Persius/hicric huggingface dataset:
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 enrollee is now appropriate for SNF level of 
care. The Plan denied your request. The Plan says based on Medicare guidelines, the requested SNF services do 
not meet the requirements for approval. 
 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the power wheelchair purchased on June 16, 2022, from a 
provider not certified by Medicare. 
 
You asked the Plan to pay for the power wheelchair. You say that this device was medically necessary for the 
enrollee. The Plan denied your request. The Plan says Medicare requires specific evaluations be done prior to 
approval of any power wheelchair. 
 
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 power wheelchair purchased on June 
16, 2022, from a provider not certified by Medicare.
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 requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you received oral medications, had stable vital signs and your lungs were clear. You 
do not require skilled nursing or therapy services on a daily basis. You do not meet 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with multiple 
power options, including power tilt and power recline seating, and other components and accessories. 
 
You asked the Plan to pre-approve the Group 3 PWC with multiple power options. You say that it is felt that 
the requested PWC is needed. The Plan denied your request. The Plan says the criteria for this PWC are not 
met. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 PWC with multiple power options may 
only be covered when the enrollee meets criteria for a power tilt and power recline seating system. 
 
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 Group 3 PWC with multiple power 
options. Our reviewer says that the requested PWC base does not meet coverage criteria. Our physician reviewer found based on the medical records provided, there is no documentation that the enrollee meets the 
criteria for a power tilt and recline seating system, thereby allowing coverage for the group 3 power wheelchair 
with multiple power options as defined by Medicare's Local Coverage Determination. Provided records do not 
support that the enrollee is high risk for skin breakdown, has a history of pressure ulcer(s) or has had skin flap 
surgery. Records do not document the enrollee performs bladder self-catheterization and is unable to transfer 
independently or that the enrollee has increased muscle tone or spasticity.  
 
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 Group 3 PWC with multiple power options have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with multiple power 
options, including power tilt and power recline seating, and other components and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 3, 2021, billed with 
codes 81206, 81235, 81292, 81295, 81298, 81317, 81321, 81402, 81162, 81301, 81191, and 81309. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says this claim has not been billed as 
required by Medicare billing regulations. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 3, 2021, billed with codes 81206, 81235, 81292, 81295, 81298, 81317, 81321, 81402, 81162, 81301, 
81191, and 81309.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Coflex lumbar interspinous decompression device 
(22867, 22868). 
 
You asked the Plan to pre-approve a Coflex device. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the requested Coflex lumbar interspinous decompression device is unproven and 
not medically necessary due to insufficient evidence of efficacy. 
 
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 Coflex device. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found FDA indications include the Coflex device is for use in one- or two-level lumbar stenosis from 
L1- L5 in skeletally mature patients with at least moderate impairment in function, who experience relief in 
flexion from their symptoms of leg/buttocks/ groin pain, with or without back pain, and who have undergone at 
least 6 months of non-operative treatment. FDA contraindications include prior fusion or decompressive 
laminectomy, radiographically compromised vertebral bodies, severe facet hypertrophy, spinal instability, 
scoliosis, obesity, and osteoporosis, and which have not been adequately addressed in the medical records. 
There is imaging evidence of trace anterolisthesis of L3 on L4 in neutral and flexion. Height is 67 inches, 
weight is 164 pounds, and body mass index is 25.7 kg/m2. There is no discussion of scoliosis of the lumbar 
spine, with no documentation of the Cobb angle. The x-rays note osteoporosis with no discussion indicating 
that a DEXA scan has demonstrated the lack of significant osteoporosis in this enrollee. 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 a Coflex device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Coflex lumbar interspinous decompression device (22867, 22868).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient clinic visit provided on March 23, 2022, billed 
with principal diagnosis code Z80.3. 
 
You asked the Plan to pay for the outpatient visit as billed. You say that this should be paid due to medical 
necessity. The Plan denied your request. The Plan says this claim was reported with a principal diagnosis code 
from the Unacceptable Principal Diagnosis list. 
 The Plan must follow Medicare rules. Medicare rules say that outpatient hospital claims must be processed 
through the I/OCE.  
 
We looked at the file and Medicare rules. The claim was denied based on OCE 113. Per the Integrated OCE 
(IOCE) CMS Specifications V23.0, this edit is invoked when an unacceptable principal diagnosis code is 
reported. We have confirmed that code Z80.3 is listed as one of these unacceptable codes. Based on this 
information, we decided that Medicare rules for coverage of the outpatient visit as billed have not been met. 
Therefore, we decided that the Plan does not have to pay for the outpatient clinic visit provided on March 23, 
2022, billed with principal diagnosis code Z80.3.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure is considered medically 
necessary. The Plan denied your request. The Plan says the requested procedure is considered 
experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is a 72-year-old female being treated for spondylosis without 
myelopathy or radiculopathy of the lumbar region. In this case, detailed documentation is not evident regarding 
Modic changes at the requested level of L4-5. The use of intraosseous basivertebral nerve ablation has not been 
proven in the absence of Modic changes. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
Intracept intraosseous basivertebral nerve ablation at L4-5, 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar spinal fusion. 
 
You asked the Plan to pre-approve lumbar spinal fusion. You say that the enrollee's hardware is malfunctioning 
and limiting the enrollee's daily activities. The Plan denied your request. The Plan says the clinical information 
provided does not support that the requested service is medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that lumbar fusion is only covered for certain medical 
indications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve lumbar spinal fusion. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found detailed documentation is not 
evident regarding radiographic or clinical evidence of instability. There is no documentation of a spinal 
deformity which meets functional limitation in daily activities due to back pain or discomfort and non-
responsive to at least 1 year of non-operative treatment with sagittal or coronal imbalance (by at least 5cm as 
measured on radiographic imaging of the entire spine, progression of deformity by at least 10 degrees, or 
scoliotic curvature of greater than 30 degrees.) There is not pseudoarthrosis documented on the computed 
tomography (CT) scan from May 22, 2022. There is no symptomatic compression of neural elements for which 
disc excision is necessary for decompression. Therefore, he does not have an indication that allows for 
coverage of the requested surgery. 
 
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 spinal fusion have not been met. Therefore, we decided that the Plan 
does not have to pre-approve lumbar spinal fusion.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete mandibular denture (D5120). 
 
You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says your 
benefit for the requested item or service has already been exhausted. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service July 23, 2020. Therefore, 
we decided that the Plan does not have to pre-approve a complete mandibular denture (D5120).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient stay provided from April 14, 
2022, to April 18, 2022. 
 
You asked the Plan to waive the copayment for an inpatient stay. You say that you received a bill that said you 
owed $0, then got a second one that stated $300. The Plan denied your request. The Plan says you were 
charged this cost sharing 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 $300 
copayment per stay for inpatient hospital care.  
 
You have been asked to pay a $300 copayment per stay for an inpatient stay. An inpatient stay falls 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 an inpatient 
stay provided from April 14, 2022, to April 18, 2022.
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 LTACH is medically necessary. 
 The Plan denied your request. The Plan says the LTACH is not medically necessary, and the enrollee's needs 
are being met at the current facility. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is not required to discharge elsewhere to receive ongoing acute level 
care. The enrollee requires intravenous medications every eight hours, telemetry, daily labs, daily physician 
visits and physical and occupational therapies. There is no documentation provided indicating medical 
necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care 
hospital. 
 
 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.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not qualify for SNF coverage. You do not have documented skilled nursing 
needs. You do not have documented skilled therapy needs. 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 SNF care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for outpatient services on August 11, 2021. 
 
You asked the Plan to waive the coinsurance for outpatient services. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says the cost sharing you are being charged is 
correct. 
 
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 20% 
coinsurance for each Medicare-covered medical supply. Covered services included but are not limited to 
surgical supplies, such as dressings. The allowed amount is $8.80. $8.80 x 20% = $1.76. Therefore, results in 
the total cost sharing amount of $1.76. 
 
You have been asked to pay a 20% coinsurance for outpatient services. Outpatient services fall 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 coinsurance for outpatient services on August 11, 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 you are appealing the denial of the SNF care. The 
Plan denied your request. The Plan says the SNF care is not medically necessary, and your needs can be met at 
a lower level of care such as home with supervision or home health services. 
 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there are no identifiable skilled nursing service needs that require skilled nursing 
services, including the specialized skill, knowledge and judgment of a skilled professional nurse required to 
safely and effectively provide medically necessary and reasonable treatment. There are identifiable skilled 
therapy service needs that require skilled therapy services, including the specialized skill, knowledge and 
judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable 
treatment. You do not require skilled nursing or therapy services on a daily basis. You are walking household 
distances with supervision holding onto the hallway handrail. The records do not show a significant decline in 
your functional status to necessitate daily inpatient skilled therapy services. As a practical matter, you do not 
meet 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.