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

 
We decided that the Plan does not have to pre-approve i-FACTOR Peptide Enhanced Bone Graft. 
 
You asked the Plan to pre-approve i-FACTOR Peptide Enhanced Bone Graft. You say that the requested i-
FACTOR Peptide Enhanced Bone Graft is medically necessary.  The Plan denied your request. The Plan says 
the requested i-FACTOR Peptide Enhanced Bone Graft 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 i-FACTOR Peptide Enhanced Bone 
Graft. Our reviewer says that the requested i-FACTOR Peptide Enhanced Bone Graft is not medically 
necessary.  Our physician reviewer found the enrollee was being treated for numbness in both lower extremities. He presented with persistent lower back and hip pain. There is associated numbness of the 
extremities. The low back pain is worsening and rated at 10/10 radiating down both thighs/legs. There is 
numbness and weakness. The exam reveals he ambulates with a cane. 
 
The health plan approved the L2-S1 laminectomy and fusion with an inpatient stay. However, there is limited 
published, large-scale, long-term peer-reviewed literature that shows this requested allograft to be an effective 
and/or safe treatment for the noted pathology. Further studies are needed to demonstrate this request has 
beneficial outcomes compared with conventional treatment. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
requested i-Factor Peptide enhanced bone graft, in this case, 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 i-FACTOR Peptide Enhanced Bone Graft have not been met. Therefore, we 
decided that the Plan does not have to pre-approve i-FACTOR Peptide Enhanced Bone Graft.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI).  
 
You asked the Plan to pre-approve SSBCI benefits. You say that the enrollee would benefit from these 
services. The Plan denied your request. The Plan says the criteria for eligibility have not been met.  
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of a stabilization device. 
 
You asked the Plan to pre-approve the insertion of a stabilization device. You say that the doctors want to do 
this procedure which would alleviate the pain caused by stenosis. You say that this is the best course of 
treatment, and the request should be reconsidered for approval. The Plan denied your request. The Plan says 
this procedure is considered experimental, investigational and is unproven for all indications. 
 
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 insertion of a stabilization device. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that stabilization devices are experimental for spinal stenosis. 
  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 insertion of a stabilization device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the insertion of a stabilization device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation. 
 
You asked the Plan to pre-approve percutaneous vertebral augmentation. 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 follows Medicare rules. Medicare rules say that both PVP and PVA will be considered reasonable and 
necessary for osteoporotic conditions when certain 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 percutaneous vertebral augmentation. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found one of the 
fractures has bone retropulsion which is a relative contraindication. The other is not an acute fracture. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous vertebral augmentation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve percutaneous vertebral augmentation.
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 enrollee does not need an intensive team for their care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found 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 the services are medically necessary. The Plan 
denied your request. The Plan says the enrollee does not need specialized training, staff, or equipment available 
only in 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 is medically stable. While the enrollee may benefit from physical and 
occupational therapy, their rehab needs can be provided in a lower intensity and alternate setting such a skilled 
nursing facility.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary for the enrollee 
to gain strength to begin using upper body muscles, use wheelchair, walker, and finally to stand and walk 
again. Delaying this service causes continued loss of muscle mass and more time in an immobile state. The 
Plan denied your request. The Plan says the services the enrollee needs can be provided safely in another 
setting such as a skilled nursing facility, home with home health services or home with outpatient therapy. 
 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's needs cannot be adequately 
cared for in their current condition at a long-term ventilator facility or any other lower level of care. The Plan 
denied your request. The Plan says the documentation does not support that the enrollee will have the 
appropriate mental status to be weaned from a ventilator, and that they will benefit and improve with LTACH 
care.  
 
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 is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where they are 
currently receiving care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the medical eye exam, the ophthalmic 
diagnostic imaging, and the ophthalmic biometry provided on August 17, 2022. 
 
You asked the Plan to waive the copayments for the medical eye exam, the ophthalmic diagnostic imaging, and 
the ophthalmic biometry. You say that you overpaid for these services. You say you are asking the Plan to 
review and reconsider 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). Your contract with the Plan clearly says that you must pay a $35 
copayment for each Medicare-covered exam to treat an eye condition and a $65 copayment for each covered 
diagnostic procedure or test at a network doctor's office.  
 
You have been asked to pay a $35 copayment for the medical eye exam. You have been asked to pay $32.50, 
which is less than the standard copayment, for the ophthalmic diagnostic imaging. You have been asked to pay 
$32.50, which is less than the standard copayment, for the ophthalmic biometry. The medical eye exam falls 
within the vision care benefit category. The ophthalmic diagnostic imaging and the ophthalmic biometry fall 
within the outpatient diagnostic tests and therapeutic services and supplies 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 copayments for the medical eye exam, the ophthalmic diagnostic imaging, 
and the ophthalmic biometry provided on August 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI).  
 
You asked the Plan to pre-approve SSBCI benefits. You say that you want the Plan to approve these benefits. 
The Plan denied your request. The Plan says the criteria for eligibility have not been met.  
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 21, 2022, billed 
with codes 81206 and 81170. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
December 21, 2022, billed with codes 81206 and 81170.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from April 28, 2023, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from April 28, 2023, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
not medically necessary. 
 
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 psychiatric care from April 
28, 2023, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental 
health treatment beyond the date in question of April 28, 2023, forward. Our physician reviewer found the 
enrollee did not require inpatient mental health treatment beyond April 28, 2023, as she was not a danger to 
herself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active 
treatment was taking place beyond the date in question. It did not appear that the services for the dates in 
question were reasonably expected or medically necessary to improve the enrollees condition or for the 
purpose of diagnosis. 
 
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 psychiatric care from April 28, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from April 28, 
2023, forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a below knee flexible cover system (L5962). 
 
You asked the Plan to pre-approve the cover system described by code L5962. You say that the requested items 
should be approved.  The Plan denied your request. The Plan says the special covering is not medically 
necessary.  
 
The Plan follows Medicare rules. Medicare rules say that a L5962 prosthesis cover may be reasonable and 
necessary for enrollees who have special needs for protection against unusually harsh environmental situations.  
 
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 cover system described by code 
L5962. Our reviewer says that the documentation does not support the medical need for the requested cover 
system. Our physician reviewer found there is no documentation of special needs that the enrollee has which would require protection against unusually harsh environmental situations where is it necessary to protect the 
lower limb prosthesis beyond the level of protection that is affordable by the approved L5704 custom shaped 
protective cover. 
 
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 cover system described by code L5962 have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a below knee flexible cover system (L5962).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 12 physical therapy (PT) visits.  
 
You asked the Plan to pre-approve the PT visits. You say that the services are medically necessary, you had 
your shoulder replaced and have not been able to lift your arm over your shoulder since. The Plan denied your 
request. The Plan says ongoing skilled therapy visits at this point appear to be more habilitative and for pain 
control given the use of dry needling.   
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 PT visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found you have an effective home exercise program and are able to resume 
golf and tennis. Continued input from a skilled therapist 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 PT visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an additional 12 physical therapy (PT) visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve exploration of spinal fusion represented by code 22830. 
 
You asked the Plan to pre-approve code 22830. You say that the documentation provided supports the need for 
the service which remains in dispute The Plan denied your request. The Plan says the spine surgery levels 
needed do not match the spine levels the enrollee's provider requested.  
 
The Plan must follow Medicare rules. Medicare rules say that a physician should not unbundle services that are 
integral to a more comprehensive procedure.  
 
We looked at the file and Medicare rules. The documentation provided shows that the Plan pre-approved 
lumbar decompression and fusion services. The exploration fusion code in dispute is integral to the more 
comprehensive and primary fusion code that the Plan has been pre-approved. Therefore, it cannot be unbundled 
or paid for separately.  Based on this information, we decided that Medicare rules for coverage of code 22830 
have not been met. Therefore, we decided that the Plan does not have to pre-approve exploration of spinal 
fusion represented by code 22830.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the sprint PNS system (64555, L8680). 
 
You asked the Plan to pre-approve the sprint PNS system. You say that the service is medically necessary. The 
Plan denied your request. The Plan says this service 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 sprint PNS system. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case.  Our 
physician reviewer found this service is considered experimental. 
 
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 sprint PNS system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the sprint PNS system (64555, L8680).