Persius/hicric huggingface dataset:
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 receive medical management and therapy services to return to prior level of function. The Plan denied your 
request. The Plan says ongoing skilled care could have been 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 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing visits and physical therapy visits. 
 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 the most 
recent nurse visit described you not needing any medication changes or instructions to the caretaker and the 
most recent physical therapy note describes you requiring moderate assist with transfers and required minimal 
assistance with wheelchair mobility. It appears that you were stable functionally and does not require skilled 
nursing or physical therapy at home at this time. There was no indication that you would decline in function 
without these services or that the caretaker would not be able to guide you to do an exercise regimen and take 
medications. 
 
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 skilled nursing visits and physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar brace and a knee brace provided on November 14, 
2022. 
 
You asked the Plan to pay for a lumbar brace and a knee brace. 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 a lumbar brace and a 
knee brace provided on November 14, 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 services are medically necessary, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an aflibercept injection provided on 
September 21, 2022. 
 
You asked the Plan to waive the coinsurance for an aflibercept injection. You say that the coinsurance is too 
high. 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for an aflibercept injection. This item/service falls within the 
Medicare Part B prescription drugs 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. The total you owe is $365.16 ($1,825.78 allowed amount x 20% = $365.16). 
Therefore, we decided that the Plan does not have to waive the coinsurance for an aflibercept injection 
provided on September 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an injection of upper or middle spine facet joint, third 
and additional levels; and use of sedation by a physician during injection procedure (64490, 64491, 64492, 
99152). 
 You asked the Plan to pre-approve injections. You say that your pain is debilitating and can increase without 
the injections. The Plan denied your request. The Plan says based on national guidelines, injections are not 
covered more than at the second level. These procedures were denied as they did not meet medical necessity 
guidelines. 
 
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 injections. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found according to the coverage criteria, limitations of facet injections include one to two levels, 
either unilateral or bilateral, are allowed per session per spine region. The need for a three or four-level 
procedure bilaterally may be considered under unique circumstances and with sufficient documentation of 
medical necessity on appeal. Neither conscious sedation nor monitored anesthesia care (MAC) is routinely 
necessary for intra-articular facet joint injections or medial branch blocks and are not routinely reimbursable. In 
addition, general anesthesia is considered not reasonable and necessary for facet joint interventions. Individual 
consideration may be given on redetermination (appeal) for payment in rare, unique circumstances if the 
medical necessity of sedation is unequivocal and clearly documented in the medical record. In this case, three 
levels have been requested and the provider has recommended the use of sedation. The review has determined 
that you do not meet criteria for the requested injections. The injections are 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 injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an injection of upper or middle spine facet joint, third and additional levels; and use of sedation 
by a physician during injection procedure (64490, 64491, 64492, 99152).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 07, 2022. 
 
You asked the Plan to pay for an office visit. You say that the services should be covered. 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 September 07, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the care management provided on March 31, 2023, by an 
OON provider.  
You asked the Plan to pay for the care management. You say that the enrollee was unable to leave their home 
due to COVID-19. The Plan denied your request. The Plan says the services were not authorized. 
  
 
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 the care management provided on March 31, 
2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B prescription drugs 
provided on January 03, 2023, to January 04, 2023. 
 
You asked the Plan to waive the coinsurance for Medicare Part B prescription drugs. 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). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for Medicare Part B prescription drugs. This item/service falls 
within the Medicare Part B prescription drugs 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. The total allowed amount for the prescription drugs is $12,367.90. You are 
being asked to pay $2,473.58 ($12,367.90 x 20% = $2,473.58). Therefore, we decided that the Plan does not 
have to waive the coinsurance for Medicare Part B prescription drugs provided on January 03, 2023, to January 
04, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a C4-5 and C6-7 total disk arthroplasty, and C5-6 
instrumented anterior cervical discectomy and fusion (ACDF). 
 
You asked the Plan to pre-approve the surgical services. You say that without this procedure the enrollee's 
condition will continue to worsen. You also say that the enrollee complains of balance issue and spinal 
narrowing that the magnetic resonance imaging (MRI) revealed. The Plan denied your request. The Plan says 
two-disc arthroplasties with a fusion in-between must be considered experimental/investigational instead of 
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 services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows 
this request to be an effective and/or safe treatment for the noted pathology. The use of artificial disc 
replacement surgery has been approved for 2 contiguous levels of pathology. This request is for disc prostheses 
at two non-contiguous levels. There is a request for an ACDF (anterior cervical discectomy and fusion) at the 
level between the artificial disc placements. This is a hybrid procedure. This combination/hybrid-type 
procedure is currently still being studied and is without long-term results to support the hybrid procedure. 
There are limited large-scale, long-term references showing the safety and efficacy of the requested surgery in 
this clinical setting. No compelling rationale is presented, or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the reviewer found that the requested C4-5 and 
C6-7 total disc arthroplasty and a C5-6 instrumented anterior cervical discectomy and fusion (ACDF) 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 the surgical services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a C4-5 and C6-7 total disk arthroplasty, and C5-6 instrumented anterior cervical 
discectomy and fusion (ACDF).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ViviGen allograft. 
 
You asked the Plan to pre-approve a ViviGen allograft. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says this 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 ViviGen allograft. Our reviewer says 
that the requested ViviGen allograft is not considered medically reasonable and necessary in this case. Our 
physician reviewer found 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 ViviGen allograft is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ViviGen allograft have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a ViviGen allograft.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and related services provided on February 15, 
2023. 
 
You asked the Plan to pay for an office visit and related services. You say that this service is supported in the 
records. 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 and 
related services provided on February 15, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing (G0299 x3). 
 You asked the Plan to pre-approve home health services. You say that this is medically 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 that the 
documentation shows that the enrollee has functional impairments however there are on acute clinical status, 
medication changes specified and skilled nursing goals listed have been met thus the records do not show that 3 
additional home health skilled nursing visits would be required to effectively provide treatment, care, and/or 
services in order to improve the enrollee's condition, or to establish/perform a maintenance program to 
maintain the enrollee's condition and/or prevent deterioration. 
 
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 skilled nursing (G0299 x3).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on February 23, 2023. 
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration for the denied 
payment. 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 the office visit provided 
on February 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on May 09, 2023. 
 
You asked the Plan to waive the copayment for an office visit. You say that this service should not have a 
copayment. 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 
copayment for each specialist visit furnished in a physicians office or by telehealth. 
 
You have been asked to pay a $20 copayment for an office visit. This item/service falls within the each 
specialist visit furnished in a physicians office or by telehealth 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 copayment for an office visit provided on May 09, 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 for the enrollee 
to receive the care needed as well as intensive therapy services before returning 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.