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

 
We decided that the Plan does not have to waive the cost sharing for the shoulder arthroscopy with rotator cuff 
repair, and the bupivacaine liposome injection provided by an in-network provider on March 20, 2023. 
 
You asked the Plan to waive the cost sharing for the shoulder arthroscopy, and the injection. You say that you 
already paid for these services. 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 $150 deductible which applies to outpatient surgery, including 
services provided at hospital outpatient facilities and ambulatory surgical centers. Your contract with the Plan 
also says that you must pay a 10% coinsurance of the approved amount for in and out-of-network Medicare 
Part B prescription drugs administered in an outpatient facility, and a 10% coinsurance of the approved 
amount, after you meet the annual deductible for in and out-of-network outpatient surgery services. 
 
You have been asked to pay a $18.35 coinsurance for the injection ($183.54 allowed amount x .10 = $18.35). 
This item/service falls within the Medicare Part B prescription drugs benefit category. You have also been 
asked to pay a $68.92 deductible, and a $285.69 coinsurance for the shoulder arthroscopy ($2856.98 allowed 
amount x .10 = $285.69 rounded down). This item/service falls within the outpatient surgery, including 
services provided at hospital outpatient facilities and ambulatory surgical centers benefit category.  
 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $150 deductible which 
applies to outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. This cost sharing is a contractual obligation that had not been met at the time the shoulder 
arthroscopy, and the injection were provided on March 20, 2023. Therefore, we decided that the Plan does not 
have to waive the cost sharing for the shoulder arthroscopy with rotator cuff repair, and the bupivacaine 
liposome injection provided by an in-network provider on March 20, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need rehabilitation to be able to return home 
safely.  The Plan denied your request. The Plan says that you do 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the requested IRF care is considered medically reasonable and necessary based on Medicare guidelines. 
Our doctor found that your condition is complex and fragile, and, given your strong desire to make a sustained 
return home there is reason to expect that, if given the chance, you will participate in and benefit from services 
at an IRF-level to include at minimum of physical and occupational therapy, neuropsychic, physician oversight 
of your cardiopulmonary and wound issues, as well as case manager coordination to ensure you have the 
proper services to make a sustained return home or have the detailed conversations needed to prepare for 
alternate living arrangements. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that after your stroke you require therapy to get back to 
your prior level. The Plan denied your request. The Plan says you do 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 that you continue to have a need for skilled therapy with ongoing safety concerns and 
a potential for functional improvement. However, the documentation doesnt support that you would meet 
criteria for admission to an acute inpatient rehabilitation facility. You can receive further services at a lower 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hot tub. 
 
You asked the Plan to pre-approve a hot tub. You say that the item is necessary. The Plan denied your request. 
The Plan says the requested item is not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a hot tub.
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 enrollee has a need for skilled therapy at this 
time. The Plan denied your request. The Plan says the SNF services you are requesting 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require skilled nursing or skilled therapy services that require 
the specialized skill, knowledge, and judgement of a skilled professional nurse or therapist. The enrollee does 
not require skilled services on a daily basis. The enrollee does not require skilled services 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 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 the Vertiflex device (22869). 
 
You asked the Plan to pre-approve the Vertiflex device. You say that this is medically necessary. The Plan 
denied your request. The Plan says unproven and not medically necessary procedures are not covered. 
 
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 Vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Vertiflex device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex device (22869).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has 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. The Plan 
denied your request. The Plan says that 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the enrollee's condition is complex and at risk for future catastrophic falls without mitigation by 
coordinated rehab, and there is every reason to expect that they will participate in and benefit from services to 
include at minimum physical and occupational therapy, physician oversight of various risk factors, and case 
manager coordination of any additional services they might need to make a sustainable return to previous living 
environment. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve CGM. You say that the G7 system is better for the enrollee when there is 
not anyone there to help. The Plan denied your request. The Plan says the enrollee already has a CGM that was 
furnished on April 8, 2021 and has not been damaged beyond repair. 
 
The Plan must follow Medicare rules. Medicare rules say that replacement of equipment is not covered within 
the reasonable useful lifetime except in cases of loss or irreparable damage.  
 
We looked at the file and Medicare rules. The enrollees current CGM is still within its reasonable useful 
lifetime and the record does not show that it has experienced loss or irreparable damage. Based on this 
information, we decided that Medicare rules for coverage of CGM have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Dexcom G7 continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 standard power wheelchair (K0822). 
 
You asked the Plan to pre-approve a group 2 standard power wheelchair. You say that your back is in poor 
condition. You also say that the wheelchair you were approved for is too heavy, and you are more interested in 
having this requested wheelchair because it is lighter and easier to travel with. The Plan denied your request. 
The Plan says this request does not meet the requirements for approval. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a group 2 standard power wheelchair. 
Our reviewer says that the group 2 power wheelchair is not medically necessary. Our physician reviewer found 
the enrollee is functionally non-ambulatory due to their lumbar spine and knee degeneration. The enrollee is at 
risk for falling and cannot use a cane or walker for mobility. Our reviewer found that the enrollee is noted to 
have shoulder osteoarthritis on the wheelchair evaluation but there is no indication of this in the clinical 
progress notes. Additionally, the evaluation does not provide a range of motion assessment of their upper 
extremities. It is unclear why the enrollee cannot propel a manual wheelchair or operate a power scooter. Our 
physician reviewer also found that there is no formal evaluation for the power wheelchair in terms of the 
enrollees dimensions and fitting, if they can safely operate it, and if their home is accessible. 
 
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 group 2 standard power wheelchair have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a group 2 standard power wheelchair (K0822).
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 currently meets IRF admission criteria 
under Medicare guidelines. 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 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 are no complex nursing or rehabilitation needs. While the medical records 
support 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. 
 
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 hyperbaric oxygen therapy (HBOT). 
 
You asked the Plan to pre-approve HBOT. You say that the enrollee is at risk of losing a leg. The Plan denied 
your request. The Plan says that the requested service does not meet the requirements for approval. 
 
The Plan follows Medicare rules. Medicare rules say that HBOT may be covered under certain circumstances. 
 
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 HBOT. Our reviewer says that the 
enrollee meets one of the limitations/exclusions for this procedure. Our physician reviewer found that the 
enrollee has a cutaneous wound dehiscence of a surgical wound with chronic peripheral vascular insufficiency, 
a condition for which that hyperbaric oxygen treatment is not covered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HBOT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve hyperbaric oxygen therapy (HBOT).
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 the enrollee requires IRF services to include case 
management to coordinate post discharge needs, medical assistive device needs, and to provide education to 
family on how to assist once home. The Plan denied your request. The Plan says the enrollee does not meet the 
requirements 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 that the complexity of the enrollees 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. While enrollee may have a need for physical therapy 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that the 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 an IRF admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve external mobile cardiovascular telemetry with 
electrocardiographic recording (93228, 93229). 
 
You asked the Plan to pre-approve external mobile cardiovascular telemetry with electrocardiographic 
recording. You say that this is medically necessary. The Plan denied your request. The Plan says this request 
does not meet established standard of care and does not demonstrate the need for live, real-time surveillance by 
qualified personnel. 
 
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 external mobile cardiovascular 
telemetry with electrocardiographic recording. Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found there is no 
supportive evidence that the ordering practitioner documented any standard, non-mobile cardiac outpatient 
telemetry, ambulatory electrocardiogram monitoring. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of external mobile cardiovascular telemetry with electrocardiographic recording 
have not been met. Therefore, we decided that the Plan does not have to pre-approve external mobile 
cardiovascular telemetry with electrocardiographic recording (93228, 93229).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block. 
 
You asked the Plan to pre-approve a genicular nerve block. 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 a genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found no compelling rationale is presented or extenuating circumstances noted to support 
the medical necessity of this request as an exception. Therefore, the requested genicular nerve block is not 
medically reasonable or necessary.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Gel-One injection. 
 
You asked the Plan to pre-approve the injection. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the injection. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found detailed documentation regarding a trial and failure of recent, reasonable, comprehensive, less 
invasive conservative care measures is not evident. Your knee pain is not clearly documented to be interfering 
with your daily 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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Gel-One injection.