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

 
We decided that the Plan does not have to pre-approve the bone marrow aspiration. 
 
You asked the Plan to pre-approve the bone marrow aspiration 
. You say that you would like reconsideration because the requested service is medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of bone marrow aspirate in the setting of 
spinal fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
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 bone marrow aspiration 
. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found there is no specific indication provided to support the request for bone 
marrow aspirate for the approved surgery. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of bone marrow aspiration in conjunction with the 
planned cervical spine 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.  
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 bone marrow aspiration 
 have not been met. Therefore, we decided that the Plan does not have to pre-approve the bone marrow 
aspiration.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for a health club membership. 
 
You asked the Plan to reimburse you for a health club membership. You say that you didnt know 
reimbursement for the health club membership had a deadline. The Plan denied your request. The Plan says the 
member missed the timeframe to submit reimbursement for the 2020 Wellness Allowance benefit. 
Reimbursement requests must be received by the Plan by no later than March 31st of the following year 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
The Plans rules for coverage of gym benefits have not been met because you missed the timeframe to submit 
reimbursement for the 2020 Wellness Allowance benefit. Therefore, we decided that the Plan does not have to 
reimburse you for a health club membership.
Appeal type: Practitioner Services
Decision: Unfavorable

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

 
We decided that the Plan does not have to pay for the self-administered drugs provided on July 27, 2021, and 
July 28, 2021. 
 
You asked the Plan to pay for the self-administered drugs. The Plan denied your request. The Plan says self-
administered drugs are not covered by Medicare, and therefore is not covered by your healthcare plan. The Plan 
also says that you are responsible for this amount. 
 
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 pay for the self-administered drugs 
provided on July 27, 2021, and July 28, 2021.  
 Benefits for the self-administered drugs 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: 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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 the enrollee does not require at least 3 hours a day/5 days a week, or 15 hours over 7 
consecutive days, of therapy services. The documentation does not support that there is a reasonable 
expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair and patient lift (E1038, E0630). 
 
You asked the Plan to pre-approve the manual wheelchair and patient lift. You say that the wheelchair and lift 
are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. Medicare rules state that mechanical patient lifts are only covered for those that 
would be bed confined without the use of the device. 
 
The file shows that you have already been provided with a power wheelchair. The power wheelchair serves the 
same purpose as the requested manual wheelchair. No medical records were provided to show that the enrollee 
is confined to a bed without the mechanical lift. Therefore, we decided that the Plan does not have to pre-
approve a manual wheelchair and patient lift (E1038, E0630).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the left shoulder surgery-reverse total shoulder 
arthroplasty. 
 
You asked the Plan to pre-approve the left shoulder surgery-reverse total shoulder arthroplasty. You say that 
you would like reconsideration because the requested procedure is medically necessary. The Plan denied your 
request. The Plan says there is no peer-reviewed literature to support the medical necessity of this procedure 
without documented active range of motion of greater than 90 degrees and intact deltoid function. 
 
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 left shoulder surgery-reverse total 
shoulder arthroplasty. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found detailed documentation is not evident 
regarding magnetic resonance imaging (MRI) evidence of a large, irreparable rotator cuff. Additionally, the 
provided exam does not demonstrate pseudoparalysis, as range of motion values were not noted and not 
demonstrated for both active and passive motion. 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 to 
guidelines. 
 
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 left shoulder surgery-reverse total shoulder arthroplasty have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the left shoulder surgery-reverse total 
shoulder arthroplasty.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided to the enrollee on September 8, 
2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the destination is not a covered benefit. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patients health. The Plan follows the same rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the 
documentation does not support that other means of transport were contraindicated. The enrollee did not 
require the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped 
ambulance can provide for safe transport on September 8, 2021. 
 
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 pay for ambulance services provided to the enrollee on September 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit, removal of skin lesion and removal of 
foreign body provided by an out-of-network provider on September 8, 2021. 
 
You asked the Plan to pay for the office visit, removal of skin lesion and removal of foreign body. You say that 
you were unaware the provider is not participating and did not know the service required a referral. You say 
that the provider rendered service based on medical necessity and the services should be reimbursed. The Plan 
denied your request. The Plan says out-of-network services were not authorized. 
  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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit, removal of skin lesion and 
removal of foreign body provided by an out-of-network provider on September 8, 2021.
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 you meet requirements for LTACH. The 
Plan denied your request. The Plan says based on Medicare guidelines, the requested LTACH services do not 
meet the requirements for approval. 
 
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 appear to be improving and requires only short-term additional acute care 
services that can safely be administered at the current facility. You do not require services at the LTACH that 
are not already available at the current facility. There are no services at the LTACH that you require that are 
not already available and covered at the current facility. Transfer to an LTACH is not medically necessary as it 
would not be clinically advantageous. Transfer to a lower level of care may be considered when treatment is 
completed. 
 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: 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 intensity of service requires the 
enrollee to have an acute level of care. The Plan denied your request. The Plan says criteria for admission to the 
LTACH have not been met. 
 
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 the enrollee appears to not be improving and requires short-term additional acute 
care services that can safely be administered at the current facility. The enrollee does not require services at the 
LTACH that are not already available at the current facility. There are no services at the LTACH that the 
enrollee requires that are not already available and covered at the current facility. Transfer to LTACH is not 
medically necessary as it would not be clinically advantageous. Transfer to a lower level of care may be 
considered when treatment is completed. 
 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 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 daily 
skilled services are not necessary. Our physician reviewer found the enrollee may benefit from continued 
skilled therapy services. The documentation does not support that it is medically reasonable and necessary to 
provide skilled therapy services 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 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 continuous glucose monitor (K0553, K0554). 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose 
monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of the 
continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor (K0553, K0554).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia (99100) provided on April 21, 2021. 
 
You asked the Plan to pay for the anesthesia (99100). You say that the attached medical records support the 
claim charges. The Plan denied your request. The Plan says CPT code 00300 is supported on appeal. The Plan 
also says CPT code 99100 remains denied as bundled services are not eligible for separate reimbursement. 
 
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, the CPT Code Manual definition of code 99100 is anesthesia for patient of extreme age, younger 
than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure).  
We find that CPT code 99100 is not supported in the medical record. Specifically, CPT code 99100 has a status 
indicator of B. This means that CPT code 99100 is considered bundled and not separately payable. Based on 
this information, we decided that Medicare rules for coverage of the anesthesia (99100) have not been met. 
Therefore, we decided that the Plan does not have to pay for the anesthesia (99100) provided on April 21, 
2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) 
provided on September 9, 2021. 
 
You asked the Plan to pay for ambulance response and treatment, no transport. You say that you were in a 
parking lot having an anxiety attack and you did not call the ambulance. You say when the ambulance arrived 
you told them you were fine and did not need assistance. The Plan denied your request. The Plan says 
ambulance service is a transport benefit, and it is only payable when you're transported to a hospital. If an 
ambulance is called and you received care but decide not to be transported to a hospital, we do not cover those 
services. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on September 9, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport 
(A0998) provided on September 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat facet joint injection. 
 
You asked the Plan to pre-approve the repeat injection. You say that it is felt that a confirmatory injection 
should be allowed. The Plan denied your request. The Plan says there was not sufficient relief from the initial 
facet joint injection. 
 
The Plan follows Medicare rules. Medicare rules say that secondary facet joint injections are covered when the 
primary injection produced at least 80% pain relief.  
 
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 repeat injection. Our reviewer says 
that the criteria for the repeat injection are not met. Our physician reviewer found under Medicare guidelines, 
this request is not medically necessary because the records do not show that the enrollee had a positive 
response of at least 80% relief of primary pain. It is not reasonable or medically necessary for the enrollee to 
have the requested procedure. 
 
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 repeat injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a repeat facet joint injection.