Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says admission to an IRF is not medically necessary.  
 
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 documentation does not support the necessity for admission to an IRF. The 
complexity of the enrollee's medical, rehabilitation, and nursing needs does not require an acute hospital 
inpatient rehabilitation stay with an interdisciplinary approach to rehabilitative care. The enrollee's 
rehabilitation needs can be safely provided in an alternate and low intensity setting such as in an SNF. 
 
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 an IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve the injections. You say that you would like authorization for the injections.  
The Plan denied your request. The Plan says facet joint injections are 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 injections. Our reviewer says that 
the enrollee does not meet the coverage criteria. Our physician reviewer found that repeat diagnostic blocks at 
two level bilaterally are medically reasonable and necessary, however a third level would exceed the utilization 
criteria of the LCD. 
 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant placement, tooth 18, 19, 20, 3, 30, 31, 4, 5 
(D6010), gum surgery tooth 18, 20 (D4266), custom abutment, tooth 18, 19, 20,3,30,31,4,5 (D6057) and 
implant supported porcelain fused to metal crown, tooth 18, 19, 20, 3, 30, 31, 4,5 (D6066). 
 
You asked the Plan to pre-approve implants and supported services. You say that this is medically necessary. 
The Plan denied your request. The Plan says implants are covered only when medically necessary and when a 
single tooth is missing in an arch (not including your wisdom teeth). Your other teeth in the arch must also 
have good bone support, do not have large cavities, and are expected to last long term. You must also have 
enough space where your tooth is missing to place an implant. This implant is denied because our records show 
you are missing more than one tooth in this arch of your mouth. There may be other treatment options for your 
dentist to replace your missing teeth, such as a partial denture. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers implants and 
supported services when the services are medically necessary and reasonable.  
 
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 implants and supported services. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found we are unable to 
determine whether the procedures that enrollee is requesting is of medical necessity as we are unable to read 
the x-rays. They are mostly black and undiagnostic, and therefore we cannot make a determination. We need to 
be able to see the teeth and areas where teeth are missing clearly in order to make a determination. The 
included X-rays are a photocopy and are mostly black in color, and we cannot make out any individual teeth or 
any structures in the jaw. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of implants and supported services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve implant placement, tooth 18, 19, 20, 3, 30, 31, 4, 5 (D6010), gum surgery 
tooth 18, 20 (D4266), custom abutment, tooth 18, 19, 20,3,30,31,4,5 (D6057) and implant supported porcelain 
fused to metal crown, tooth 18, 19, 20, 3, 30, 31, 4,5 (D6066).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L4 kyphoplasty (22514). 
 
You asked the Plan to pre-approve L4 kyphoplasty. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet the criteria for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be covered when specific criteria are 
met. 
 
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 L4 kyphoplasty. Our reviewer says that 
the enrollee does not meet criteria for coverage. Our physician reviewer found there is no indication of a 
progression of the body height loss, kyphotic deformity, or a severe impact on daily activities. Moreover, there 
is magnetic resonance imaging corroboration of other plausible causes of back pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L4 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L4 kyphoplasty (22514).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the lumbar spine. 
 
You asked the Plan to pre-approve an MRI. You say that your new provider requires an MRI to properly treat 
you. The Plan denied your request. The Plan says the requested MRI is not medically necessary. 
 
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 reviewer says that the 
requested service is not medically necessary and reasonable. Our physician reviewer found the record provided 
does not document the presence of red flag symptoms or abnormal neurological findings; Thus, the information 
is insufficient to establish the medical necessity of the requested test 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 an MRI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an MRI of the lumbar spine.
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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There is no support in the 
documentation that you require the intensive medical care and the intensive rehabilitation therapy program 
provided in an inpatient rehabilitation facility. The medical records do not clarify that continued home health 
treatment is 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oncology services to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve OON services. You say that you received a referral for blood work. The 
Plan denied your request. The Plan says the requested service is available in-network.  
 
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 
oncology services 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 image guidance for radiation therapy. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee is in pain. The Plan denied 
your request. The Plan says there are not enough studies to support this type of treatment.  
 
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 requested services. Our physician 
reviewer found that for the palliative treatment of bone metastases, the use of image guided radiation therapy 
(IGRT) is generally considered not medically necessary outside of a medically plausible rationale. In this case, 
the intent is clearly palliative, and it is not clear what benefit IGRT would afford. There does not seem to be 
any exceptional circumstances with this enrollee necessitating the need for IGRT. The records do not justify the 
need for IGRT.  IGRT is not an accepted standard of care for routine use in the palliative treatment of bone 
metastases. Therefore, the request 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve image guidance for radiation therapy.
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 you require rehabilitation to improve mobility and 
regain strength. The Plan denied your request. The Plan says the enrollee does not meet the requirements for an 
IRF admission. 
 
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 you do 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 or occupational therapy, there is no documented need for intensive rehabilitation 
services. There is not a reasonable expectation that you will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. Medically necessary care can be provided in a 
different 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 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide x5 visits. 
 
You asked the Plan to pre-approve the aide services. You say that the request for a home health aide is 
medically necessary. The Plan denied your request. The Plan says the enrollee is no longer requiring skilled 
nursing care per the clinical documentation. The request has been denied. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
  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 aide services. Our reviewer says 
that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee does 
not have documented skilled nursing needs or skilled therapy needs. The services of a home health aide are not 
shown to be medically necessary to assist in the treatment of acute illness or injury. As such, the requested 
home health aide services are not medically necessary or coverable. 
 
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 aide services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve home health aide x5 visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377) and harness for 
upgrade to expandable controller (E2313). 
 
You asked the Plan to pre-approve an expandable controller and harness . You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
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 an expandable controller and harness. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found based on the medical records provided there is no documentation that 
the expandable controller and harness for the expandable controller at issue in this case meet all Medicare 
criteria for medically reasonable and necessary for the enrollee. Provided records document that the enrollee 
has 3+/5 right upper extremity strength and is independent with eating (with set up) thus indicating he has 
adequate upper extremity strength and function to operate the wheelchair's power options with their own 
switches. 
 
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 expandable controller and harness have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an expandable controller (E2377) and harness for upgrade to 
expandable controller (E2313).
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 enrollee is below baseline and requires the level 
of care provided at an IRF. The Plan denied your request. The Plan says the IRF services requested do not meet 
the requirements for approval. 
 
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 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 or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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. Medically necessary care can 
be provided in a different 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 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: 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 services are medically necessary for the 
enrollee's complex medical care needs. The Plan denied your request. The Plan says the enrollee does not meet 
the criteria for admission to an IRF. 
 
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 treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hospital observation services provided 
on December 09, 2022. 
 
You asked the Plan to waive the copayment for the hospital observation services. You say that you were told 
you had met your out-of-pocket maximum. 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 $275 
copayment for outpatient hospital observation. 
 
You have been asked to pay a $275 copayment for the hospital observation services. This item/service falls 
within the outpatient hospital observation 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. The records show a previous claim was adjusted, and the copayment was 
correctly applied towards the out-of-pocket maximum. Therefore, we decided that the Plan does not have to 
waive the copayment for the hospital observation services provided on December 09, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the endoscope procedure provided on 
March 02, 2023. 
 
You asked the Plan to waive the copayment for the endoscope procedure. You say that you want to appeal this 
copayment. 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 $350 
copayment for outpatient surgery. 
 
You have been asked to pay a $350 copayment for the endoscope procedure. This item/service falls within the 
outpatient surgery 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 the endoscope 
procedure provided on March 02, 2023.