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

 
We decided that the Plan does not have to pre-approve spine surgery. 
 
You asked the Plan to pre-approve spine surgery. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
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 spine surgery. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found surgical approaches to lumber spinal stenosis are generally considered medically reasonable 
and necessary for patients with disabling symptoms despite nonsurgical treatments. The case file contains 
insufficient documentation of nonsurgical treatment such as a reasonable course of physical therapy and spinal 
injection procedures. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of spine surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve spine surgery.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips. 
 
You asked the Plan to pre-approve additional trips. You say that you need additional trips for dialysis 
treatments. The Plan denied your request. The Plan says you are requesting 310 additional trips for routine 
transportation. The Plan also says your benefit only allows 48 trips for this service. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 48 one-way trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that this request exceeds the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional trips.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) with 
concurrently acquired computed tomography (CT) scan (78815). 
 
You asked the Plan to pre-approve a PET CT scan. You say that you recommend the PET CT for further 
evaluation of this high-risk prostate cancer for metastasis. The Plan denied your request. The Plan says there is 
no documentation that the enrollee has received treatment for prostate cancer nor that this PET CT is being 
requested to guide subsequent management after completion of initial anti-cancer therapy. The Plan also says 
this PET CT is not reasonable or necessary at this time. 
 
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 a PET CT scan. Our reviewer says that 
a PET CT scan is not medically reasonable and necessary for the enrollee. Our physician reviewer found the 
record indicates that the enrollee has an enlarged prostate and elevated prostate specific antigen. Our reviewer 
found that the record does not indicate that the enrollee has a biopsy confirming the diagnosis of prostate 
cancer or has undergone treatment for prostate cancer. The rules state that the requested test is non-covered for 
the initial anti-tumor treatment strategy in members with adenocarcinoma of the prostate. Our physician 
reviewer also found that the elements of the coverage criteria are not satisfied, and the requested service is not 
recommended. 
 
 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 PET CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) with concurrently acquired computed tomography 
(CT) scan (78815).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99140 billed for date of service August 15, 
2022. 
 
You asked the Plan to pay for procedure code 99140. You say that this provider is a participating provider and 
CPT code 99140 is payable under the anesthesia contract. You say that the claim should be reviewed and 
reprocessed for payment. The Plan denied your request. The Plan says procedure code 99140 is considered 
bundled and not separately payable. 
 
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 99140 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99140 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99140 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99140 billed for date of service August 15, 2022.
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 to receive the care needed and ability to return to prior level of function. The Plan denied your 
request. The Plan says the enrollee is receiving the care needed at the current facility. 
 
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 there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where they are currently 
receiving care. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 
does not require intensive rehabilitation physician or nursing oversight in an IRF. The enrollee's functional 
level does not require treatment by multiple therapies including physical or occupational therapy in an intensive 
rehabilitation program in an IRF. While the enrollee may benefit from additional therapy the documentation 
does not support that the enrollee requires or can tolerate this therapy on an IRF level. 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging (MPI) (78452). 
 
You asked the Plan to pre-approve MPI. You say that the services are necessary. The Plan denied your request. 
The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that cardiology non-emergent outpatient stress testing is 
covered under certain circumstances. 
 
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 MPI. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found there is no documentation that the 
electrocardiogram (ECG) shows an uninterpretable pattern or that you are unable to exercise. There is no 
evidence provided that would support the need for radionuclide stress testing at this time. In summary, there is 
insufficient documentation to support the medical necessity for the requested cardiac stress testing in your 
clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MPI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve myocardial perfusion imaging (MPI) (78452).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Adakveo. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the enrollee is receiving concomitant Oxbryta therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 drug. Our reviewer says that the 
requested drug is medically reasonable and necessary. Our physician reviewer found that in this case, the 
record indicates that the enrollee has a diagnosis of sickle cell disease. The Food and Drug Administration has 
stated that the requested drug is indicated as the originator biological product to reduce the frequency of 
vasoocclusive crises (VOCs) in adults and pediatric patients aged 16 years and older with sickle cell 
disease. The Medicare-approved drug compendia do not contain a restriction for the use of the requested drug 
in combination with Oxbryta. The elements of the coverage criteria are satisfied.  
 
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 drug have been met. Therefore, we decided that the Plan has to pre-approve 
Adakveo.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty procedure of the lower back at spinal level 
L1. 
 
You asked the Plan to pre-approve kyphoplasty procedure. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty procedures are only covered for certain 
indications. 
 
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 kyphoplasty procedure. Our reviewer 
says that the documentation does not support that the requested services are medically reasonable or necessary. 
Our physician reviewer found the enrollee had a fall in September 2022 and suffered an L1 compression 
fracture. The record indicates that a magnetic resonance imaging (MRI) performed at least twelve weeks after 
injury demonstrated a L1 compression fracture without bone marrow edema and other potential etiologies of 
the enrollee's radicular pain. Therefore, the enrollee does not meet criteria for the requested services. 
The elements of the coverage criteria are not satisfied 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve kyphoplasty procedure of the lower back at spinal level L1.
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 necessary for the enrollee as they 
still require care. The Plan denied your request. The Plan says the enrollee would not meet requirements or be 
able to accomplish intensive services that are required in acute inpatient rehab. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Lite Test Strips. 
 
You asked the Plan to pre-approve Freestyle Lite Test Strips. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of Freestyle Lite Test Strips have been 
met. Specifically, medical records were not provided. Medical necessity cannot be established without this 
documentation. Therefore, we decided that the Plan does not have to pre-approve Freestyle Lite Test Strips.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 
does not require intensive rehabilitation physician or nursing oversight in an IRF. The enrollee's functional 
level does not require treatment by multiple therapies including physical or occupational therapy in an intensive 
rehabilitation program in an IRF. While the enrollee may benefit from additional therapy, the documentation 
does not support that she requires or can tolerate this therapy on an IRF level. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home mechanical ventilator. 
 
You asked the Plan to pre-approve a home mechanical ventilator. You say that the clinical information 
provided supports the need for the item in dispute. The Plan denied your request. The Plan says the requested 
home mechanical ventilator set in volume-assured pressure support (VAPS) mode with Auto- expiratory 
positive airway pressure (EPAP). 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home mechanical ventilator. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found the record 
indicates that the enrollee has chronic respiratory failure from chronic obstructive pulmonary disease and of 
Covid-19. The record indicates that the enrollee was successfully treated with BiPAP.  The provided primary source documentation does not contain sufficient detailed information in the medical record to justify the 
treatment modality prescribed. The enrollee could be treated with a BiPAP machine with AVAPS capability.  
The plan has indicated coverage for such a device is available upon request. The elements of the coverage 
criteria are not satisfied.  The requested service cannot be recommended. 
 
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 home mechanical ventilator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home mechanical ventilator.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vectibix (panitumumab) (J9303). 
 
You asked the Plan to pre-approve panitumumab. The Plan denied your request. The Plan says the clinical 
value and effectiveness of Vectibix (panitumumab) in the setting of goblet cell carcinoma have not been 
demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 panitumumab. Our reviewer says that 
panitumumab is not medically reasonable and necessary for the enrollee. Our physician reviewer found the 
FDA has not stated that the requested drug, as prescribed, is indicated for the enrollee's condition. The 
Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested 
drug, as prescribed, in the enrollee's clinical situation. Our reviewer found that no literature from Medicare 
approved cancer journals were submitted for review. The elements of the coverage criteria are not satisfied. 
Our physician reviewer also found that the requested service cannot be recommended. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of panitumumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Vectibix (panitumumab) (J9303).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is needing treatment and 
placement in an LTACH, so they can recover and regain maximum functions after having an amputation. The 
Plan denied your request. The Plan says an LTACH admission is not medically necessary, and the enrollee can 
receive the care they need 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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where the enrollee is currently receiving care. The health plan has approved ongoing care in 
the current acute care 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 LTACH services.