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

 
We decided that the Plan does not have to pre-approve a third level facet joint injection. 
 
You asked the Plan to pre-approve a third level facet joint injection. You say that a third level facet joint 
injection is medically necessary. The Plan denied your request. The Plan says one to two levels, either 
unilateral or bilateral, are allowed per session per spine region. The provider did not provide evidence of 
unique circumstances for a third level with sufficient documentation of medical necessity on appeal. Two 
levels were approved by the Plan. 
 
The Plan follows Medicare rules. 
 
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 third level facet joint injection. Our 
reviewer says that a third level facet joint injection is not considered medically necessary. Our physician 
reviewer found that the Medicare LCD limits the number of MBBs to two level bilaterally. There was no 
unusual circumstance that mandated a third level. Only two levels were 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 a third level facet joint injection have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a third level facet joint injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with single power 
option. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a Group 3 PWC is covered when specific criteria 
are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a neurological disorder 
with functional deficits. The documentation does not indicate that the enrollee has any pressure injuries or 
requires intermittent catheterization of the bladder or have spasticity that would necessitate power tilt or 
recline. The criteria for coverage of the Group 3 PWC are not met and the services are therefore not reasonable 
or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Group 3 power wheelchair (PWC) with single power option.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that you believe the denial of the Intracept 
procedure is unwarranted and unsupported by the enrollee's current medical status and current peer reviewed 
literature. The Plan denied your request. The Plan says this procedure 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 Intracept procedure. 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 contain a magnetic resonance imaging (MRI) that shows modic 
endplate changes without facet degenerative joint disease (DJD) and foraminal stenosis. The cause of back pain 
is not clear.  
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64628, 64629).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve procedure code 22830. 
 
You asked the Plan to pre-approve procedure code 22830. You say that the services are necessary. The Plan 
denied your request. The Plan says payment for code 22830 is bundled into payment for code 22612 and code 
22558.  

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, we have confirmed that code 22830 
is a column II code to column I code 22612 and 22830 is a column II code to column I code 22558. This claim 
has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare 
billing criteria have not been met. Therefore, we decided that the Plan does not have to pre-approve procedure 
code 22830.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy (PBT). 
 
You asked the Plan to pre-approve PBT. 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 PBT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found PBT is not medically reasonable and necessary in this case. There is insufficient prospective, 
long-term clinical data available to determine whether or not proton beam radiation therapy for bladder cancer 
is superior, inferior, or equivalent to external beam radiation therapy or Intensity modulated radiotherapy 
(IMRT) with regards to safety and efficacy.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PBT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve proton beam therapy (PBT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a calf rest/pad (E0995). 
 
You asked the Plan to pre-approve a calf rest/pad. You say that the custom power wheelchair is medically 
necessary for the enrollee. The Plan denied your request. The Plan says code E0995 is included in the 
allowance of power wheelchair base group 3 (K0856). The Plan also says these items or services still do not 
meet the coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that a calf rest/pad (E0995) is included in the 
allowance for a group 3 power wheelchair (K0856). 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a calf rest/pad have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a calf rest/pad (E0995).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve seven additional extractions (D7210). 
 
You asked the Plan to pre-approve seven additional extractions (D7210). You say that you are requesting 
reconsideration for the additional extractions. You say you need to have your teeth removed for your dentures. 
The Plan denied your request. The Plan says your supplemental dental benefit covers two dental extractions per 
year. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan approved two dental extractions which is the limit for total extractions per year. Therefore, we 
decided that the Plan does not have to pre-approve seven additional extractions (D7210).
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 necessary for 
the enrollee to regain their maximum/prior level of functioning and continue a multi-disciplinary approach to 
care. The Plan denied your request. The Plan says the enrollee does not meet Medicare guidelines for services 
in an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not already 
available at the current facility.  There are no services at the LTACH that the enrollee requires that are not already available and covered at the 
current facility. Transfer to the LTACH is not medically necessary as the enrollee is not yet stable for transfer 
and as it would not be clinically advantageous.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on December 25, 2022. 
 
You asked the Plan to pay for self-administered drugs. You say that you were seen in the emergency room 
where they determined you had a felon on your finger and required an antibiotic. The Plan denied your request. 
The Plan says self-administered drugs do not fall under Medicare Part B coverage. 
 
  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 pay for self-administered drugs provided 
on December 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
array, epidural (63650) implantable neurostimulator electrode, each (L8680). 
 You asked the Plan to pre-approve the surgical procedure. You say that you would like to appeal this decision 
because you need this procedure because it will relieve the pain. The Plan denied your request. The Plan says 
based on Medicare guidelines, 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 the surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the request is for a spinal cord stimulation trial. The enrollee has chronic lower back 
pain due to L4-5 and L5-S1 spondylosis and degenerative disc disease causing radiculopathy. The enrollee 
received several sacroiliac joint injections which have provided some relief. The enrollee had more than six 
weeks of physical therapy and medications trials. A magnetic resonance imaging (MRI) study of the lumbar 
spine, which showed facet arthropathy L3-4 through the L5-S1 levels of your lumbosacral spine. The enrollee 
does not have an indication that is approved by the NCD and LCD. Therefore, the request is deemed 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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve percutaneous implantation of neurostimulator electrode array, epidural (63650) 
implantable neurostimulator electrode, each (L8680).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 sensor. 
 
You asked the Plan to pre-approve the FreeStyle Libre 2 sensor. The Plan denied your request. The Plan says 
the enrollee does not require insulin three or more times daily. 
 
 
 
 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the FreeStyle Libre 2 sensor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a FreeStyle Libre 2 sensor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient mental health care. 
 
You asked the Plan to pre-approve inpatient mental health care. You say that the enrollee requires inpatient 
mental health care for detoxification. The Plan denied your request. The Plan says the enrollee does not meet 
the criteria for an inpatient mental health admission. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient mental health care. Our 
physician reviewer found the records provided for the admission of this enrollee does not meet criteria for acute 
inpatient mental health treatment as this enrollee was not shown to be a danger to themself or others, no 
auditory or visual hallucinations. The enrollee is noted to be cooperative and compliant with treatment while 
not showing any aggressive behaviors. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient mental health care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional speech therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that the enrollee will not be able to regain 
maximum speech function without therapy. The Plan denied your request. The Plan says 4 visits have been approved, and the remaining 8 visits requested for the speech therapy services are not considered medically 
reasonable and 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 the therapy services. 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 may improve function over time, but little material 
gain can be expected 10 months post stroke. Speech therapy does not improve cognition post stroke as multiple 
reviews have shown. The enrollee can continue with a home exercise program to address their chronic 
functional impairment. Continued input from a skilled therapist is not medically necessary after an additional 4 
speech therapy visits. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 8 additional speech therapy visits.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from December 13, 
2022, to December 31, 2022. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you should not be responsible for the 
copayment since the member was not inpatient for over 20 days. 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 $0 copayment for days 1 to 20, a $172 copayment per day for days 21 to 60, and $0 copayment for 
days 61 to 100 for SNF care.  
 The enrollee has been asked to pay a $1,892 copayment for a SNF stay ($172 per day x 11 days = $1,892). This 
item/service falls within the SNF 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 waive the 
copayment for a SNF stay provided from December 13, 2022, to December 31, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has a limb threatening 
infection and requires intense monitoring with daily labs. The Plan denied your request. The Plan says the 
enrollee's medical needs are being met in the current setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be stabilizing but it is not clear how much more acute care 
they will need. The enrollee requires additional acute care services at the current facility until more stable and 
appropriate for transfer to a lower level of care. The enrollee does not require services at the LTACH that are 
not already available at the current facility. Completion of treatment at the current facility is 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an in-network angiogram provided on 
December 6, 2022. 
 
You asked the Plan to waive the coinsurance for an in-network angiogram. You say that you should not have to 
pay coinsurance on top of a copayment. It should all be included in the copay. The Plan denied your request. 
The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare-covered medical supply. The allowed amount of this procedure was $10,360.06, 
resulting in a $2,072.01 coinsurance ($10,360.06 x 20% = $2,072.01).  
 You have been asked to pay a $2,072.01 coinsurance for an in-network angiogram. This item/service falls 
within the Medicare-covered medical supply 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 coinsurance 
for an in-network angiogram provided on December 6, 2022.
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 the services that the enrollee needs can be provided safely in another setting 
such as a skilled nursing facility. 
 
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. The enrollee is 
essentially at their baseline level of function and primarily has decreased endurance due to their cardiac and 
respiratory issues. The enrollee has not had an acute change in their neurological status or level of function. 
The enrollee does not require the intensity of therapies provided in an acute inpatient rehabilitation. 
 
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.