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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee can safely receive the services needed in other settings. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for confusion, falls and 
a urinary tract infection. The enrollee's medical problems are stable. There are no complex nursing or 
rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
supports 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 this patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition 
does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the gene panel testing provided on June 26, 2020. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says coverage of 
comprehensive genomic profile testing is limited to one bundled test per specimen. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and the rules. We find that the gene panel was not billed with the appropriate CPT code. 
Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the gene panel testing provided on June 26, 2020.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee is medically stable and has no complex medical or 
specialized needs. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for metastatic prostate 
cancer with compression fracture thoracic spine. The enrollee's medical problems are stable. There are no 
complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including 
either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the 
medical record supports 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 this patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition 
does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the lateral sacral 
branches. 
 
You asked the Plan to pre-approve RFA. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says the requested admission 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 RFA. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has chronic low back pain and is status post L3 to L5 decompression. The enrollee 
is taking Gabapentin and cyclobenzaprine for pain. The enrollee had a right sacroiliac joint injection 
(diagnostic) which gave the enrollee 75-80% pain relief for six days. This is considered an experimental/ 
investigational procedure due to the wide variation in efficacy reported in the literature. Therefore, the enrollee 
does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of RFA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve radiofrequency ablation (RFA) of the lateral sacral branches.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve PET with concurrently acquired CT for attenuation correction and 
anatomical localization imaging; skull base to mid-thigh (CPT code 78815), for the enrollee. 
 
You asked the Plan to pre-approve the testing. You say that the testing is necessary. The Plan denied your 
request. The Plan says that this test can be covered up to three (3) times while on treatment for the enrollee's 
condition. The Plan states the enrollee's records show that the enrollee has had this test four (4) times in the last 
year. The Plan states further total body scans are needed when a routine (computed tomography (CT) scan has 
an unclear result. The Plan states the enrollee's your records show they have not had a recent routine scan with 
an unclear result; therefore, this total body scans is not medically necessary. The Plan states the imaging 
needed can be done with routine (computed tomography or CT) scans. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
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 testing. Our physician reviewer 
found although the enrollee has had>3, per CT it seems the CT does not accurately image disease. Therefore, 
our physician reviewer found that the PET CT should be approved. 
 
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 testing have been met. Therefore, we decided that the Plan has to pre-
approve PET with concurrently acquired CT for attenuation correction and anatomical localization imaging; 
skull base to mid-thigh (CPT code 78815), for the enrollee.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
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 enrollee is not safe to return home in her current 
condition. The Plan denied your request. The Plan says the enrollee does not require an intensive, complex, 
multidisciplinary approach to daily 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 physician reviewer found 
that the enrollee was admitted to the acute hospital for non-operative management of a subdural hematoma 
after a fall. Her medical problems are stable. There are no complex nursing needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, in an 
intensive rehabilitation therapy program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Cardio MEMS device (33289, C2624). 
 
You asked the Plan to pre-approve the insertion of a Cardio MEMS device. You say that this is necessary to 
monitor and reduce your excess fluid. The Plan denied your request. The Plan says this is 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 insertion of a Cardio MEMS device. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the efficacy of the CardioMEMS heart failure system remains uncertain at 
this time. Further clinical study is needed to determine the efficacy and safety of this device. 
 
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 Cardio MEMS device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the insertion of a Cardio MEMS device (33289, C2624).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a vascular surgery consultation to be provided by an out 
of network provider. 
 
You asked the Plan to pre-approve a vascular surgery consultation with an out of network provider. You say 
that you have been treating this enrollee since 2017. The Plan denied your request. The Plan says there are 
multiple in-network providers within a reasonable distance that can provide this service. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a vascular 
surgery consultation to be provided by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that you would like reconsideration because this 
device is medically necessary. The Plan denied your request. The Plan says there is no documentation of cystic 
fibrosis, bronchiectasis or a covered neuromuscular disease. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
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 HFCWOD. Our reviewer says that the 
member does not have a Medicare covered diagnosis for this device. Our physician reviewer found there is 
insufficient evidence that HFCWOD is beneficial for the member's condition, and it is therefore considered 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 a HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for retainer crowns (D6752 x2) provided on January 23, 2020. 
 
You asked the Plan to pay for retainer crowns. You say that you disagree how the service was coded, and you 
would like the Plan to reconsider payment of the service. The Plan denied your request. The Plan says this 
service is not a covered benefit. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for retainer 
crowns (D6752 x2) provided on January 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT, abdomen; with contrast material(s) (CPT code 
74160), for the enrollee. 
 
You asked the Plan to pre-approve the CT scan. You say that the scan is necessary. The Plan denied your 
request. The Plan says the enrollee had surgery for a cyst in their abdomen. The Plan states the enrollee had a 
prior scan on October 2, 2020, and that scan did not show that the cyst had returned. The Plan states they did 
not receive recent records showing new signs that the cyst has returned (such as new pain in the abdomen); 
therefore, this test is not medically necessary. The Plan states that imaging needed can be done with another 
test (ultrasound). 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT scan. Our physician reviewer 
found the available documentation does not indicate that the repeat CT scan is medically necessary or 
reasonable. No further evaluation of the enrollee has occurred since the last scan that demonstrated no evidence 
of cyst residual or recurrence. The pancreas had no suspicious findings at that time that required follow-up. The 
elements of the controlling Medicare rule are not satisfied. The requested service cannot be recommended 
based upon the available documentation.  
 
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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve CT, abdomen; with contrast material(s) (CPT code 74160), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses deluxe frames (V2025) and single vision 
lenses (V2100) provided October 10, 2020. 
 
You asked the Plan to pay for the eyeglass frames and lenses. You say that your glasses were provided quicker 
and less expensive from the out-of-network (OON) provider. The Plan denied your request. The Plan says 
items and services from OON providers are not covered. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when they are provided by the Plan's vision benefits providers. 

We looked at the file and the Plan's rules. You purchased frames and lenses from an OON provider. The Plan 
does not cover items or services from an OON provider. Based on this information, we decided that the Plan 
does not have to pay for the eyeglasses deluxe frames (V2025) and single vision lenses (V2100) provided 
October 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc. 
 
You asked the Plan to pre-approve Synvisc. You say that you would like reconsideration because this drug is 
medically necessary. The Plan denied your request. The Plan says the member does not meet step therapy 
exception criteria. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Synvisc. Our reviewer says that the 
Plan requires a trial of drug(s) Orthovisc and Monovisc before they will approve Synvisc. The records do not 
show that the member has tried and failed a trial of the required drugs. Our physician reviewer found based on 
the medical records provided there is no indication that the Plan's required drugs would likely be less effective 
and/or likely have adverse effects. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Synvisc.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to preapprove inpatient hospital care services. 
 
You asked the Plan to preapprove acute inpatient hospital care. You say that without surgery the enrollee could 
lose function in the right shoulder. The Plan denied your request. The Plan says there is no documentation 
provided to support the expectation the enrollee will require a greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 preapprove acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found based on the provided documentation, there was insufficient justification 
made for this patient to utilize inpatient services surrounding a low-risk surgery. There was no documented 
expected complications or issues surrounding this procedure to support this request. Therefore, this request for 
inpatient admission will be considered not medically necessary. Lower level of care would be appropriate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to preapprove inpatient hospital care services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have the Temporomandibular joint (TMJ) surgery and associated dental 
services 76376, 99201, 70330, 70355, 21242, J0702, 0232T, Q3014, 0226U provided on August 11, 2020, and 
October 8, 2020. 
 
You asked the Plan the TMJ surgery and associated dental services You say that there were no closer network 
providers to perform the services. The Plan denied your request. The Plan says the provider has opted out of 
Medicare and therefore the services are not covered. Additionally, the Plan states there were other available 
network providers in the area who could perform the services. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have the 
Temporomandibular joint (TMJ) surgery and associated dental services 76376, 99201, 70330, 70355, 21242, 
J0702, 0232T, Q3014, 0226U provided on August 11, 2020, and October 8, 2020.