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

 
We decided that the Plan does not have to pay more for the emergency room visit provided on January 19, 
2023. 
 
You asked the Plan to pay more for the emergency room visit. You say that you are requesting reconsideration 
of the payment. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay 20% coinsurance of the cost up to $95 for emergency care.  
 
The enrollee has been asked to pay $35.63, which is 20% coinsurance of the allowed amount for the emergency 
room visit ($178.15 allowed amount x 20% = $35.63). This item/service falls within the emergency care 
benefit category This means that the enrollee has been asked to pay the correct amount based on the contract 
with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. 
Therefore, we decided that the Plan does not have to pay more for the emergency room visit provided on 
January 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the chiropractic manipulative treatment. 
 
You asked the Plan to pre-approve the chiropractic manipulative treatment. You say that you should not have 
to get prior approval for benefits you are supposed to have. The Plan denied your request. The Plan says that 
the chiropractic manipulative treatment is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
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 chiropractic manipulative treatment. 
Our reviewer says that that the chiropractic manipulative treatment is not medically necessary. Our physician 
reviewer found that you have lumbar subluxation and radiculopathy. However, the records of the visits do not 
support progressive improvement of symptoms but rather maintenance therapy. Also, the record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. 
Therefore, the elements of the coverage criteria are not satisfied, and the requested service is not recommended. 
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 chiropractic manipulative treatment have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the chiropractic manipulative treatment.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you need two-person assistance for bathing and 
grooming. You say that you are currently non-ambulatory and transfers with total assistance. The Plan denied 
your request. The Plan says a SNF admission is not medically necessary.  
 
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 that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve continued SNF care. You say that you need additional therapy prior to 
discharge. The Plan denied your request. The Plan says you no longer are making meaningful progress and do 
not need skilled therapies 5 days a week. The Plan says care can be provided in a long-term care setting with 
intermittent therapy services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve continued 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 that at the time of admission, you required skilled rehab services to 
improve function due to weakness and deconditioning. There were no skilled nursing needs. As of the last 
covered day, you did not require any skilled nursing or rehab services on a daily basis. You are not expected to 
make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent 
deterioration with mobility or self-care tasks. You do not require skilled therapy to establish a safe and 
effective maintenance program. As a practical matter, you did not require any skilled services on an inpatient 
basis, at a skilled level of care as of December 20, 2023. You do not have any parental medications, complex 
wound care needs, or nutrition given via a feeding tube. Your function was at or near your new baseline level 
of function, and you can be discharged to a lower level of care for further services as you require primarily 
custodial services. The denial for further inpatient skilled care beyond the last covered day is upheld.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that the services are necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found you do not 
have documented skilled nursing needs. As such, home health skilled nursing services are not medically 
necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that the medication is medically necessary. 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 Botox.  Benefits for Botox 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: 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 LTACH services are medically 
necessary. The Plan denied your request. The Plan says the LTACH services are 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 There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the Plan. Given there are offered alternatives, LTACH 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 51741 rendered on August 17, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there is no documentation of separately identifiable testing other than the UroCuff testing. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 51741 is "Complex uroflowmetry (eg, calibrated 
electronic equipment)." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the procedure report includes documentation of a Urocuff performed; however, a complex uroflowmetry was not included in documentation. 
For CPT 51741 is the process of measuring how much liquid the patient excretes from the bladder. It is 
measured in cubic centimeters per second. The rate is the ratio of volume over time. This procedure was not 
found in medical record and cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 51741 rendered on August 17, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bronchoscopy. 
 
You asked the Plan to pre-approve bronchoscopy. You say that it is medically necessary. The Plan denied your 
request. The Plan says it 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 bronchoscopy. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the records do not document that other techniques including rehabilitation, that there is no 
evaluation of an echocardiogram, and the enrollees obesity and decreased diffusion it is unclear if this is 
necessary or reasonable. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bronchoscopy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bronchoscopy.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular radiofrequency ablation. 
 
You asked the Plan to pre-approve the genicular radiofrequency ablation. You say that the enrollee has 
underwent left total knee replacement and still has pain. You say that the enrollee has exhausted all options and 
this procedure is the last hope to provide them with relief. The Plan denied your request. The Plan says the 
genicular radiofrequency ablation is considered experimental.  
 
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 genicular radiofrequency ablation. 
Our reviewer says that the genicular radiofrequency ablation is considered experimental. Our physician 
reviewer found that the genicular radiofrequency ablation is considered the subject of ongoing clinical trials 
and is considered experimental therapy.  
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 genicular radiofrequency ablation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the genicular radiofrequency ablation.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 additional home health physical therapy visits. 
 You asked the Plan to pre-approve home health services. You say that these services are medically necessary 
for the enrollee. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee 
does not have documented skilled therapy needs. The enrollee is functioning at a level commiserate with a 
lower level of care (such as a home exercise plan, outpatient therapy or layperson supervision). As such, the 
requested home health physical therapy services are not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 6 additional home health physical therapy visits.
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 very weak and the IRF services will 
help regain their strength. The Plan denied your request. The Plan says the enrollee does not meet the 
requirements for IRF services.  
 
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's medical problems are stable and there are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies 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. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cervical laminoplasty with decompression of the 
spinal cord. 
 
You asked the Plan to pre-approve a cervical laminoplasty. You say that the enrollee has severe spinal stenosis 
at C5-6 and C6-7. You say for continuation of care, it is highly recommended that the enrollee proceed with 
C5-6 and C6-7 laminoplasty. The Plan denied your request. The Plan says the request 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 cervical laminoplasty. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the physical examination does not show a neurologic deficit that correlates with 
imaging studies. There is no severe spinal cord compression and neurologic deficit. Therefore, the surgery is 
not clinically needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a cervical laminoplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a cervical laminoplasty with decompression of the spinal cord.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo (J9299) and Ipilmumab (J9228). 
 
You asked the Plan to pre-approve Opdivo and Ipilmumab. 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 Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Opdivo and Ipilmumab. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the documentation does not 
support that the requested drugs are medically reasonable and necessary or safe and effective for the enrollee. 
The enrollee has progressed on nivolumab and is unlikely to have a response given progressing on 
nivolumab/relatlimab. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Opdivo and Ipilmumab have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Opdivo (J9299) and Ipilmumab (J9228).
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 this admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee is receiving adequate and necessary 
intensive rehabilitation in the current facility, and transfer to an SNF is not medically necessary at this time. 
 
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 that the enrollee has stabilized medically and has been receiving skilled rehab 
services in an inpatient rehabilitation facility (IRF). The enrollee has tolerated inpatient rehab services and 
continues to improve with daily skilled nursing and/or skilled therapy services. She would benefit from 
continued services at the current level of care. The enrollee has made slow progress with therapy; there is no 
indication that transfer to a skilled nursing facility is required. She can continue to receive skilled rehab 
services at the current IRF or be stepped down to a lower level of care when appropriate. There are no services 
offered at a SNF that are not offered at an inpatient rehab facility. Admission to a SNF for inpatient skilled 
rehab services is not 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.