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

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve a SNF admission. You say that the enrollee cannot stand without assistance. 
The Plan denied your request. The Plan says the record does not show that the enrollee requires daily skilled 
nursing or skilled therapy in a SNF setting. The Plan also says that the services the enrollee requires are called 
custodial care, which is not a covered benefit. 
 
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 a SNF admission. Our reviewer says 
that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee 
does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a 
skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized 
skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled 
nursing and/or skilled therapy on an inpatient basis in a 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 a SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stapedectomy or stapedotomy with reestablishment of 
ossicular continuity to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a stapedectomy or stapedotomy with reestablishment of ossicular continuity. 
You say that you are appealing with supporting records. The Plan denied your request. The Plan says this is not 
a medical emergency, and your network provides this service. 
 
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 
a stapedectomy or stapedotomy with reestablishment of ossicular continuity to be provided by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Spinal cord stimulator battery replacement to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve Spinal cord stimulator battery replacement. You say that you would like to 
see a specific OON provider. The Plan denied your request. The Plan says the provider is out-of-network and 
over 100 miles away from the member's home residence.  There is an in-network provider who is closer. 
 
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 
Spinal cord stimulator battery replacement to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair (E0240). 
 
You asked the Plan to pre-approve a shower chair. You say that you cannot stand in the shower and is afraid of 
falling with the chair that you have because it is wobbly. The Plan denied your request. The Plan says this item 
is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair (E0240).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the abdomen and pelvis. 
 
You asked the Plan to pre-approve an MRI of the abdomen and pelvis. You say that the imaging is necessary to 
determine a treatable cause for the member's chronic, debilitating back, abdominal, and pelvic pain. The Plan 
denied your request. The Plan says an MRI is not reasonable and necessary under Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 an MRI of the abdomen and pelvis. Our 
reviewer says that an MRI of the abdomen and pelvis is not medically necessary. Our physician reviewer found 
the fact that the enrollee continues to have chronic pain without explanation and other tests have been 
performed does not prove the medical necessity of the requested MRI of the abdomen and pelvis. No equivocal 
or unexplained findings were described on the 2020 CT scan and no further imaging workup has been advised 
in the records provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the abdomen and pelvis have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an MRI of the abdomen and pelvis.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tramadol. 
 
You asked the Plan to pre-approve Tramadol. You say that this is medically necessary. The Plan denied your 
request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan. 
 
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 pre-approve Tramadol.  
 
 
 Benefits for Tramadol 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intraosseous ablation (22899). 
 
You asked the Plan to pre-approve intraosseous ablation. You say that this service is medically necessary in 
treating the enrollee's back pain. The Plan denied your request. The Plan says intraosseous radiofrequency 
ablation of the basivertebral nerve for the treatment of vertebrogenic back pain is considered investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of intraosseous ablation have not been met. Therefore, we decided that the Plan does not have to pre-
approve intraosseous ablation (22899).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve. 
 
You asked the Plan to pre-approve thermal destruction of intraosseous basivertebral nerve. The Plan denied 
your request. The Plan says based on Medicare guidelines, the back procedure (Intracept Intraosseous Nerve 
Ablation System) you and/or your provider is requesting does not meet the requirements for approval. 
 
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 thermal destruction of intraosseous 
basivertebral nerve. Our reviewer says that the requested thermal destruction of intraosseous basivertebral 
nerve not considered medically reasonable and necessary in this case. Our physician reviewer found the 
Intracept procedure is experimental for back pain. More research is needed. 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of thermal destruction of intraosseous basivertebral nerve have not been met. 
Therefore, we decided that the Plan does not have to pre-approve thermal destruction of intraosseous 
basivertebral nerve.
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 SNF care is needed to help the enrollee regain some 
independence. 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 daily 
skilled services are not necessary. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chiropractic manipulation treatment provided on November 
24, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a chiropractic manipulation treatment. You say that you are a participating 
provider with Medicare. The Plan denied your request. The Plan says the rendering provider is a non-
participating provider and there is no referring provider involved in these services. The Plan also says that they 
did not authorize any services for this provider or the facility. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. 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 a chiropractic manipulation treatment provided on 
November 24, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Acupuncture services provided on November 19, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Acupuncture services. You say that of the Plans 2021 Evidence of Coverage 
(EOC) The Plan denied your request. The Plan says the provider is out-of-network and prior authorization is 
required for an out-of-network visit. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. 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 Acupuncture services provided on November 19, 
2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chiropractic manipulative treatment provided on December 
17, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a chiropractic manipulative treatment. You say that you are a participating 
provider with Medicare. The Plan denied your request. The Plan says the rendering provider is a non-
participating provider and there is no referring provider involved in these services. The Plan also says that they 
did not authorize any services for this provider or the facility. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. 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 a chiropractic manipulative treatment provided on 
December 17, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the cervical spine. 
 
You asked the Plan to pre-approve an MRI. The Plan denied your request. The Plan says that the request is not 
medically necessary at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 an MRI. Our physician reviewer found 
that the enrollee has cervicalgia who has debilitating pain. An electromyography (EMG) shows abnormal 
findings, but the question remains whether her symptoms are due to cervical spine issues or polyneuropathy. 
Because of the abnormal EMG, the requested MRI of the cervical spine will be used to sort out the possibility 
the symptoms in her upper extremities are related to polyneuropathy or be secondary to mechanical 
encroachment within the cervical spine. Therefore, the requested testing is medically reasonable and 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 an MRI have been met. Therefore, we decided that the Plan has to pre-approve 
magnetic resonance imaging (MRI) of the cervical spine.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient hospital services provided on November 30, 2021 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Outpatient hospital services. You say that you would like to appeal the denial of 
the claim. The Plan denied your request. The Plan says prior authorization is required for an out-of-network 
visit. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. 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 Outpatient hospital services provided on 
November 30, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for radiation therapy services provided from 
November 4, 2021, through November 30, 2021. 
 
You asked the Plan to waive the coinsurance for radiation therapy services. You say that you received a letter 
stating you have met your out-of-pocket limit, so you are not supposed to pay anything. The Plan denied your 
request. The Plan says coinsurance 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 20% 
coinsurance for Medicare-covered therapeutic radiology services, including, but not limited to: radiation 
therapy and/or hyperbaric oxygen.  
 You have been asked to pay $1,234.86, which is 20% of the allowed amount for radiation therapy services. The 
allowed amount is $6,174.18 (20% x $6,174.18 = $1,234.86). Radiation therapy services fall within the 
Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. The records show your 
maximus out-of-pocket was not met until after this claim was processed. 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 radiation therapy services provided from November 4, 2021, through November 30, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says you no longer require daily skilled 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 the services. Our reviewer says that the 
requested continuation of services is not medically reasonable or necessary. Our physician reviewer found bon 
the medical records provided, there is no documentation that the patient requires skilled nursing services, i.e., 
the specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and 
effectively provide medically necessary and reasonable treatment. The records do not document the need for 
intravenous medications, new tube feeding, or ostomy care or daily complex wound care. There is no 
documentation that further daily skilled services are required. After more than two months of daily skilled 
therapy the patient has shown minimal improvement in ambulation or transfers. Part time therapy services now 
appear indicated. There is no documentation that the patient requires the services on an inpatient basis, only in 
a skilled nursing facility setting. Records do not document that services in the home with home health care or 
in a long-term care facility on a part time basis are not appropriate 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for anesthesia services provided on July 27, 2021. 
 
You asked the Plan to waive the coinsurance for the anesthesia services. You say that you should not owe 
anything since you also have Medicaid. The Plan denied your request. The Plan says that the correct 
coinsurance was applied. 
 
The rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). Specifically, the Plan did not provide information specific to the 
amount of cost sharing for the Medicare portion of the Plans coverage. Without this information, we are 
unable to determine if the correct cost sharing was applied. Therefore, we decided that the Plan has to waive 
the coinsurance for anesthesia services provided on July 27, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hydrocodone/Apap tablets. 
 
You asked the Plan to pre-approve Hydrocodone/Apap tablets. The Plan denied your request. The Plan says 
this drug falls under the pharmacy (drug) benefit and you do not have a pharmacy benefit with the Plan. 
 
  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 pre-approve Hydrocodone/Apap tablets.