropriate DRG.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from June 11, 2020, to June 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) rendered by the out-of-network 
(OON) provider on November 18, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99203) rendered by the out-of-network (OON) provider on  
November 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150) provided February 9, 2022. 
 
You asked the Plan to pay for the comprehensive oral exam. You say that you feel the provider should have 
verified insurance.  The Plan denied your request. The Plan says you have exceeded the frequency limit for this 
service. 
 
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. The Plan covers the 
comprehensive oral exam once every three calendar years.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive 
exam was previously covered on September 15, 2020. Based on this information, we decided that the Plan's frequency limit for coverage of the comprehensive oral exam has been exceeded. Therefore, we decided that 
the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) 
provided February 9, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3 home health physical therapy visits. 
 
You asked the Plan to pre-approve 3 home health physical therapy visits. 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 must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services.  
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 3 home health physical therapy visits. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found based on the 
medical records provided there is no documentation that skilled therapy services are required to effectively 
provide treatment, care, and/or services in order to improve your level of function, or to establish/perform a 
maintenance program to maintain your level of function and/or prevent deterioration. Provided records do not 
document a skilled need. You are walking 125 feet with a rolling walker with stand-by to contact guard 
assistance and is stand-by assist for transfers. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 3 home health physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 3 home health physical therapy visits.
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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing 
needs or skilled therapy needs. You are not shown to have an acute decline in function. Daily skilled services 
are not required to establish a maintenance program or to prevent deterioration of your condition. Your care 
needs, custodial and intermittent, can, 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 skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Minuteman G3R Interspinous device. 
 
You asked the Plan to pre-approve a Minuteman G3R Interspinous device. 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 a Minuteman G3R Interspinous device. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the minuteman device is experimental. More research is needed to 
show 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 a Minuteman G3R Interspinous device have not been met. 
 
 
 
  
 Therefore, we decided that the Plan does not have to pre-approve a Minuteman G3R Interspinous device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture treatment to be rendered by the out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says there are in-network providers available to render the 
requested service. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the service at issue in this appeal. We found no exception that would require the 
Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve acupuncture 
treatment to be rendered by the out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 home health occupational therapy and 3 home health 
physical therapy. 
 
You asked the Plan to pre-approve 2 home health occupational therapy and 3 home health physical therapy. 
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 must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 
 
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 2 home health occupational therapy and 
3 home health physical therapy. Our reviewer says that the services are not medically necessary. Our physician 
reviewer found you do not have documented, ongoing, home health skilled therapy needs. As such, the 
requested, home health skilled therapy services are not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 2 home health occupational therapy and 3 home health physical therapy have 
not been met. Therefore, we decided that the Plan does not have to pre-approve 2 home health occupational 
therapy and 3 home health physical therapy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. 
 
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 long term acute care hospital (LTACH) 
services.