Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for physical therapy (PT) services provided from March 17, 2023, to 
March 24, 2023. 
 
You asked the Plan to pay for the therapy services. You say that the claims should be approved and paid since 
there was no adequate explanation for their denials. The Plan denied your request. The Plan says that the 
benefits have been exhausted for the requested therapy 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. Specifically, the Plan has not forwarded information about prior therapy 
services. Without this information, we are unable to verify if the number of services exceeds the allowable 
amount per Medicare regulations. It is the burden of the Health Plan to substantiate their denial with evidence. 
In this case, the Plan's denial is not substantiated, so we must find in your favor. Therefore, we decided that the 
Plan has to pay for physical therapy (PT) services provided from March 17, 2023, to March 24, 2023.  
 
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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided 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 LTACH 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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there is not a reasonable expectation that this patient will be able to fully participate 
in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the specialist office visit provided on 
November 17, 2022. 
 
You asked the Plan to waive the deductible for the specialist office visit. You say that you should have a $10 
copayment for specialist office visits. 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. Your 
contract with the Plan says that there is a $500 deductible which applies to specialist physician/practitioner 
services. The Plan contract also says that enrollees must pay a $10 copayment after meeting the deductible for 
specialist office visits. 
 
 The item or service you asked the Plan to waive the deductible for falls within the physician/practitioner 
services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is a $500 deductible which applies to in-network physician/practitioner services. This cost sharing is a 
contractual obligation that had not been met at the time the specialist office visit was received on November 17, 
2022. Therefore, we decided that the Plan does not have to waive the deductible for the specialist office visit 
provided on November 17, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that Durolane is 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has knee osteoarthritis. She had a prior trial of viscosupplementation but does not document that the treatment provided pain relief or 
improved functional capacity. The records do not support that the criteria for coverage are met; therefore, 
Durolane is not reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Durolane.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shoe inserts provided on December 21, 2022.  
 
You asked the Plan to pay for the shoe inserts. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
The records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for the shoe inserts provided on December 
21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve driveline maintenance supplies, including sterile gloves 
and dressings, for a left ventricular assist device (LVAD). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that LVAD supplies are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the requested supplies can be purchased 
individually from in-network providers. There is no evidence in the submitted records that it is reasonable and 
medically necessary for the out-of-network LVAD supplies in your clinical management. 
 
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 driveline maintenance supplies, including sterile gloves and dressings, for a left ventricular 
assist device (LVAD).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the $25 benefit allowance. 
 
You asked the Plan to pre-approve the $25 benefit allowance. You say that you were unaware of the existence 
of the benefit and would like your first quarter allowance to be carried over. The Plan denied your request. The 
Plan says the service is not a covered benefit. 
 
Medicare generally does not cover OTC items. However, the Plan offers an OTC benefit that exceeds Medicare 
coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers an OTC benefit in excess of Medicare coverage, the requested item is not among those 
covered under this benefit. The Plan must follow Medicare rules. The rules say that Medicare does not pay for 
OTC items and the $25 benefit allowance is an OTC item. Therefore, we decided that the Plan does not have to 
pre-approve the $25 benefit allowance.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for the arthroplasty, prosthetic device, and drug 
injections provided on February 14, 2023. 
 
You asked the Plan to reduce the cost share for the arthroplasty, prosthetic device, and drug injections. You say 
that you were only told about the $120 copayment for the surgery. 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 $120 
copayment for in-network outpatient surgery provided at an ambulatory surgical center. Your contract with the 
Plan also clearly says that you must pay 20% coinsurance for in-network prosthetic devices and related 
supplies. Your contract with the Plan also clearly says that you must pay 20% coinsurance for in-network 
Medicare Part B drugs. 
 
You have been asked to pay a $120 copayment for the arthroplasty. This item/service falls within the outpatient 
surgery benefit category. You have also been asked to pay 20% coinsurance for each prosthetic device. This 
item/service falls within the prosthetic devices and related supplies benefit category. You have also been asked 
to pay 20% coinsurance for each drug injection. This item/service falls within the Medicare Part B drugs 
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 reduce the cost share for the arthroplasty, prosthetic 
device, and drug injections provided on February 14, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implantation of the Minuteman G3R Interspinous 
device to L2-L3. 
 
You asked the Plan to pre-approve the implantation of the Minuteman G3R Interspinous device. You say that 
the enrollee has tried and failed conservative treatments and the treatment is safe and effective. The Plan denied 
your request. The Plan says the implantation of the Minuteman G3R Interspinous device remains experimental, 
and more research is needed to show safety and efficacy. 
 
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 implantation of the Minuteman G3R 
Interspinous device. Our reviewer says that the requested service is not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee is being treated for lumbar radiculopathy. However, current evidence-based medical guidelines and peer-reviewed literature do not fully support the 
interspinous fusion device procedure over the gold standard of lumbar fusion. There is a lack of large-
volume, long-term peer-reviewed outcome studies to support the use of this device for the enrollees medical 
condition. The record also shows there are multiple alternate pain generators plausibly significantly 
contributing to the clinical condition that have not been fully documented as having been excluded and/or ruled 
out. There is no compelling rationale presented or any 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 implantation of the Minuteman G3R Interspinous device have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the implantation of the Minuteman G3R 
Interspinous device to L2-L3.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy duty extra wide hospital bed and heavy duty 
manual wheelchair. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that hospital beds and manual wheelchairs are 
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 these services. Our reviewer says that 
the criteria for coverage are not met. Our physician reviewer found the records show that you do not have a 
medical condition that requires positioning not feasible in a standard bed. The assessment indicates you are 
able to stand and walk but have difficulty accessing resources outside of the home. A wheelchair is not covered 
for use outside of the home. The criteria for coverage of the requested bed and wheelchair are not met and the services are 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a heavy duty extra wide hospital bed and heavy duty manual wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that the compression stockings are 
medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested 
item is non-covered under the surgical dressing benefit as it does not meet the statutory definition of a dressing. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from LTACH 
services to allow for full recovery. The Plan denied your request. The Plan says the LTACH services requested 
do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving acute hospital care, and acute care services have not been 
denied. The documentation shows there are no required medical services identified that are available at the 
LTACH, that are not available at the current health care setting being offered by the health plan. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (PWC). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a Group 2 PWC is 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 these services. Our reviewer says that 
the criteria for coverage are not met. Our physician reviewer found the records show that you have chronic 
back pain from narrowing of the spine (spinal stenosis). You are able to transfer from the wheelchair without 
assistance and do not have high risk for skin breakdown or spasticity and do not require a catheter. The criteria 
for coverage are not met and the PWC is therefore not reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Group 2 power wheelchair (PWC).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee can benefit from acute inpatient 
rehabilitation.  The Plan denied your request. The Plan says an IRF admission is not medically necessary, and 
the enrollee's needs can be met at a lower level of care.  
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 IRF admission and services.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a TBS. 
 
You asked the Plan to pre-approve a TBS. You say that a TBS is medically necessary. The Plan denied your 
request. The Plan says that TBS is not considered medically necessary. The Plan says this determination is 
supported by Hayes, the national evidence-based medical assessment source, that gave the TBS a D2 rating. 
Hayes concluded in their recent review of the topic that a low-quality body of evidence has not provided 
consistent evidence that use of the TBS improves the accuracy of fracture prediction as an adjunct to standard 
techniques such as DEXA. 
 
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 a TBS. Our reviewer says that the 
requested TBS is considered medically reasonable and necessary in this case. Our physician reviewer found 
that the enrollee has had severe osteoporosis on DEXA with a T-score of -3.6. The enrollee is on Prolia. The 
request for additional trabecular bone measurement is reasonable due to the enrollees zero negative 
rheumatoid arthritis and sever osteoporosis.  
 
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 TBS have been met. Therefore, we decided that the Plan has to pre-approve a 
TBS.  
 
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.