Persius/hicric huggingface dataset:
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 LTACH services are medically 
necessary. The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
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 appears to be more stable and improving and should only require 
short-term additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for a lower level of care. 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 LTACH services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home sleep study. 
 
You asked the Plan to pre-approve the study. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no discussion of the enrollee's diagnosis of sleep apnea as it pertains the home 
study request. 
 
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 study. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the provided records do not document adequate details with regard to the patient's abnormal sleep 
patterns and other clinical signs and symptoms to certify that further evaluation with a home sleep study is 
reasonable, necessary, safe and effective for the patient's condition. No history or physical examination data are 
provided to support the diagnosis of obstructive sleep apnea or the necessity and safety of a home sleep study. 
 
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 study have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a home sleep study.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided from July 11, 2022, 
through July 25, 2022, by a provider who has opted out of Medicare. 
 
You asked the Plan to pay for the psychotherapy services. You say that you would like to be reimbursed for 
these services. The Plan denied your request. The Plan says this provider does not accept Medicare payment. 
 
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 to pay for the 
psychotherapy services provided from July 11, 2022, through July 25, 2022, by a provider who has opted out of 
Medicare.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electric seat lift mechanism (E0627). 
 
You asked the Plan to pre-approve an electric seat lift mechanism. You say that the enrollee is having a 
planned elective shoulder surgery and needs the device. The Plan denied your request. The Plan says the 
enrollee does not meet criteria for coverage of the seat lift mechanism and her difficulty is temporary in nature. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section are met. 
 
We looked at the file and Medicare rules. The LCD confirms that a seat lift mechanism is covered if certain 
criteria is met. Based on this information, we decided that Medicare rules for coverage of an electric seat lift 
mechanism have not been met. Therefore, we decided that the Plan does not have to pre-approve an electric 
seat lift mechanism (E0627).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services provided to the enrollee on April 
8, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says an assistant surgeon was not needed. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 28820. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the 
services have not been met. Therefore, we decided that the Plan does not have to pay for surgical assistant 
services provided to the enrollee on April 8, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued SNF care. 
 
You asked the Plan to pre-approve continued SNF care. The Plan denied your request. The Plan says the 
continued SNF stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 continued SNF care. Our reviewer says 
that the requested SNF care is not considered medically reasonable and necessary based on Medicare 
guidelines. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the 
specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily 
skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional 
therapist. Our reviewer also found the enrollee does not require daily skilled nursing and/or skilled therapy on 
an inpatient basis in a skilled nursing facility (SNF) 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued SNF care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Taltz injections. 
 
You asked the Plan to pre-approve Taltz injections. You say that , due to the enrollee's primary malignancy and 
chemotherapy treatment, most traditional rheumatoid arthritis medications are contraindicated while 
undergoing treatment or with a primary malignancy. You say that Taltz has been shown effectiveness and 
should be approved to help improve the enrollee's deteriorating quality of life. The Plan denied your request. 
The Plan says the requested drug is on the self-administered drug list and is excluded from coverage under Part 
B. The Plan says that they do not administer Part D benefits for the enrollee. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Taltz injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve AccuCheck Guide Meter and test strips. 
 
You asked the Plan to pre-approve AccuCheck Guide Meter and 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 follows Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers as long as the enrollee retains access to all medically necessary items (including non-
preferred brands). 
 
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 AccuCheck Guide Meter and test strips. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found in this case, the 
record indicates that the enrollee has diabetes. The record provided does not indicate that the plan's preferred 
products are not capable of meeting the enrollee's medical needs. The record provided does not establish the 
medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of 
the coverage criteria are not satisfied. 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 AccuCheck Guide Meter and test strips have not been met. Therefore, we 
decided that the Plan does not have to pre-approve AccuCheck Guide Meter and test strips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair accessory, addition to power seating system, 
center mount power elevating leg rest/platform, complete system, any type, each. E1012 Power wheelchair 
accessory, electronic connection between wheelchair controller and two or more power seating system motors, 
including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting 
hardware E2311. 
 
You asked the Plan to pre-approve the items. You say that this is medically necessary. The Plan denied your 
request. The Plan says the power elevating leg rests are not medically necessary and the requested power 
features come with their own switches. 
 
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 items. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the requested items exceed the enrollee's medical needs. The documentation does not reveal that the 
patient has leg edema, contractures in the lower extremities, inability to flex her knees, or requires this to be 
used with the approved power tilt feature.  
 
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 items have not been met. Therefore, we decided that the Plan does not have to pre-approve wheelchair accessory, addition to power seating system, center mount power elevating leg 
rest/platform, complete system, any type, each. E1012 Power wheelchair accessory, electronic connection 
between wheelchair controller and two or more power seating system motors, including all related electronics, 
indicator feature, mechanical function selection switch, and fixed mounting hardware E2311.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation to the sacroiliac (SI) joint. 
 
You asked the Plan to pre-approve radiofrequency ablation to the SI joint. 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 radiofrequency ablation to the SI joint. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found this is considered experimental/investigational due to the wide 
variation in efficacy reported in the literature. Therefore, the request is deemed 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 radiofrequency ablation to the SI joint have not been met. Therefore, we 
decided that the Plan does not have to pre-approve radiofrequency ablation to the sacroiliac (SI) joint.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that another machine would not have the pressure the 
enrollee needs. The Plan denied your request. The Plan says a ventilator is not covered by Medicare for this 
purpose. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide continuous or 
bilevel positive airway pressure therapy, regardless of the underlying medical condition, are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve use 
of a ventilator.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve continued inpatient psychiatric level of care. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that the enrollee needs 
psychiatric services until stabilized. The Plan denied your request. The Plan says that the enrollee can be 
treated in a less intensive setting. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospital services. 
Our reviewer says that the enrollee meets Medicare criteria for inpatient psychiatric care. Our physician 
reviewer found it is expected that the enrollee will improve in a reasonable period of time as the enrollee was 
showing both auditory and visual hallucinations. The enrollee did not have any aggressive behaviors. It appears 
medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather 
than a lower level of care. Active treatment is taking place. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric hospital services have been met. Therefore, we decided 
that the Plan has to pre-approve continued inpatient psychiatric level of care.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment, includes placement 
(D6057). 
 
You asked the Plan to pre-approve a custom fabricated abutment. You say that you disagree with the denial. 
The Plan denied your request. The Plan says the requested service is not a covered benefit with your Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 pre-approve a 
custom fabricated abutment, includes placement (D6057).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prostate artery embolization. 
 
You asked the Plan to pre-approve prostate artery embolization. You say that this procedure is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says prostate artery embolization 
is not routine medical treatment for the enrollee's medical condition. 
 
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 prostate artery embolization. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee is a 67-year-old male with benign prostatic hyperplasia (BPH) 
and lower urinary tract symptoms of nocturia, urgency, and frequency. In this case, prostatic arterial 
embolization (PAE) is considered an experimental technique to treat symptomatic BPH. Very limited studies 
have demonstrated possible short-term safety and efficacy. The most recent American Urological Association 
(AUA) guidelines do not recommend this procedure outside of a clinical trial setting due to the heterogeneity in 
the available literature and safety concerns regarding radiation exposure, postembolization syndrome, vascular 
access, technical feasibility, higher clinical failure rate compared with more traditional methods.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prostate artery embolization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve prostate artery embolization.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital outpatient clinic visit coded G0463 provided on 
October 22, 2021. 
 
You asked the Plan to pay for the hospital outpatient clinic visit. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
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, the CPT Code Manual definition of code G0463 is hospital outpatient clinic visit for assessment 
and management of a patient. 
 
 We find that CPT code G0463 is not supported in the medical record. Specifically, diagnostic services 
(including clinical diagnostic laboratory tests) provided to an enrollee by the admitting hospital, or by an entity 
wholly owned or wholly operated by the admitting hospital, within three days prior to and including the date of 
the enrollees admission are deemed to be inpatient services and included in the inpatient payment. This means 
that these services are not separately payable. Based on this information, we decided that Medicare rules for 
coverage of the hospital outpatient clinic visit have not been met. Therefore, we decided that the Plan does not 
have to pay for the hospital outpatient clinic visit coded G0463 provided on October 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88341, 88342, 88360, and 88381 billed for 
date of service February 11, 2022. 
 You asked the Plan to pay for procedure codes 88341, 88342, 88360, and 88381. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says these codes are included in the facility 
payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT codes 88341, 88342, 88360, 
and 88381. This means there is both a professional and technical component for the CPT codes. In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT codes 88341, 88342, 
88360, and 88381. Based on this information, we decided that Medicare rules for coverage of procedure code 
88341, 88342, 88360, and 88381 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure codes 88341, 88342, 88360, and 88381 billed for date of service February 11, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. 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. 
 
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 Euflexxa. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found in this case, you have not tried and failed 
the required drugs. There is no documentation provided indicating that the plans required drugs would likely 
be less effective and/or likely have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.