Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic manipulation services provided from April 
5, 2022, through April 12, 2022. 
 
You asked the Plan to pre-approve chiropractic manipulation services. You say that you would like this claim 
reprocessed and approved for payment based on medical necessity. The Plan denied your request. The Plan 
says chiropractic manipulation services were not medically necessary because there was no diagnosis of spinal 
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.  
 
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 chiropractic manipulation services Our reviewer says that the requested chiropractic manipulation services were not medically reasonable and 
necessary. Our physician reviewer found the record indicates that the enrollee has cervical, thoracic, and 
lumbar pain and spasm. The record does not document the presence of subluxation shown by x-ray or physical 
exam. The elements of the coverage criteria were not satisfied in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of chiropractic manipulation services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve chiropractic manipulation services provided from April 5, 2022, 
through April 12, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient psychiatric services provided from May 14, 2022, through 
May 20, 2022. 
 
You asked the Plan to pay for the inpatient psychiatric services. You say that you would like these inpatient 
services reprocessed and approved for payment. The Plan denied your request. The Plan says that the enrollee 
has exhausted their 190-day lifetime benefit psychiatric services. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan has denied coverage stating that the 190-day lifetime 
benefit for psychiatric care was exhausted. However, the Plan has failed to forward information that confirms 
the 190-day lifetime benefit was met. Without confirmation of the dates the enrollee has received inpatient 
psychiatric care, the Plan has failed to support their decision. Therefore, we decided that the Plan has to pay for 
the inpatient psychiatric services provided from May 14, 2022, through May 20, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Allograft. 
 
You asked the Plan to pre-approve Allograft. You say that the enrollee has suffered from both midline and 
paramidline pain while walking, standing, and lifting with an average reported pain level of 6 out of 10 on a 
numberic/visual analog scale. You say that interventional treatment including pain and functional limits persist. 
You say that radiologic finding demonstrates early to moderate disc degeneration at L3-S1 levels, disc 
bulging/protrusion at L3-L5. You say that provocative discography or functional anesthetic discography 
identify L4 level with concordant pain. You say that there is confirmed absence of fracture, tumor, or infection. 
The Plan denied your request. The Plan says there is little evidence in the medical literature to suggest that the 
requested treatment is an appropriate procedure for the enrollee's back pain. The Plan says that the requested 
procedure is experimental and 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 Allograft. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is limited published, large-scale, long-term peer-reviewed literature that shows this request to be an effective and/or safe treatment for the noted pathology. Cell therapy alone has not shown itself to provide 
sufficient intervention with regard to either efficacy or duration. Further studies are needed. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested injection of VIA Disc Matrix allograft, 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 Allograft have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Allograft.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from January 25, 2022, 
through January 28, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that you do not understand why you are 
being charged for these medications. The Plan denied your request. The Plan says these drugs are not covered 
under your medical benefit. 
 
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 from January 25, 2022, through January 28, 2022.   
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan provided on May 10, 2022. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you are not able to afford to pay the 
copayment for a CT scan and would like the Plan to waive the cost. The Plan denied your request. The Plan 
says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment per day for other Medicare-covered diagnostic radiology.  
 
 
 
 
 
 
 You have been asked to pay $315.89, which is less than the standard $325 copayment per day for a CT scan. 
This item/service 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 CT scan provided on May 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient services on April 25, 2022. 
 
You asked the Plan to waive the copayment 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 $100 
copayment or $150 copayment for each Medicare-covered outpatient hospital facility visit. If you are having 
surgery in a hospital facility, you should check with your provider about whether you will be an inpatient or 
outpatient. Unless the provider writes an order to admit you as an inpatient to the hospital, you are an outpatient 
and pay the cost sharing amounts for outpatient surgery. Even if you stay in the hospital overnight, you might 
still be considered an outpatient. 
 
 
 You have been asked to pay a $100 copayment for outpatient services. Outpatient services fall within the 
Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
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 outpatient services on April 25, 
2022.
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 the Intracept procedure is medically 
necessary. The Plan denied your request. The Plan says the clinical effectiveness of the Intracept procedure in 
the setting of Vertebrogenic low back pain have not been demonstrated in the peer-reviewed literature. The 
Plan says that more research is needed to show safety and efficacy of the procedure. 
 
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 Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are multiple plausible pathologic sources of significant pain generation. The 
non-radiating midline back pain, the noted pain-aggravating (aggravated with household chores, standing, 
yardwork, walking, personal care/hygiene, caring for others, bending, working, and lifting) and pain-relieving 
factors (lying down), and intact neurologic exam were/are all non-specific to any pathologic entities. Overall, 
documentation is lacking regarding reasonably detailed and/or evidenced findings supportive of the spinal 
vertebral bodies as being the overwhelming primary generators of the enrollees chronic persistent pain. Documentation does not support actual formal surgical ablation of pre-designated basivertebral nerves as being 
medically necessary and/or reasonable at this time. 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 the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's medical management and rehabilitation 
needs a required IRF stay and close physician supervision. The Plan denied your request. The Plan says the IRF 
admission is not medically necessary under Medicare guidelines. 
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for surgical management of a hip infection. Medical problems are stable. There are no 
complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that this 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 IRF admission and 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 you live alone on the second floor. You also say that 
you need to be at the SNF to get stronger. The Plan denied your request. The Plan says based on Medicare 
guidelines and the information we have about this condition; you do not meet all the requirements. 
 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 the enrollee does not have documented skilled nursing needs. Our physician reviewer 
also found that the enrollee's 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 skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a battery-operated scooter. 
 
You asked the Plan to pre-approve a battery-operated scooter. You say that you want to use the requested 
scooter inside because you are unable to get around. The Plan denied your request. The Plan says there is no 
evidence that the enrollee cannot use a standard wheelchair. The Plan says that there is no evidence that there is 
adequate access between rooms in the enrollee's residence to safely use the scooter. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 battery-operated scooter. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee is a 
90-year-old female with a medical history of diabetes mellitus type II, peripheral neuropathy, and hypertension. 
A clinical progress note dated July 14, 2022, indicated that the enrollee has difficulty walking longer distances due to her peripheral neuropathy with risk of falling. She was noted to have no focal neurological deficits. 
There is limited clinical information regarding the enrollees current mobility status. She appears to be 
independent with mobility in her home but requires the requested power scooter for mobility in the community. 
There is limited clinical information in terms of the enrollees physical examination findings, most notably 
motor strength, and why her mobility needs cannot be met with a manual wheelchair. There is also limited 
information provided regarding the accessibility of the enrollee's home for the power scooter as well as her 
ability to safely use it. Therefore, the power mobility device or power scooter is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a battery-operated scooter have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a battery-operated scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure improves the quality of 
life of patients suffering from vertebrogenic low back pain. You also say that the requested procedure received 
initial Food and Drug Administration (FDA) clearance in 2016. The Plan denied your request. The Plan says 
the requested procedure is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found there is not enough research to support this procedure. The reviewer found that 
this is considered an experimental procedure at the current time. Therefore, the requested procedure is 
considered 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 Intercept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a monovisc injection (J7327) and Arthrocentesis, 
aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound 
guidance (20610) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that your request is not medically necessary because records do not 
document that the first course of treatment produced relief. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The enrollee has a 
history of osteoarthritis of the left knee. He has been treated with medical therapy and received 
viscosupplementaiton on April 5, 2022. There is no documentation indicating that the first course of treatment 
produced relief. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage 
of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a monovisc injection (J7327) and Arthrocentesis, aspiration and/or injection, major joint or 
bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance (20610) for the enrollee.
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 LTACH care is medically necessary. The 
Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient care and is currently 
unstable for transfer to an LTACH. 
 
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 all medically necessary care is being provided in the current acute care setting. 
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The health plan has approved ongoing care in the current acute care setting. 
The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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.