Persius/hicric huggingface dataset:
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 need IRF care. The Plan denied your request. 
The Plan says rules for IRF care have not been met. 
 
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 on review of the available records you have a left hip fracture and recent surgery. 
You are medically stable and do not need physical medicine and rehabilitation physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical 
conditions. An uncomplicated hip fracture patient 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. You need 
physical therapy and occupational therapy at a lower intensity level. More so with your age and fatigue level, 
you will not tolerate IRF level of therapies. IRF admission is not medically necessary based on lack of medical 
complexity, and lack of acute rehab nursing needs. Document does not support the necessity for admission to 
an IRF. While you may benefit from therapy services, your rehab needs can be safely met in an alternate and 
lower intensity setting such as in a skilled nursing facility. 
 
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 admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found no required skilled nursing services are 
identified. Your needs appear to be custodial. Any therapy services could be provided at a lower level of care. 
The documentation does not support that it is medically reasonable and necessary to provide skilled therapy 
services to you on a "daily basis" on an inpatient basis, in a skilled nursing facility 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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF is not 
medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have daily 
skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and 
judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled 
therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services received on November 1, 2021. 
 
You asked the Plan to pay for the services. You say that you went to the chiropractor for a back and foot 
problem instead of having surgery. The Plan denied your request. The Plan says only manual manipulation of 
the spine is covered to correct subluxation. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The manual manipulation of the spine was covered with applicable copayment. However, the other services are 
not a covered benefit according to your Medicare and plan benefits. 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 pay for chiropractic services received on November 1, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation and psychotherapy 
provided from August 14, 2021, through September 1, 2021. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation and psychotherapy. You say that you have 
been going to this provider for years and she has helped. You say that you want to continue with this provider. 
The Plan denied your request. The Plan says the provider opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care.  
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
psychiatric diagnostic evaluation and psychotherapy provided from August 14, 2021, through September 1, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit, and electrocardiogram 
provided on August 15, 2021. 
 You asked the Plan to pay for the emergency department visit and electrocardiogram. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are 
not covered. 
 
The Plan must follow Medicare rules. Medicare does not pay for services provided to enrollees in custody 
under a penal statute unless certain criteria are met.  
 
We looked at the file and Medicare rules. The file shows that the enrollee was in custody at the time these 
services were provided as evidenced by the records. Medicare payment may not be made for these services. 
Therefore, we decided that the Plan does not have to pay for the emergency department visit, and 
electrocardiogram provided on August 15, 2021.
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 transfer to an SNF is in your best interest, and you 
are a high risk for readmission, falls, and failure at home. The Plan denied your request. The Plan says you are 
currently receiving adequate and necessary care in an inpatient rehabilitation facility (IRF) and these services 
have not been denied. All the services you need are being offered in your current setting, and transfer to an 
SNF is not medically necessary. The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not have identifiable skilled nursing 
needs which would require the specialized skill, knowledge and judgement of a skilled professional nurse to 
safely and effectively provide medically necessary and reasonable treatment. You do have skilled therapy 
needs, but you do not require these skilled therapy services on a daily basis in an inpatient setting. As a 
practical matter, you do not meet the severity of illness or intensity of service criteria for an inpatient basis in a 
skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infrared therapy and acupuncture provided on August 31, 
2020. 
  You asked the Plan to pay for infrared therapy and acupuncture. You say that medical records are attached, and 
the claim should be reconsidered. The Plan denied your request. The Plan says a licensed acupuncturist is not a 
covered physician. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. These treatments may be provided by a physician in accordance with state requirements, or 
by physician assistants, nurse practitioners/clinical nurse specialists, and auxiliary personnel if they meet 
certain licensure requirements. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, a licensed acupuncturist is not a covered physician. 
Therefore, we decided that the Plan does not have to pay for infrared therapy and acupuncture provided on 
August 31, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) of the 
inner spine provided on September 13, 2021. 
 
You asked the Plan to waive the copayment for an MRI of the inner spine. You say that the test was performed 
incorrectly, and the images were blank. 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 a $150 
copayment for diagnostic radiological services, including MRIs.  
 
The medical records show the MRI was successfully completed. You have been asked to pay a $150 
copayment for an MRI of the inner spine. An MRI of the inner spine falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 a magnetic resonance imaging (MRI) of the inner spine provided on September 13, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for a neurostimulator generator and neurostimulator 
leads provided on August 6, 2021. 
 
You asked the Plan to waive the coinsurance for a neurostimulator generator and neurostimulator leads. You 
say that you did not know the neurostimulator generator and neurostimulator leads were prosthetics. The Plan 
denied your request. The Plan says that 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. Your 
contract with the Plan says that enrollees must pay 0% coinsurance for durable medical equipment except 
motorized wheelchairs and electric scooters. 
 
The neurostimulator generator and leads are not prosthetic devices. They are categorized as durable medical 
equipment medical/surgical supplies. The Plan says you must pay 20% coinsurance for a neurostimulator 
generator and neurostimulator leads. Based on the Plan contract, however, you cannot be asked to pay more 
than 0% coinsurance for a neurostimulator generator and neurostimulator leads. Therefore, we decided that the 
Plan has to waive the coinsurance for a neurostimulator generator and neurostimulator leads provided on 
August 6, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) to the sacroiliac (SI) 
joint. 
 
You asked the Plan to pre-approve RFA to the SI joint. You say that this is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says RFA to SI Joint is 
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 RFA to the SI joint. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the review indicates that the enrollee is a 69-year-old male with a history of 
sacroiliac dysfunction. He has been treated with medical therapy including opiates and sacroiliac joint 
injections. His provider is requesting an SI joint RFA. According to the literature, sacral lateral nerve branch 
blocks and/or ablations/neurotomies for the diagnosis and/or treatment of sacroiliac joint mediated pain is 
considered experimental and investigational.  Studies completed say that this procedure does not improve 
outcomes compared to standard treatment of SI joint pain. Radiofrequency ablation for denervation, whether 
performed using traditional, cooled, or pulsed radiofrequency, is considered investigational and therefore, 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 to the SI joint have not been met. Therefore, we decided that the Plan does 
not have to pre-approve radiofrequency ablation (RFA) to the sacroiliac (SI) joint.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667). 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no mention of edema or swelling on the abdominal wall. 
 
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 there is no documentation in the history or examinations recorded that you have lymphedema of the 
chest, trunk, or abdomen. As the medical records provided do not document that the enrollee has lymphedema 
of the chest, trunk, or abdomen, no documentation has been provided that the enrollee has unique 
characteristics that would indicate the segmented pump over a standard pump. The records do report a trial 
with a standard pump; however, this trial did not last four weeks as required. 
 
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 a pneumatic compression device (E0652, E0667).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Arformoterol. 
 
You asked the Plan to pre-approve Arformoterol. You say that this is medically reasonable for the enrollee's 
condition. The Plan denied your request. The Plan says step therapy criteria have not been met. 
 
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 Arformoterol. Our reviewer says that 
the requested drug is not medically reasonable and necessary. Our physician reviewer found the record 
indicates that the enrollee has chronic obstructive pulmonary disease.  The requested medication is a new start.  
The provided records do not indicate that the enrollee has tried and failed the Plans preferred step one 
alternative. The record does not indicate that the enrollee has a contraindication to, or would have an adverse 
effect from the plan's preferred step one alternative. The elements of the coverage criteria are not satisfied. The 
requested service cannot be 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 Arformoterol have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Arformoterol.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ER visit provided on September 29, 2020. 
 
You asked the Plan to pay for the ER visit. You say that the family will not submit the claim for Medicare 
payment or denial. You say that the claim should be processed, and payment should be sent. The Plan denied 
your request. The Plan says the member will need to pay the provider then submit the claim for reimbursement. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ER visit have not been met. Therefore, we decided that the Plan does not have to pay for the 
ER visit provided on September 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy duty, multiple braking system, variable wheel 
resistance walker. 
 
You asked the Plan to pre-approve the walker. You say that the doctor prescribed this walker, and you need it. 
The Plan denied your request. The Plan says you are able to use a standard walker. 
 
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 walker. Our reviewer says that the 
requested walker is not considered medically reasonable and necessary in this case. Our physician reviewer 
found based on the medical records provided, there is no documentation that the enrollee meets the criteria for 
a heavy duty, multiple braking system, variable wheel resistance walker as records do not document that you 
are unable to use a standard walker due to a severe neurologic disorder or any other condition causing the 
restricted use of one hand. 
 
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 walker have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a heavy duty, multiple braking system, variable wheel resistance walker.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve coagulation factor II prothrombin (F2) and factor V 
Leiden (F5) gene testing. 
 
You asked the Plan to pre-approve F2 and F5 genetic testing. You say that this testing is needed for diagnosis. 
The Plan denied your request. The Plan says these tests are not covered by Medicare except for pregnant 
patients. 
 
The Plan must follow Medicare rules. Medicare rules say that F2 and F5 genetic testing are considered 
investigational for all indications except for pregnant women.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of F2 and F5 genetic testing have not been met. Therefore, we decided that the Plan does not have to 
pre-approve coagulation factor II prothrombin (F2) and factor V Leiden (F5) gene testing.