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 to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve IRF care. You say that the requested IRF admission is medically necessary. 
The Plan denied your request. The Plan says there are no extenuating circumstances making it medically 
necessary to obtain the services out-of-network. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services to be provided by an out-of-network (OON) 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667).  
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says it cannot be said at this time that this request is reasonable and 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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that as the provided records do not document a failure of four weeks of regular, daily, multiple-hour 
home usage of a standard pump after careful, in-person fitting, training and supervision by a technician who is 
skilled in and who successfully uses the pump, it cannot be said that the enrollee has unique characteristics that 
would indicate the segmented pump over a standard pump.  
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device (E0652, E0667).
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 now have a colostomy bag and feel due to this 
and being ill you need this stay and care. The Plan denied your request. The Plan says the enrollee does not 
meet the requirements and can safely receive the services in other settings. For example: 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 you were admitted for weakness, fever, and diarrhea. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. While you have a need for physical or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on December 23, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a duplicate 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be exact duplicates of another claim or claim line are denied.  We looked at the file and Medicare rules. The services in question were billed on a duplicate claim to one 
previously processed and paid by the Plan. Duplicate claims are not payable. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan 
does not have to pay for the services provided on December 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional miles for non-emergent transportation. 
 
You asked the Plan to pre-approve additional miles for non-emergent transportation. You say that you are 
requesting 10.1 excess miles for non-emergent transportation. The Plan denied your request. The Plan says the 
request exceeds the benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. 
 
We looked at your request, the records in the case file, and the rules. You are requesting transportation from 270 Dry Bone Road Ash Flat, AR 72513 to 901 Burnett Drive Mountain Home, AR 72653. Per Google maps 
the shortest distance is 60.1 miles which exceeds the 50 miles. Per Google maps the distance avoiding 
highways, tolls and ferries is 60.1 miles which also exceeds the 50 miles. Therefore, we decided that the Plan 
does not have to pre-approve additional miles for non-emergent transportation.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo. 
 
You asked the Plan to pre-approve Vabysmo. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug does not meet step therapy 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 Vabysmo. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a diagnosis of Exudative age-related macular degeneration, right eye, with active 
choroidal neovascularization. The documentation does not support that the enrollee has tried and failed 
Avastin. The documentation does not support that Avastin would likely be less effective, and/or would likely 
have adverse effects for the enrollee in this case. Therefore, the enrollee does not meet criteria for the requested 
drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vabysmo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vabysmo.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that records do not show that the enrollee requires treatments that 
can only be given in a hospital 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. The patient 
does not appear to be in acute enough condition to justify inpatient care and a lower level of care such as 
improved home health care including wound care services would be more appropriate at this stage. The patient 
does not require services at the LTACH that are not already available at home or as outpatient. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the current evidence-based medical 
guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 
gold standard of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome 
studies to support the use of this device for this enrollees medical condition as discussed above. The services 
are therefore not reasonable or medically necessary. 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Vertiflex Superion spacer.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac rehabilitation services (93797). 
 
You asked the Plan to pre-approve cardiac rehab. You say that the providers recommended by the Plan do not 
offer cardiac services, and this care is medically necessary according to your primary care physician. The Plan 
denied your request. The Plan says the criteria for coverage of cardiac rehabilitation services are not met. There 
is no evidence provided to show that you have had one or more acute myocardial infarction within the last 12 
months, coronary artery bypasses surgery, current stable angina pectoris, heart valve repair or replacement, 
percutaneous transluminal coronary angioplasty (PTCA), coronary stenting or a heart or heart-lung transplant 
which would necessitate this care. 
 
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 cardiac rehab. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found an exhaustive review of the literature shows evidence of clinical benefit of cardiac 
rehabilitation in patients with certain events such as acute myocardial infarction or revascularization. For 
patients with stable coronary artery disease, the evidence to support the use is weaker. A 2018 review of seven 
studies that compared cardiac rehabilitation with no exercise control found no clear evidence of benefit in all-
cause mortality, acute myocardial infarction or cardiovascular-related hospital admissions. Hence, practice 
guidelines have been formulated to define patient groups most likely to achieve meaningful benefit from a 
cardiac rehabilitation program. In summary, cardiac rehabilitation is not clinically warranted and not 
considered medically reasonable or necessary in the management of this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cardiac rehab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve cardiac rehabilitation services (93797).
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 LTACH services. You say that LTACH services are medically necessary. 
The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient care at the current 
hospital and can remain there until ready for discharge to a lower level of care such as in a skilled nursing 
facility or at home with home health services. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not already 
available at the current facility. 
 
 
 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says the requested drug does not meet step therapy 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 Prolia. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found you have a diagnosis of other osteoporosis without current pathological fracture. The documentation 
does not support that you have tried and failed intravenous bisphosphonate therapy (such as zoledronic acid). 
The documentation does not support that an intravenous bisphosphonate therapy (such as zoledronic acid) 
would likely be less effective, and/or would likely have adverse effects for you. Therefore, you do not meet 
criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus Gene Panel coded as 81206, 81210, 81235 and 
81272 provided July 7, 2021. 
 
You asked the Plan to pay for the molecular pathology testing. You say that you request reconsideration and 
coverage of the Tempus Gene Panel at the in-network benefit level. The Plan denied your request. The Plan 
says does not meet Medicare NCD/LCD criteria.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, we find that CPT codes 81206, 81210, 81235 and 81272 are not supported in the medical record. 
Specifically, Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel. 
Those two or more genes will be considered part of the same panel. A panel constitutes a single procedural 
service, so one CPT code must be submitted for the panel. Based on this information, we decided that Medicare 
rules for coverage of the molecular pathology testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the Tempus Gene Panel coded as 81206, 81210, 81235 and 81272 provided July 7, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) of the face and sinuses 
without contrast (70486). 
 
You asked the Plan to pre-approve a CT of the face and sinuses. You say that this imaging is medically 
necessary. The Plan denied your request. The Plan says the requested CT scan is not medically necessary. The 
documentation provided does not include other tests or treatment that was provided for your nose problem, and 
it is not clear how this imaging will impact your plan of care. 
 
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 a CT of the face and sinuses. Our 
reviewer says that the requested CT scan is not medically necessary in this case. Our physician reviewer found 
there is no specific clinical rationale for the requested CT prior to evaluation by an ear, nose and throat (ENT) 
specialist. The review has determined that the requested (CT) of the face and sinuses without contrast (70486) 
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 CT of the face and sinuses have not been met. Therefore, we decided that the 
Plan does not have to pre-approve computed tomography (CT) of the face and sinuses without contrast 
(70486).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat facet joint radiofrequency ablation services. 
 
You asked the Plan to pre-approve repeat facet joint radiofrequency ablation services. You say that this is 
medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says 
the benefit limit for radiofrequency ablation services has been exhausted. 
 
The Plan must follow Medicare rules. Medicare rules say that for each covered spinal region no more than two 
(2) radiofrequency sessions will be reimbursed per rolling 12 months. 
 
We looked at the file and Medicare rules. In this case, the documentation confirms that two radiofrequency 
sessions have already been covered which has exhausted the benefit limit for radiofrequency ablation. Based on 
this information, we decided that Medicare rules for coverage of repeat facet joint radiofrequency ablation 
services have not been met. Therefore, we decided that the Plan does not have to pre-approve repeat facet joint 
radiofrequency ablation services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient surgery for the opening of the narrowing 
blood vessels with balloon, stent, or calcium cutting device. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show problems in the iliac segment. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation suggests that no further procedures are being planned or requested and the ongoing 
request for coverage of the codes in question likely represent a clerical error. The patient was seen in the office 
on 4/19/2022. At that time, the patient was noted to have a decrease in ABI and evidence of severe in-stent 
stenosis in the right iliac artery. The plan was for diagnostic angiography and possible intervention and the 
codes for iliac intervention were approved should the angiogram demonstrate that they were necessary. On 
5/2/2022 the patient underwent diagnostic angiography that demonstrated no significant iliac disease. The prior 
iliac stents were noted to be patent without flow-limiting stenoses. No treatment was required. The runoff was checked and other than some stenosis at the right common femoral artery there were essentially normal arteries 
in the legs bilaterally. The current request appears to address the denial of coverage of codes for lower 
extremity arterial treatment however the need for these codes to be approved has been rendered moot.  As there 
is no documentation of any need or request for additional services, approval of additional service code are not 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve outpatient surgery for the opening of the narrowing blood vessels with balloon, stent, or 
calcium cutting device.