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

 
We decided that the Plan does not have to pre-approve the SNF admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that you believe the enrollee needs additional 
care to improve their quality of life. The Plan denied your request. The Plan says the information received does 
not show that the enrollee has completed their full course of care in the inpatient rehabilitation facility (IRF). 
The records show that the enrollee continues to require intensive therapy and will continue to benefit from 
rehabilitation services in order to return to the community/home safely. 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 the requested SNF admission is not considered medically reasonable and necessary based on Medicare 
guidelines. Our physician reviewer found that there are no identifiable skilled nursing service needs. There are 
identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services 
daily. This enrollee does 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 the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the SNF admission.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve destruction. 
 
You asked the Plan to pre-approve genicular nerve destruction. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because the evidence for this procedure is low quality and still under investigation. 
 
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 genicular nerve destruction. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the role of genicular nerve radiofrequency ablation is still being evaluated 
and it is considered experimental at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular nerve destruction have not been met. Therefore, we decided that the 
Plan does not have to pre-approve genicular nerve destruction.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device insertion. 
 
You asked the Plan to pre-approve the Vertiflex device insertion. You say that the enrollee has suffered from 
this condition for 72 months and has failed greater than 6 months of conservative approaches to treatment. You 
say that this treatment is safe and effective and should be approved. The Plan denied your request. The Plan 
says there are not enough studies on Vertiflex Superion to show it is safe and effective. 
 
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 Vertiflex device insertion. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show 
safety and efficacy. 
 
 
  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 Vertiflex device insertion have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Vertiflex device insertion.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care to be provided by 
a network facility. 
 
You asked the Plan to pre-approve the SNF care. You say that you would like the enrollee to be approved to go 
to a skilled nursing facility. The Plan denied your request. The Plan says authorization denied because the SNF 
care 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 care. Our reviewer says that 
the SNF care is not medically necessary. 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. The enrollee does not require skilled nursing or therapy services 
on a daily basis. As a practical matter, the enrollee does 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 the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the skilled nursing facility (SNF) care to be provided by a network facility.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the documentation does not support that the requested ventilator is medically reasonable or necessary. Our 
physician reviewer found the enrollee has chronic respiratory failure from chronic obstructive pulmonary 
disease.  The provided primary source documentation does not contain sufficient detailed information in the 
medical record to justify the treatment selected. The enrollee could be treated with a bi-level positive airway 
pressure (BiPAP) machine with average volume-assured pressure support (AVAPS) capability.Therefore, the enrollee does not meet criteria for the requested device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. You asked the Plan to pre-approve a power scooter. The Plan denied your request. The Plan says the enrollee's 
limitation can be resolved with a standard wheelchair. 
 
The Plan must follow Medicare rules. Medicare rules say that power mobility devices are only covered under 
certain medical indications.  
 
We looked at the file and Medicare rules. The records show that the enrollee uses a walker in the home. There 
are no records to show that the enrollee is unable to self-propel in a manual wheelchair. Based on this 
information, we decided that Medicare rules for coverage of a power scooter have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a power scooter.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF continued stay after August 27, 2022. 
 
You asked the Plan to pre-approve continued SNF services. You say that you are requesting continued SNF 
stay for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
continued SNF care after August 27, 2022. 
 
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. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found that the medical records do not document that 
you require services on an inpatient basis, only 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve extended SNF continued stay after August 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency medical transportation to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the non-emergency medical transportation. You say that the in-network 
provider denied the transportation service because they do not have the right type of equipment. You also say 
that you would like the OON provider to render the transportation, and it is unacceptable that your insurance is 
denying this coverage. The Plan denied your request. The Plan says the medical records do not support why a 
network transportation provider is not able to provide transportation. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
non-emergency medical transportation to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device insertion. 
 
You asked the Plan to pre-approve the Vertiflex device insertion. You say that the enrollee has suffered from 
this condition for over a year and has failed more than 6 months of conservative approaches to treatment. You 
say that this treatment is considered safe and effective and should be approved. The Plan denied your request. 
The Plan says there are not enough studies on Vertiflex Superion to show it is safe and effective. 
 
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 Vertiflex device insertion. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that current evidence based medical guidelines and peer reviewed literature 
do not fully support the spinal decompression device procedure over the standard lumbar laminectomy. 
 
 
  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 Vertiflex device insertion have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Vertiflex device insertion.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abdominoplasty and thigh lift services. 
 
You asked the Plan to pre-approve abdominoplasty and thigh lift services. You say that this is medically 
reasonable and necessary. The Plan denied your request. The Plan says the requested services are considered 
cosmetic in nature and not covered by Medicare or the Plan. 
 
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 abdominoplasty and thigh lift services. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that you are a 39-year-old female with history of morbid obesity who 
underwent a laparoscopic sleeve gastrectomy in 2018 with significant weight loss and current body mass index 
of 30 kg/m2 with abdominal pannus that hangs to her pubic bone and laxity and skin of both thighs. In this 
case, abdominoplasty is generally considered a cosmetic procedure. The request is not for panniculectomy. 
Your abdominal pannus is not documented with history of recurrent refractory infections. Your thigh lift would 
be considered cosmetic as there is no documentation of infection refractory to medical treatment with anti-
fungal powders.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of abdominoplasty and thigh lift services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve abdominoplasty and thigh lift services.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve the LINX Reflux Management System. 
 
You asked the Plan to pre-approve the LINX Reflux Management System. You say that this is medically 
necessary for the enrollee' condition. The Plan denied your request. The Plan says that the requested procedure 
is considered experimental/investigational for the enrollee's condition. 
 
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 LINX Reflux Management System. 
Our reviewer says that the requested items/services are considered medically reasonable and necessary in this 
case. Our physician reviewer found that the enrollee is a 64-year-old male with medically refractory 
gastroesophageal reflux disease (GERD). 24 hour pH revealed an elevated DeMeester score consistent with 
GERD. Esophagogastroduodenoscopy revealed no evidence of Barrett's with history of remote Barrett's. 
Esophageal motility was normal.  
 
LINX is a standard surgical treatment for GERD refractory to medication. The patient does not document any 
exclusion to treatment, such as body mass index > 35 kg/m2, large hiatal hernia > 3 cm, or Barrett's esophagus 
with dysplasia at this time. The treatment has efficacy similar to laparoscopic nissen fundoplication with less 
morbidity, mortality and risk of dysphagia in published literature. It is a considered a standard treatment for 
GERD by Society of American Gastrointestinal and Endoscopic Surgeons and several other medical societies 
with published 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 LINX Reflux Management System have been met. Therefore, we decided 
that the Plan has to pre-approve the LINX Reflux Management System.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable to transfer to the 
LTACH and the enrollee needs increased physician monitoring. The Plan denied your request. The Plan says 
the records do not show that is it medically necessary for the enrollee to be in an LTACH in place of an acute 
care hospital. The current acute care hospital can provide acute care services until the enrollee's condition 
allows transfer to an alternate level of care, such as a skilled nursing facility, acute inpatient rehabilitation, 
home health care, nursing home, or home. 
 
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 be still somewhat unstable and requires short-term 
additional acute care services that can safely be administered at the current facility until more stable and 
appropriate for a lower level of care. 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 the enrollee is not stable for transfer and as it 
would not be clinically advantageous at this time. Completion of acute care treatment at the current facility is 
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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0394T billed for date of service October 13, 
2021. 
  You asked the Plan to pay for procedure code 0394T. You say that the medical notes justify billing two units of 
0394T as there were two separate treatment sites. You say that only one unit was paid, and additional payment 
should be made. The Plan denied your request. The Plan says payment for code 0394T is bundled into payment 
for code 77401. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 0394T 
is a column II code to column I code 77401. This code has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 0394T billed for date of service October 13, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy duty walker and walker seat attachment. 
 
You asked the Plan to pre-approve a heavy duty walker and walker seat attachment. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says you do not meet criteria for the requested 
item. 
 
The Plan must follow Medicare rules. Medicare rules say that heavy duty walkers are covered when the 
enrollee weighs more than 300 pounds. 
 
We looked at the file and Medicare rules. Review of the file does not support that you are more than 300 
pounds. Based on this information, we decided that Medicare rules for coverage of a heavy duty walker and 
walker seat attachment have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
heavy duty walker and walker seat attachment.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram (EKG) provided on 
January 31, 2022. 
 
You asked the Plan to waive the copayment for the EKG. You say that the EKG should be covered by 
insurance. 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 $5 
copayment for diagnostic lab services and diagnostic procedures and tests.  
 
You have been asked to pay a $5 copayment for the EKG. The EKG 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 an electrocardiogram (EKG) provided on January 31, 2022.