Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing visits. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found it is not clear from the submitted 
records that the enrollee is homebound, as he is able to attend primary care appointments. He does not have 
documented skilled nursing needs. His care needs appear to be custodial in nature. The requested services are 
not intermittent. The home health services are therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home health skilled nursing visits.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Budesonide. 
 
You asked the Plan to pre-approve Budesonide. You say that this is medically necessary. 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 Budesonide.  
 
Benefits for Budesonide 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) any joint of lower 
extremity; without contrast (73721). 
 
You asked the Plan to pre-approve an MRI of the knee. You say that the requested MRI of the knee is 
medically necessary. The Plan denied your request. The Plan says the requested MRI of the knee does not meet 
criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an MRI of the knee. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the exam reveals tenderness to 
palpation of the lumbar spine. There is a positive anterior drawer sign on the right side. X-rays of the right knee 
have impressions of chronic post-traumatic or post-surgical changes of the proximal anterior tibial; no acute 
fracture seen. Documentation is not evident regarding trial and failure of recent, reasonable, and comprehensive 
less invasive conservative care measures directed to the knee. Additionally, the findings noted on exam could 
not be reasonably attributable to an acute knee pathology versus low back problem. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. 
 
 
 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 MRI of the knee have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a magnetic resonance imaging (MRI) any joint of lower extremity; without contrast 
(73721).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar decompression at L3-4 and L4-5 surgery with a 
vertiflex device. 
 
You asked the Plan to pre-approve lumbar decompression surgery with a vertiflex device. You say that the 
requested lumbar decompression surgery procedure is medically necessary. The Plan denied your request. The 
Plan says the requested lumbar decompression surgery procedure does not meet criteria. 
 
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 lumbar decompression surgery. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the vertiflex device is experimental. There is insufficient evidence of 
efficacy and 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 lumbar decompression surgery have not been met. Therefore, we decided that 
the Plan does not have to pre-approve lumbar decompression at L3-4 and L4-5 surgery with a vertiflex device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neurology services provided to the enrollee on September 24, 
2021. 
 
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 did not bill as required by Medicare coding regulations. 
 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 G0453 
is a column II code to column I code 95887. 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 neurology services provided to the enrollee on September 24, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH). 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says you are receiving appropriate in-patient acute care and does not require 
transfer to a Long-Term Acute Care Hospital (LTACH). 
 
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 that in this case, you admitted with altered mental status due to symptomatic 
bradycardia requiring pacemaker placement. The record indicates that you are improving but still require acute 
care services. You continue to receive acute care services and these have not been denied. The medical record 
does not indicate that you require services that you are not currently receiving but that would be available at the 
LTACH facility. The elements of the coverage rules are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a long term acute care hospital (LTACH).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve Stereotactic Body Radiation Therapy (SBRT) services. 
 
You asked the Plan to pre-approve SBRT services. You say that this procedure is medically necessary to treat 
the enrollee's cancer. The Plan denied your request. The Plan says that the requested SBRT services are 
unlikely to result in clinical cancer control and/or functional improvement. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SBRT services. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found that for this patient, 3 prior sites of metastases have been ablated and the recent chest computed 
tomography scan showed growing lung metastases and 2 that are stable. Part of the basis for denial was that all 
lesions are not to be treated. The clinical records are a bit contradictory as they state that the lesions are too 
small for SBRT (which is subjective) and that they would be treated in the future. The letter of appeal notes 
that they were not positron emission tomography (PET) avid (recent PET was not in the case file) though they 
are likely too small for accurate PET characterization.  
 
On the basis of standard medical necessity criteria, the treatment offered to this patient - SBRT to 2 sites of 
oligoprogression among 4 lesions seen on imaging could be considered to be furnished in accordance with 
accepted standards of medical practice, acknowledging that the data supporting this treatment continue to arise. 
 
The LCD allow for treatment of lung metastases but specify that the tumor burden be completely encompassed 
with acceptable toxicity risks. It is a judgement call as to whether or not this applies, as 2 lesions are not to be 
treated now, but based on serial imaging and PET/CT (per appeal letter) those 2 sites are not active. As the 
patient has only 2 sites of active disease, without widespread other sites of disease (with only 2 lesions that 
seem inactive) the requested services appear 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 SBRT services have been met. Therefore, we decided that the Plan has to pre-
approve Stereotactic Body Radiation Therapy (SBRT) services.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a back injection procedure performed on 
October 22, 2021. 
 
You asked the Plan to waive the coinsurance for the injection. You say that the procedure should be fully 
covered by the Plan. The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
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 15% 
coinsurance for each outpatient surgical service up to a maximum of $200.  
 
You have been asked to pay $60.66, which is 15% of the allowed amount for the injection ($404.41 allowed 
amount x 15% coinsurance = $60.66). The injection falls within the Outpatient Hospital Services 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 a back injection procedure performed on 
October 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care (99223) provided on September 3, 
2021. You asked the Plan to pay for the hospital care. You say that these services were billed appropriately and are 
supported in the record. The Plan denied your request. The Plan says this service was billed with Place of 
Service (POS) code 21, which is designated for inpatient hospital care. However, the documentation shows that 
the enrollee was outpatient on the date of services. This claim is not supported as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules state that for services rendered to a patient who is registered inpatient or an outpatient of a hospital, the 
correct POS code, regardless of where the face-to-face service occurs, is that of the appropriate inpatient POS 
code (at a minimum POS code 21) or that of the appropriate outpatient hospital POS code (at a minimum POS 
code 19 or 22, for outpatient services performed off campus or on campus). 
 
We find that POS code 21 is not supported in the medical record. Specifically, the record reflects that the 
enrollee was outpatient observation status at the time of services and was not inpatient status. Based on this 
information, we decided that Medicare rules for coverage of the hospital care have not been met. Therefore, we 
decided that the Plan does not have to pay for the initial hospital care (99223) provided on September 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient rehabilitation services provided 
from March 26, 2021, to April 5, 2021. 
 
You asked the Plan to waive the copayment for the inpatient rehabilitation services. You say that you were 
informed by staff that it would be 100% covered. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $185 per 
day for days 1-5 and $0 per day after day 5 for each hospital stay.   
The file shows that you were in the rehabilitation facility from March 26, 2021, to April 5, 2021. Therefore, 
you have been asked to pay $185 per day for the first 5 days of inpatient rehabilitation services. The total for 
your stay is $925 ($185 copayment x 5 days = $925). Please note that this copayment applies to both hospital 
and rehabilitation facility admissions. The inpatient rehabilitation services fall 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 inpatient rehabilitation services 
provided from March 26, 2021, to April 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G Orthotic device for the enrollee. 
 
You asked the Plan to pre-approve a MyoPro Motion G Orthotic device. You say that this item would 
immediately restore her arm function and range of motion. The Plan denied your request. The Plan says that 
this device has deluxe features that exceed the enrollee's need and replaces, rather than improves the function 
of the enrollee's arm. 
 
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 Motion G Orthotic device. 
Our reviewer says that a MyoPro Motion G Orthotic device is not considered medically reasonable and 
necessary in this case. The requested robotic orthosis is not proven to be more beneficial for treatment of the 
patient's medical condition/function of hemiparesis after stroke than any available standard therapy such as 
conventional treatments for post stroke hemiparesis therapy including constraint induced movement therapy, 
conventional muscle strengthening, and botox for spasticity if needed. The requested device is not reasonable 
and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a 
malformed body member. The MyoPro 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 this patient, 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. Our physician reviewer found that the enrollee's condition does not meet criteria for 
coverage of a MyoPro Motion G Orthotic device. 
 
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 Motion G Orthotic device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a MyoPro Motion G Orthotic device for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 16 skilled nursing visits, 11 physical therapy visits, and 
11 occupational therapy visits. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee did not qualify for home 
health services on October 9, 2021. She did not have documented skilled nursing needs or skilled therapy 
needs. She is functioning at a level that does not require home health skilled care. The services are not 
reasonable or medically necessary at this time. 
 
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 pre-approve 16 skilled nursing visits, 11 physical therapy visits, and 11 occupational therapy visits.
Appeal type: Drugs
Decision: Partially Favorable

 
We decided that the Plan has to hold you harmless for the therapeutic radiology simulation-aided field setting 
(77280). We decided that the Plan does not have to waive the copayment for radiation treatment delivery.  
 
You asked the Plan to hold you harmless for the therapeutic radiology simulation-aided field setting (77280) 
and waive the copayment for the radiation treatment delivery (77401).  
 
You say that you would like reconsideration because you were authorized for 16 sessions. The Plan says that 
the cost share applied is correct and the denied services are not billable to you. 
 
We decided that the Plan has to hold you harmless for the therapeutic radiology simulation-aided field 
setting (77280).  
 
The Plan follows Medicare rules. Medicare rules say that a contract provider is an agent of the plan. Services 
and referrals given by a contract provider are considered approved by the plan unless notice is provided that the 
services will not be covered. The Plan follows these rules. 
 
We looked at your request, the file and Medicare rules. You were referred for the therapeutic radiology 
simulation-aided field setting by a contract provider. The file does not show that the Plan provided notice that 
this service would not be covered. Under Medicare rules, this means the therapeutic radiology simulation-aided 
field setting is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless 
for the therapeutic radiology simulation-aided field setting (77280).  
 
We also decided that the Plan does not have to waive the copayment for radiation treatment delivery 
(77401). 
 
The Plan follows Medicare rules. Medicare rules say that a health 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 $60 copayment for radiation therapy. 
 
You have been asked to pay a $27.01 copayment for each radiation therapy service. This means that you have 
been asked to pay less than your contracted 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 hold you harmless for radiation treatment delivery. 
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on April 29, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider is not 
enrollee in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
 
 
 
 Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the services provided on April 29, 2021.