Persius/hicric huggingface dataset:
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 the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
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 is functional at a home care level. Admission to a SNF for daily skilled 
therapy is not medically necessary. There is no daily skilled nursing need. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis using the implantation of the Minuteman 
G3R device to L3-L4. 
 
You asked the Plan to pre-approve the surgery. You say that the surgery is medically necessary. You say that 
the enrollee has tried conservative treatments which failed to provide sufficient relief. The Plan denied your 
request. The Plan says the implantation of the Minuteman G3R device to L3-L4 is not medically necessary 
because medical studies have not proven that this service is helpful for the treatment of your health problem. 
 
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 surgery. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee was being treated for lumbar radiculopathy, spinal stenosis with neurogenic claudication, back pain; back spasms, and sacroiliitis. 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 this enrollees medical condition. The record also shows that there are multiple alternate pain 
generators plausibly significantly contributing to the enrollee's clinical condition that have not been fully 
documented as having been excluded and/or ruled out. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve arthrodesis using the implantation of the Minuteman G3R device to L3-L4.
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 the enrollee requires LTACH level of 
care to successfully recover.  The Plan denied your request. The Plan says an LTACH admission is not 
medically necessary.  
 
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 there is no documentation that was provided indicating medical necessity for 
admission to a LTACH. The enrollee does not require services at the LTACH that are not available at the acute 
care hospital where the enrollee is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 24 additional physical therapy visits. 
 
You asked the Plan to pre-approve physicals therapy visits. You say that the enrollee requires additional 
physical therapy services as they have increased energy levels, however they are unable to sweep or vacuum at 
home. The Plan denied your request. The Plan says 24 additional physical therapy visits are not medically 
necessary.  
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 physicals therapy visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found that the enrollee has responded to an effective physical 
therapy program for their clinical arthritis. While the enrollee has a chronic condition there is no indication for 
continued input from a skilled therapist they can continue with an effective program at home. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physicals therapy visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 24 additional physical therapy visits.
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 is not able to move around on their own 
and is needing more intensive therapy. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary, and the enrollee's needs can be met at an alternate 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: 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. The Plan denied your request. The Plan says the enrollee does not 
meet the Medicare 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 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 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. Our reviewer found that 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. Our physician reviewer also found that 
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 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 enrollee is still rather unstable and requires 
assistance, and for additional therapy and continued care. The Plan denied your request. The Plan says the 
enrollee does not meet the Medicare 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 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 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. Our reviewer found that 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. Our physician reviewer also found that 
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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for incomplete endodontic therapy; inoperable, 
unrestorable or fractured tooth (D5213) provided on February 8, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you are asking for reconsideration and to 
look at your situation and the bill you received. The Plan denied your request. The Plan says you are 
responsible for any charged amount above the Plans cost-sharing amount when your services are received 
from an out-of-network provider.  
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for incomplete endodontic therapy; inoperable, 
unrestorable or fractured tooth (D5213) provided on February 8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair (K0861) and 
additional items and accessories (codes E1007, E1012, E2311, E2312, E2361, E2377, E2607, E2620, and 
K0040). 
 
You asked the Plan to pre-approve a group 3 standard power wheelchair and additional items and accessories. 
The Plan denied your request. The Plan says there is no documentation of neurologic disorder, myopathy, or 
congenital skeletal diagnosis to meet group 3 power wheelchair criteria. The Plan also says the enrollee does 
not have a medical diagnosis of neurological disease, myopathy, or congenital skeletal deformity causing 
mobility limitation for which a Group 3 power wheelchair base would be medically necessary. 
 The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, 
myopathy or congenital skeletal deformity. The record show that the enrollee's current mobility deficit is a 
result of amputations. Therefore, we decided that the Plan does not have to pre-approve a group 3 standard 
power wheelchair (K0861) and additional items and accessories (codes E1007, E1012, E2311, E2312, E2361, 
E2377, E2607, E2620, and K0040).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Novolog Flexpen (J1815). 
 
You asked the Plan to pre-approve the medication. The Plan denied your request. The Plan says the medication 
is not covered as a medical benefit under 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 a Novolog Flexpen (J1815).   
Benefits for the medication 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from February 1, 
2023, to February 5, 2023. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you are unable to afford the cost share 
applied. 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 $0 
copayment for days 1 to 20 and a $196 copayment per day for days 21 to 100 for SNF care.  
 
 
  You have been asked to pay $784 for a SNF stay ($196 per day x 4 days = $784). This item/service falls within 
the SNF care 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 SNF stay provided from 
February 1, 2023, to February 5, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G orthosis (L8702). 
 
You asked the Plan to pre-approve a MyoPro orthosis. You say that you are requesting reconsideration of the 
denied authorization. The Plan denied your request. The Plan says that the requested orthosis 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 a MyoPro orthosis. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the MyoPro orthosis is not known to be effective, based on scientific evidence, 
professional standards, and expert opinion, in improving health outcomes. The MyoPro is not the standard of 
care for the enrollee's condition or in widespread use for the enrollee's condition based on scientific evidence. There is insufficient evidence in the literature that the MyoPro orthosis will improve the long-term outcomes 
for the enrollee. There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities. 
 
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 MyoPro orthosis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a MyoPro Motion G orthosis (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the catheter supplies provided on January 
13, 2023. 
 
You asked the Plan to waive the cost share for the catheter supplies. You say that this payment is much higher 
than your usual payments. 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 $300 deductible which applies to durable medical equipment and 
related supplies. Your contract with the Plan also clearly says that you must pay 20% coinsurance after meeting 
the deductible for durable medical equipment and related supplies. 
 
You have been asked to pay $86.09 toward the deductible. The item or service you asked the Plan to waive the 
cost share for falls within the durable medical equipment and related supplies benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $300 deductible which applies to 
durable medical equipment and related supplies. This cost sharing is a contractual obligation that had not been 
met at the time the catheter supplies was received on January 13, 2023.  
 
You have also been asked to pay $330.18, which is less than the standard 20% coinsurance for the catheter 
supplies. This item/service falls within the durable medical equipment and related supplies benefit category. 
You have been asked to pay a total of $416.27 ($86.09 deductible + $330.18 coinsurance = $416.27). 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 cost share for the catheter supplies provided on January 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the MRIs and specialist office visit provided 
from February 3, 2023, to February 14, 2023. 
 
You asked the Plan to waive the cost share for the MRIs and specialist office visit. You say that you were told 
by the office that you would have a $75 copayment for each MRI. 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 $550 deductible which applies to out-of-network outpatient diagnostic 
tests and therapeutic services, as well as out-of-network specialist physician/practitioner services. 
 
Your contract with the Plan also clearly says that you must pay 40% coinsurance after meeting the deductible 
for out-of-network advanced imaging services. Your contract with the Plan also clearly says that you must pay 
a $60 copayment after meeting the deductible for out-of-network specialist office visits. 
 
You have been asked to pay $550 towards the deductible. The items or services you asked the Plan to waive the 
cost share for fall within the outpatient diagnostic tests and therapeutic services, and physician/practitioner 
services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is a $550 deductible which applies to outpatient diagnostic tests and therapeutic services. This cost sharing is a 
contractual obligation that had not been met at the time the MRIs and specialist office visit was received on 
February 3, 2023, to February 14, 2023.  
 
You have also been asked to pay $64.50, which is less than the standard 40% coinsurance for the MRI provided 
on February 14, 2023. This item/service falls within the outpatient diagnostic tests and therapeutic services 
benefit category. You have been asked to pay a total of $614.50 ($550 deductible + $64.50 coinsurance = 
$614.50). 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 cost share for the MRIs and specialist office visit provided 
from February 3, 2023, to February 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nerve branch injection provided on March 20, 2023. 
 
You asked the Plan to pay for the injection. The Plan denied your request. The Plan says the claim was not 
billed with a payable diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code and diagnosis code. 
 
In this case, coverage for CPT code 64454 is limited to a specific list of diagnoses. Your claim shows diagnosis 
codes of M17.11 and G89.29, which are not among the coverable diagnosis codes.  
 We find that CPT code 64454 has not been billed with an appropriate diagnosis code. Based on this 
information, we decided that Medicare rules for coverage of the injection have not been met. Therefore, we 
decided that the Plan does not have to pay for the nerve branch injection provided on March 20, 2023.