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. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary to receive the therapy 
needed and prevent losing additional function of legs, arms, fingers and toes. The Plan denied your request. 
The Plan says you do not meet all the required Medicare criteria for admission to an inpatient rehabilitation 
facility. 
 
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 documents do not support necessity for admission to an IRF. The complexity of 
your nursing, rehab, and medical needs does not require an acute hospital inpatient rehab stay with an 
interdisciplinary approach to rehabilitative care. While the medical record supports a need for physical and 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PT services to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve PT services. You say that physical therapy services are necessary. The Plan 
denied your request. The Plan says services requested can be provided by an in-network provider. 
 
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 
PT services to be provided by an out-of-network (OON) provider.
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 enrollee will benefit from an acute inpatient 
rehab and requires care that cannot be accomplished at a lower level of care. The Plan denied your request. The 
Plan says the services the enrollee needs can be provided safely in another setting. 
 
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 documents do not support necessity for admission to an IRF and the complexity of 
the enrollee's nursing, rehab, and medical needs does not require an acute hospital inpatient rehab stay with an 
interdisciplinary approach to rehabilitative care. While the medical record supports a need for physical and 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Synvisc-One. 
 
You asked the Plan to pre-approve Synvisc-One. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step-therapy rules for coverage of the requested drug 
have 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 Synvisc-One. Our reviewer says that 
the requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that 
the Plan requires a trial of Euflexxa and of Durolane, Gelsyn-3 or Supartz FX before they will approve the 
requested drug, Synvisc-One. There is indication in the case record that the enrollee has tried Euflexxa, but 
there is no indication that the enrollee has tried and failed Durolane, Gelsyn-3 or Supartz FX. Based on the 
medical records provided and the Medicare-approved major drug compendia, there is no indication that 
Durolane, Gelsyn-3 or Supartz FX would likely be less effective and/or likely have adverse effects for the 
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 Synvisc-One have not been met. Therefore, we decided that the Plan does not 
have to pre-approve treatment with Synvisc-One.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cervical, multiple post collar, occipital/mandibular 
supports, adjustable provided on November 2, 2022. 
 
You asked the Plan to pay for the device. You say that this should be paid for. The Plan denied your request. 
The Plan says the documentation submitted did not sufficiently support the billed supply code. 
 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 pay for the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the enrollee was prescribed a cervical spine collar orthosis for the treatment of her 
medical condition. There is no clear documentation available for review that supports the enrollee has 
significant cervical spine pain or any abnormal physical findings involving the cervical spine. The requested 
orthosis does not appear appropriate to the patients medical needs and condition. 
 
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 pay for a cervical, multiple post collar, occipital/mandibular supports, adjustable provided on November 2, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) of the lower extremities 
without dye (73700). 
 
You asked the Plan to pre-approve the CT scan. You say that this imaging is medically necessary and 
reasonable. The Plan denied your request. The Plan says a CT is not medically necessary in this case. 
 
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 reviewer says that the 
documentation provided does not support the medical necessity of a CT scan. Our physician reviewer found 
that the enrollee has left hip pain and muscle spasm without history of trauma. X-rays from March 21, 2023, 
showed only mild degenerative changes. The history and physical exam documentation did not describe a red 
flag for diagnosis, nor was there documented plans for a surgery or other procedure requiring advanced 
imaging or documentation of a full trial of conservative treatments to justify this request for CT. This imaging 
cannot be considered medically necessary at this time. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve computed tomography (CT) of the lower extremities without dye (73700).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued coverage of a home ventilator (E0466). 
 
You asked the Plan to pre-approve continued coverage of a home ventilator. You say that this device is 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 continued coverage of a home 
ventilator. Our reviewer says that continued coverage of the home ventilator is not medically necessary. Our 
physician reviewer found a device download covering January 29 to February 27, 2023 showed use of the 
device for at least 4 hours/day for only 3.3% of days. The device is not being used enough to be effective. 
 
 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 coverage of a home ventilator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve continued coverage of a home ventilator (E0466).
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 and could jeopardize their health if denied. The Plan denied your request. The Plan says the 
services the enrollee needs could be provided in another setting, such as an acute rehabilitation facility, skilled 
nursing facility, nursing facility, outpatient setting or home care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not support that the enrollee has need for complex medical 
treatment in a LTACH. The enrollee has improved medically and can receive further care at the current acute 
care hospital or in a lower level of care when deemed appropriate.  Denial for admission into a LTACH upheld. 
 
 
 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMeMS heart monitor device (33289). 
 
You asked the Plan to pre-approve a CardioMeMS heart monitor device. You say that the device is medically 
necessary. The Plan denied your request. The Plan says the requested device is not medically necessary for the 
enrollee. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 
 
 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CardioMeMS heart monitor device. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the CardioMEMS device was approved by the FDA in 2014 and 
consists of a sensor device placed in the pulmonary artery to allow measurement of pulmonary artery pressure 
in the management of enrollees with CHF. The clinical study on which FDA approval was based showed 
improved clinical outcomes and decreased hospitalizations in enrollees in whom the CardioMEMS system was 
implanted, reflecting an enrollee population with preserved ejection fraction and was somewhat limited in 
scope. Subsequent follow-up studies remain encouraging and suggest an improvement in heart failure 
symptoms with the use of the device. In addition, published expert opinion in the cardiology literature is 
supportive of the clinical usefulness of CardioMEMS.  Nonetheless, there remains a dearth of randomized, 
blinded clinical studies examining long-term clinical outcomes establishing the value of CardioMEMS in 
enrollee management. As a result, at this time the CardioMEMS system would not be considered medically 
appropriate and necessary in this enrollee's 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 a CardioMeMS heart monitor device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a CardioMeMS heart monitor device (33289).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous implantation of a neurostimulator 
(63650) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a percutaneous implantation of a neurostimulator. You say that the provider 
is fully equipped to help the enrollee regain the maximum benefits from the procedure. It has been deemed a 
medical necessity for the enrollee to proceed with this procedure. The Plan denied your request. The Plan says 
records received do not indicate that the enrollee has an emergent or urgent medical condition or needs 
specialized service(s) that are not available in the network. There are in-network provider locations within a 
reasonable distance from the enrollee's location that can provide this service and/or item. 
 
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 
a percutaneous implantation of a neurostimulator (63650) to be provided by an out-of-network (OON) 
provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an X-ray exam provided on September 3, 2022. 
 
You asked the Plan to pay for an X-ray exam.. You say that claim needs to be reprocessed The Plan denied 
your request. The Plan says Original Medicare is responsible for payment. 
   
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for an X-ray exam provided on September 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $64.88 copayment for medical vision exam; including 
optic nerve imaging and eye ultrasound. 
 
You asked the Plan to waive the $64.88 copayment for vision exam. You say that this was a routine visit, and 
you should not be responsible for the copay. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $64.88 
copayment for outpatient diagnostic test and vision care.  
 
You have been asked to pay a $64.88 copayment for vision exam; which includes $45 copayment for an office 
visit, $10 copay for diagnostic testing, and $9.88 copay for an eye ultrasound; totaling $64.88. This 
item/service falls within the outpatient diagnostic test and vision care benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the $64.88 copayment for medical vision exam; including optic nerve imaging and eye 
ultrasound.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intraosseous ablation of the basivertebral nerve 
(Intracept) (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that you are appealing for wrongful denial 
for intraosseous ablation of the basivertebral nerve, which is accomplished with the Intracept Procedure. The 
Plan denied your request. The Plan says the Intracept procedure is considered experimental and investigational 
due to insufficient evidence to establish safety and efficacy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the intraosseous ablation of the basivertebral nerve (Intracept) (64628, 64629).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (procedure code 99152) rendered 
on July 27, 2022. 
 
You asked the Plan to pay for the services. You say that medical records were submitted for review. The Plan 
denied your request. The Plan says Current Procedural Terminology (CPT) code 99152 (1 Unit) remains not 
supported. 
 
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 99152 is "Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found that the documentation submitted did 
not indicate the presence of an independent trained observer to assist in the monitoring of the patient's level of 
consciousness and physiological status. There is insufficient documentation to corroborate the anesthesia 
services provided to confirm that Medicare coverage has been met. Therefore, the billed service cannot be 
verified. 
 
We looked at this coder'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 pay for moderate sedation services (procedure code 99152) rendered on July 27, 2022.
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 enrollee needs rehab to get stronger before 
returning home. The Plan denied your request. The Plan says the enrollee does not meet all the required 
Medicare criteria for admission to an inpatient rehabilitation facility. 
 
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 documents do not support necessity for admission to an IRF. The complexity of 
the enrollee's nursing, rehab, and medical needs does not require an acute hospital inpatient rehab stay with an 
interdisciplinary approach to rehabilitative care. While the medical record supports a need for physical and 
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.