Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the whirlpool bath equipment. 
 
You asked the Plan to pre-approve the whirlpool bath equipment.. You say that the item is medically necessary. 
The Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that hirlpool back equipment is covered when the patient 
is homebound and has a condition for which whirlpool bath can be expected to provide substantial therapeutic 
benefit. 
 
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 whirlpool bath equipment.. Our 
reviewer says that you do not need this medical item. Our physician reviewer found you do not have a 
condition for which whirlpool baths are indicated. 
 
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 whirlpool bath equipment. have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the whirlpool bath equipment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a push-rim activated power assist system (E0986). 
 
You asked the Plan to pre-approve a push-rim activated power assist system. You say that the enrollee's 
therapist has documented several reasons that the power assist is medically necessary. The Plan denied your 
request. The Plan says this request does not meet the criteria for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 push-rim activated power assist 
system. Our reviewer says that the enrollee does not meet the coverage criteria. Our physician reviewer found 
the enrollee's upper extremity strength is 5 out of 5 and they function independently in the home with a manual 
wheelchair per medical records. Our reviewer also found that the medical records do not support the enrollee 
requires the requested push rim sysetm to accomplish MRADLs. 
 
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 push-rim activated power assist system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a push-rim activated power assist system (E0986).
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 services are medically necessary. The 
Plan denied your request. The Plan says there are no services required that the enrollee is not already receiving. 
 
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 all expected and reasonable care at the acute care hospital. 
There are no specific treatments or services that would be offered at the LTACH that are not available in the 
current 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 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: 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 requires ongoing acute care 
and close monitoring of their other complex wound and medical conditions with an aggressive regimen of 
physical rehabilitation as tolerated. The Plan denied your request. The Plan says when the enrollee is ready to 
leave the hospital, they can safely receive this care in another 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 is receiving appropriate care in the current acute care setting as provided 
by Health Plan. Documentation does not support that LTACH services are medically appropriate at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: 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 services are medically necessary for 
the enrollee's complex medical needs. The Plan denied your request. The Plan says when you are ready to leave 
the hospital, you can receive this care in another 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 is receiving all expected and reasonable care at the acute care hospital. 
There are no specific treatments or services that would be offered at the LTACH. It does not appear that the 
enrollee meets the criteria for LTACH treatment. 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 pre-approve a gym membership. 
 
You asked the Plan to pre-approve a gym membership. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says according to your member handbook, the Plan offers a fitness 
benefit through a Plan specific fitness vendor. The Plan also says that therefore, the request for your fitness 
benefit at this non-participating fitness center is denied. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only when the fitness benefit is obtained through the Plan specific fitness vendor location. 
 
The Plans rules for coverage of gym benefits have not been met because the requested fitness facility is not the 
Plan specific fitness vendor the Plan covers. Therefore, we decided that the Plan does not have to pre-approve a 
gym membership.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulation, therapeutic activities, and lower-
level laser therapy provided by a chiropractor on April 10, 2023, to April 12, 2023. 
 
You asked the Plan to pay for the electrical stimulation, therapeutic activities, and lower-level laser therapy. 
You say that you do not agree with the denial of payment for the chiropractic visits. The Plan denied your 
request. The Plan says these services are not covered when provided by a Chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that electrical stimulation, and lower-level laser are not manual manipulation of the spine. 
Therefore, we decided that the Plan does not have to pay for the electrical stimulation, therapeutic activities, 
and lower-level laser therapy provided on April 10, 2023, to April 12, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the thermal destruction of intraosseous basivertebral 
nerve (Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee has tried and failed 
conservative treatment without relief. The Plan denied your request. The Plan says chronic vertebrogenic pain 
is not a qualifying diagnosis for the requested procedure. 
 
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 Intracept procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the provided documentation does not show a clear cause of the enrollee's pain. 
Therefore, the reviewer found that the requested Intracept procedure 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the thermal destruction of intraosseous basivertebral nerve (Intracept procedure 
(64628, 64629).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a laminectomry with partial facetectomy (63047), and 
laminectomy with facetectomy (63048). 
 
You asked the Plan to pre-approve the surgical services. You say that the enrollee has failed epidural steroid 
injections, nonsteroidal anti-inflammatory drugs (NSAIDs), pain medications, and physical therapy. The Plan 
denied your request. The Plan says this procedure 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 services. Our reviewer says 
that the requested surgical services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found detailed documentation is not clear regarding spinal stenosis associated claudication 
complaints. There are no objective neurologic deficits noted on exam. Additionally, the magnetic resonance imaging (MRI) provided did not corroborate severe spinal stenosis pathology that would require surgery in the 
absence of relatively corroborative clinical findings. Clearly detailed evidence of recent, reasonable and 
comprehensive less invasive treatments is not evident. No compelling rationale is presented, or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
laminectomy with partial facetectomy and laminectomy with facetectomy 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 laminectomry with partial facetectomy (63047), and laminectomy with 
facetectomy (63048).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes E0673 and E0675 billed for date of service 
March 8, 2023. 
 
You asked the Plan to pay for the billed services. You say that this device was provided for use during the 
patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a procedure is 
not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
 
 
 The claim shows that the services at issue were provided in an ambulatory surgical center. Although this item 
may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Based on this 
information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure codes E0673 and E0675 billed for date of service March 8, 2023.
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 the medical records support the medical necessity for 
IRF admission.  The Plan denied your request. The Plan says based on Medicare guidelines, the IRF services 
requested do not meet the requirements for approval. 
 
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 the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for chest pain and confusion. 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 the enrollee 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve the injections. You say that you have been living with constant pain and you 
do not believe the 80% standard described in your denial letter is fair for your circumstances as you need the 
procedure. The Plan denied your request. The Plan says facet joint injections 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 injections. Our reviewer says that 
that you do not meet the LCD coverage criteria. Our physician reviewer found that the LCD requires 80% pain 
relief on each set of diagnostic blocks, which was not achieved. 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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint injections.
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 would improve in rehab and need to continue 
with therapy. The Plan denied your request. The Plan says 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 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 9, 2022, to 
March 1, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you submitted the required 
NOA. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 9, 2022, to 
March 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the insertion of intrauterine device (IUD) (58300) provided 
on November 1, 2022. 
 
You asked the Plan to pay for the outpatient service. You say that the service was medically necessary and 
should be covered. The Plan denied your request. The Plan says procedure codes with a status of "N" in the 
Medicare Physician Fee Schedule cannot be covered when billed to Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code 58300 has a status indicator of N on the Physician Fee Schedule. This means that 
the service represented by procedure code 58300 is not payable. Therefore, we decided that the Plan does not 
have to pay for the insertion of intrauterine device (IUD) (58300) provided on November 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar spine fusion. 
 
You asked the Plan to pre-approve a lumbar spine fusion. You say that you have pain in your lower back, down 
your left side. You say that your left foot is numb. You say that your previous spinal fusions were somewhat 
helpful. You also say that you are taking Oxycodone, Morphine, and gabapentin for pain. The Plan denied your 
request. The Plan says there was no documentation to support that three months of conservative treatment had 
been trialed. 
 
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 lumbar spine fusion. Our reviewer 
says that the requested lumbar spine fusion not considered medically reasonable and necessary in this case. Our 
physician reviewer found detailed documentation regarding a trial and failure of recent, reasonable, comprehensive, less invasive conservative care measures is not evident. Recent active physical therapy is not 
clearly documented. Additionally, dynamic flexion/extension films are not provided in order to potentially 
assess the amount of movement (instability) at the requested surgical level. Detailed documentation is not 
evident regarding potential impending/inevitable temporary intra-operative instability. No compelling rationale 
is presented, or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the requested lumbar spine fusion at L2-3 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 lumbar spine fusion have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a lumbar spine fusion.