Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medial branch blocks. 
 
You asked the Plan to pre-approve the medial branch blocks. You say that you are still experiencing pain that is 
not tolerable. You say that you are digressing and have not been to therapy since January.  The Plan denied 
your request. The Plan says  the medial branch blocks are not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the medial branch blocks. Our reviewer 
says that you do not meet the coverage criteria. Our physician reviewer found that there need to be 
quantification of the degree and duration of pain relief from the first set of diagnostic medial branch blocks. 
While there are plan x-rays, advanced imaging is the criteria of the LCD. Therefore, the request is not 
medically reasonable and 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 medial branch blocks have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the medial branch blocks.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an out-of-network outpatient surgery 
provided on February 3, 2023. 
 
You asked the Plan to waive the coinsurance for an out-of-network outpatient surgery. You say that you 
disagree with the coinsurance. 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 a 40% coinsurance for out-of-network outpatient surgery.  
 
The enrollee has been asked to pay a 40% coinsurance for an out-of-network outpatient surgery. The total 
allowed amount for the outpatient surgery is $4,249.40. You are being asked to pay $1,699.76 ($4,249.40 x 40% = $1,699.76). This item/service falls within the out-of-network outpatient surgery 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 waive the coinsurance for an out-of-network outpatient surgery provided on 
February 3, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says ongoing skilled care can be provided in an alternative setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not require treatment by multiple therapies. 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: 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 live by yourself and have difficulty doing things 
for yourself. You also say you have trouble remembering and feel that SNF services will help you get better.  
The Plan denied your request. The Plan says the SNF services requested 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 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 and/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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary for the enrollee 
to regain as much functional independence as possible to help them return home. The Plan denied your request. 
The Plan says the enrollee does not meet the criteria for admission to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need physical and occupational services. 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Personal Emergency Response System (S5161). 
 
You asked the Plan to pre-approve a Personal Emergency Response System. You say that the item is medically 
necessary. The Plan denied your request. The Plan says this does not primarily serve a medical purpose. 
 
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 Personal Emergency Response System (S5161).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional trips. You say that there was an error when scheduling 
transportation. The Plan denied your request. The Plan says your benefit only allows 24 trips for this service. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case.  We looked at your request, the records in the case file, and the rules. The records show that you have used 24 
one-way trips this year. Based on this information, we decided that you have exhausted the Plan maximum 
benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve 
additional routine transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A100). 
 
You asked the Plan to pre-approve the additional trips. You say that you are requesting unlimited rides for 
transportation. You also say that you have multiple appointments per year due to your chronic conditions. The 
Plan denied your request. The Plan says your benefit does not cover more than 10 one-way trips per plan year. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 10 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to approve additional 
routine transportation trips. Based on this information, we decided that you have exhausted the Plan maximum 
benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve 
additional routine transportation trips (A100).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on September 14, 2022, by an 
OON provider.  
 
You asked the Plan to pay for nursing facility care. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advanced. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for nursing facility care provided on September 14, 
2022, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 heavy duty power wheelchair (K0858) with 
additional items and accessories (codes E0955, E0956, E1002, E1012, E1028, E2300, E2311, E2313, E2363, 
E2377, E2604, K0040, and K0108). 
 You asked the Plan to pre-approve a group 3 heavy duty power wheelchair with additional items and 
accessories. The Plan denied your request. The Plan says the enrollee has no qualifying diagnosis for a group 3 
power wheelchair. 
 
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. Specifically, the records show that the diagnosis that is causing 
limitation of mobility is morbid obesity, which is not a qualifying diagnosis for a group 3 power wheelchair. 
Therefore, we decided that the Plan does not have to pre-approve a group 3 heavy duty power wheelchair 
(K0858) with additional items and accessories (codes E0955, E0956, E1002, E1012, E1028, E2300, E2311, 
E2313, E2363, E2377, E2604, K0040, and K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A100). 
 You asked the Plan to pre-approve the additional trips. You say that the additional routine trips are very 
important. The Plan denied your request. The Plan says your 100 trips may include some trips that you have 
already scheduled but have not used. Your request for a 101st trip and beyond is not a covered benefit.  
 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 100 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve 
additional routine transportation trips. Based on this information, we decided that you have exhausted the Plan 
maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to 
pre-approve additional routine transportation trips (A100).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the EMGALITY PEN (C9399). 
 
You asked the Plan to pre-approve the medication. You say that the item should be covered. 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 the EMGALITY PEN 
(C9399).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 27, 2022. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on October 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a recliner chair (E1399). 
 
You asked the Plan to pre-approve a recliner chair. You say that the item should be covered. The Plan denied 
your request. The Plan says this is not a covered item. 
 
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 recliner chair (E1399).
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 admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says you do 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 there are no complex nursing or rehabilitation needs. While you have a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like to do peer to peer rehabilitation. The 
Plan denied your request. The Plan says you do not meet medical necessity criteria for IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
lymphedema. Medical problems are stable. 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. There is 
not a reasonable expectation that you will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ReadyBath bathing cloths. 
 
You asked the Plan to pre-approve the requested items. You say that a shower chair or transfer bench have 
been ruled out. The Plan denied your request. The Plan says the items are 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 items at issue do 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 ReadyBath bathing cloths.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections (ESIs), 2 levels. 
 You asked the Plan to pre-approve the ESIs. You say that the enrollee needs these injections. The Plan denied 
your request. The Plan says the documentation provided does not indicate the enrollee has tried and failed 
conservative treatment. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when the inability to tolerate noninvasive conservative care or medical 
documentation of failure to respond to four (4) weeks of noninvasive conservative 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 ESIs. Our reviewer says that the 
requested ESIs are not medically necessary. Our physician reviewer found the provided documentation does 
not support the inability to tolerate noninvasive conservative care or medical documentation of failure to 
respond to four weeks of noninvasive conservative care. Therefore, the reviewer found that the requested ESIs 
are 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 the ESIs have not been met. Therefore, we decided that the Plan does not have 
to pre-approve epidural steroid injections (ESIs), 2 levels.