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

 
We decided that the Plan does not have to pre-approve a left total knee arthroplasty. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no record of a completed course of supervised physical therapy. 
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that detailed documentation is not evident regarding a trial and failure of recent, reasonable, and 
comprehensive less invasive conservative care measures to include any injection therapy outside of the steroid 
injection. Additionally, there is documentation of an elevated BMI at 41 kg/m2 (portending plausible 
suboptimal outcomes and without evidence of a trial of weigh loss). There are limited large-scale, long-term 
references showing the safety and efficacy of the requested surgery in this clinical setting. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested left total knee arthroplasty, 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 the surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a left total knee arthroplasty.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the enrollee has not met 
the step therapy requirements. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia. Our reviewer says that Prolia is 
not medically reasonable and necessary in this case. Our physician reviewer found that the Plan requires a 
history of osteoporosis-related fracture or a trial of zoledronic acid before they will approve the requested drug. 
In this case, the enrollee has not tried and failed the required drug. There is no documentation provided 
indicating that the Plans required drug would likely be less effective and/or likely have adverse effects for the 
enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate during spinal surgery. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical studies have not proven that this request is better than standard allograft 
products during spinal surgery. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no specific indication provided to support the request for bone marrow aspirate for the 
approved surgery. There is a lack of large-volume, long-term peer-reviewed outcome studies to support the use 
of bone marrow aspirate for this enrollees medical condition as discussed above. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the requested bone marrow aspirate during spinal surgery, 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bone marrow aspirate during spinal surgery.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve fat grafting as part of a spinal surgery. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there are no medical indications for fat grafting as a routine part of this procedure. 
 
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 the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the records show that the patient had an unexpected dural tear during surgery which is a known 
intraoperative complication. The fat graft is part of the repair process for the dural tear and is the care standard. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pre-
approve fat grafting as part of a spinal surgery.  
 
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 pre-approve a right hip arthroplasty. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is insufficient clinical documentation to show that the criteria has 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 the surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that detailed documentation is not evident regarding a trial and failure of recent, reasonable, and 
comprehensive less invasive conservative care measures. Additionally, the imaging studies corroborated only 
mild-appearing degenerative change. There are limited large-scale, long-term references showing the safety and 
efficacy of the requested surgery in this clinical setting. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
requested right hip arthroplasty, 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 the surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a right hip arthroplasty.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from inpatient 
rehabilitation services due to their medical complexity. The Plan denied your request. The Plan says when the 
enrollee is ready to leave the hospital, they can safely receive care in another setting, such as a Skilled Nursing 
Facility (SNF), at home with home health services or outpatient setting if appropriate. 
 
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 there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program.  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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on July 20, 
2022. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you did not receive the test 
you needed. 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 a $50 
copayment for urgently needed services.  
 
You have been asked to pay a $50 copayment for an urgent care visit. This item/service falls within the 
urgently needed 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 copayment for an urgent 
care visit provided on July 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for an esophagogastroduodenoscopy. 
 
You asked the Plan to waive the cost sharing for an esophagogastroduodenoscopy. You say that you should not 
be responsible to pay this because you paid your deductible which was $200. 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. Your 
contract with the Plan says that there is a $750 deductible which applies to the outpatient hospital surgery 
services. Your contract with the Plan also clearly says that you must pay a $250 copayment outpatient hospital 
surgery services.  
 
 
 
 The item or service you asked the Plan to waive the cost sharing for falls within the outpatient hospital surgery 
services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is a $750 deductible which applies to the outpatient hospital surgery services benefit category. This cost sharing 
is a contractual obligation that had not been met at the time an esophagogastroduodenoscopy was received on 
July 21, 2022. At the time this claim was processed $677.16 was applied to your deductible.  
 
You have also been asked to pay $108.42, which is less than the standard $250 copayment amount for an 
esophagogastroduodenoscopy. You have been asked to pay a total of $785.58 ($677.16 deductible + $108.42 
copayment = $785.58). This item/service falls within the outpatient hospital surgery services benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. 
Therefore, we decided that the Plan does not have to waive the cost sharing for an 
esophagogastroduodenoscopy.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (87481, 87798) provided on March 
16, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you want the Plan to pay for the services. 
The Plan denied your request. The Plan says the provider is not a network provider, and the services were not 
urgent or emergent, nor were they 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 laboratory services (87481, 87798) provided 
on March 16, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the breast 
(77049). 
 
You asked the Plan to pre-approve a breast MRI. The Plan denied your request. The Plan says this service is 
not medically necessary. 
 
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 a breast MRI. Our physician reviewer 
found there were no abnormal physical findings of the breasts, a screening mammogram was negative, and 
importantly had breast parenchyma classified as showing scattered fibroglandular elements meaning they are 
not extremely or heterogenously dense. The bilateral whole breast ultrasound provided on June 20, 2022, was 
negative. An annual screening with conventional imaging has been recommended. Our reviewer found that the 
enrollee does have one first degree relative (mother) with a history of breast cancer, but there has been no 
documented genetic mutation including breast cancer gene. Also, there is no calculation of lifetime risk of 
breast cancer exceeding 20% using Tyrer-Cuzick or Gail models is in the records.  Our physician reviewer also 
found that without these accepted criteria as indications for a breast MRI the medical necessity of the requested 
breast MRI has not been established in the submitted records. 
 
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 breast MRI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a magnetic resonance imaging (MRI) of the breast (77049).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a medical eye examination and evaluation (92004) to be 
provided by an out-of-network provider. 
 
  You asked the Plan to pre-approve a medical eye examination and evaluation (92004). You say that you had a 
head injury and some eye problems and the provider who treated you passed away. You also say he passed on 
your files to this provider and mentored her. The Plan denied your request. The Plan says the services are 
available in your service area with participating providers. 
 
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 they are in-network. 
 
We looked at the file and the Plan's rules. The Plan rules say that routine vision services are only covered when 
they are received by a participating provider. The record shows the requested provider is not in-network, and 
the Plan has providers available who are in-network. Based on this information, we decided that the Plan's rules 
for coverage of a medical eye examination and evaluation (92004) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a medical eye examination and evaluation (92004) to be provided by 
an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pride Essential Power lift chair recliner (A9270). 
 
You asked the Plan to pre-approve the recliner chair. You say that this recliner is medically necessary due to 
your severe osteoarthritis in you left hip that affects your mobility and balance. 
 The Plan denied your request. The Plan says a Pride Essential Power Lift Chair Recliner is not a covered 
benefit by Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve Pride Essential Power lift chair recliner (A9270).
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 around the clock care is needed to ensure 
your health. The Plan denied your request. The Plan says the request 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 that you do not require services at the LTACH that are not available at the acute care 
hospital where you currently receiving care. All medically necessary care is being provided in the current acute 
care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Minuteman procedure (22612, 22840, 20930, 20931). 
 
You asked the Plan to pre-approve Minuteman procedure. You say that this procedure is medically necessary 
for the enrollee. The Plan denied your request. The Plan says the requested procedure 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 Minuteman procedure. Our reviewer 
says that the requested Minuteman procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the requested procedure is considered experimental. Therefore, the reviewer 
found that the requested Minuteman procedure is not 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 Minuteman procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Minuteman procedure (22612, 22840, 20930, 20931).
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 you are appealing the denial. The Plan 
denied your request. The Plan says the request 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 that you do not require services at the LTACH that are not available at the acute care 
hospital where you currently receiving care. All medically necessary care is being provided in the current acute 
care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) (64635) for the 
sacroiliac (SI) joint. 
 
You asked the Plan to pre-approve RFA. You say that the enrollee had 80% relief from 2 medial branch blocks 
(MBBs). You also say that this request should be approved. 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 RFA. Our reviewer says that the 
requested RFA for SI joint is not considered medically reasonable and necessary in this case. Our physician 
reviewer found radiofrequency ablation is considered experimental when used at the sacroiliac (SI) joint. 
Therefore, the reviewer found that RFA for the SI joint is not 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 RFA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve radiofrequency ablation (RFA) (64635) for the sacroiliac (SI) joint.