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 you have mobility impairment and need assistance to 
get around. The Plan denied your request. The Plan says you do not meet the 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 that you do 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown (D6750), and a pontic (D6240). 
 
You asked the Plan to pre-approve D6750 and D6240. You say that you cannot eat. The Plan denied your 
request. The Plan says these services are not medically necessary. 
 
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. The Plan covers D6750 and 
D6240 when the services are medically necessary and reasonable.  
 
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 D6750 and D6240. Our physician 
reviewer found the documentation provided does not meet the criteria for coverage for a fixed bridge replacing 
tooth #3 with a pontic (D6240) using tooth #2 as an abutment retainer (D6750). 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of D6750 and D6240 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a retainer crown (D6750), and a pontic (D6240).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network cardiologist. 
 
You asked the Plan to pre-approve these services. You say that the enrollee has been seeing this specialist for 
some time. The Plan denied your request. The Plan says the services are available from network providers. 
 
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 referral to an out-of-network cardiologist.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo. 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no role for adjuvant Opdivo in 
gastric cancer. The use as a single agent is not supported by the Medicare-approved drug compendia and 
medical literature. The use is not reasonable or medically necessary for the enrollee 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Opdivo.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found Keytruda is not approved by the Food 
and Drug Administration (FDA) for the enrollee's diagnosis. The use is also not supported by one of the major 
drug compendia or by clinical research that appears in a Medicare-approved medical journal. Keytruda is 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 Keytruda.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a capsule endoscopy (91110). 
 
You asked the Plan to pre-approve a capsule endoscopy. The Plan denied your request. The Plan says this 
request is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a wireless capsule endoscopy of the small bowel is 
considered medically reasonable and necessary when the conditions listed in the Medicare rules section of this 
letter have been met. 
 
 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 capsule endoscopy. Our reviewer says 
that the enrollee does not meet the coverage criteria for a capsule endoscopy. Our physician reviewer found the 
enrollee reportedly has a history of iron deficiency anemia but neither lab studies were provided to corroborate 
the presence of anemia nor iron deficiency. Stool has tested negative for occult blood and no overt 
manifestations of gastrointestinal (GI) bleeding have been reported in available records. Our reviewer found 
that without objective evidence of iron deficiency anemia, nor of a Hematology evaluation for same to warrant 
concern for GI blood loss, the medical necessity of wireless capsule endoscopy is not demonstrated. 
 
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 capsule endoscopy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a capsule endoscopy (91110).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve minimally invasive sacroiliac joint (SIJ) fusion and 
placement of the ChoiceSpine fixation system. 
 
You asked the Plan to pre-approve the requested SIJ fusion procedure. You say that this would be a beneficial 
treatment. The Plan denied your request. The Plan says there is not sufficient evidence to support this 
procedure. 
 
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 requested SIJ fusion procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the records do not document SIJ instability, fracture, or lesion. This type of 
procedure for degenerative low back pain is considered experimental.  
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 requested SIJ fusion procedure have not been met. Therefore, we decided 
that the Plan does not have to pre-approve minimally invasive sacroiliac joint (SIJ) fusion and placement of the 
ChoiceSpine fixation system.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the MRI of the spine provided on August 
26, 2022. 
 
You asked the Plan to waive the coinsurance for the MRI of the spine. You say that you need your money back 
and the Plan did not respond to you as it should. 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 15% 
coinsurance for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $29.76 for the MRI of the spine. (The allowed amount is $198.37; $198.37 x 15% 
= $29.76.) This item/service falls within the outpatient diagnostic tests and therapeutic services and supplies 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 coinsurance for the MRI of the spine provided 
on August 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve the requested ESI. You say that this treatment is needed. The Plan denied 
your request. The Plan says the enrollee has not yet completed a trial of physical therapy. 
 
The Plan follows Medicare rules. Medicare rules say that ESIs may only be covered after a failure of a four-
week trial of conservative care. 
 
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 requested ESI. Our reviewer says 
that the requested ESI is not shown to be medically reasonable and necessary. Our physician reviewer found 
the enrollee has not completed a course of noninvasive conservative care, as he was just prescribed a course of 
physical therapy. The review has determined that the criteria from the LCD are not met for the requested ESI. 
 
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 requested ESI have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an epidural steroid injection (ESI).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cataract surgery provided on December 10, 2021, and 
February 10, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the cataract surgery. You say that these services were medically necessary. The 
Plan denied your request. The Plan says you must receive your care from a 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the cataract surgery provided on December 10, 
2021, and February 10, 2022, 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 member will benefit from acute inpatient 
rehabilitation that cannot be accomplished at a lower level of care. The Plan denied your request. The Plan says 
the member does not meet criteria for an IRF admission. 
 
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, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bilateral RFA single facet joint L3-4 (64635 x 2) 
and each additional facet joint L4-5 (64636 x 2). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. The requested procedure was 
confirmed by the provider to be cooled and pulsed, and not using thermal heat settings as required by the LCD. 
The LCD L38801 is specific for requiring thermal settings and cool settings are not considered medically 
necessary for RFA. Therefore, we decided that the Plan does not have to pre-approve the bilateral RFA single 
facet joint L3-4 (64635 x 2) and each additional facet joint L4-5 (64636 x 2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient evaluation and management (EM) services 
provided on July 14, 2022, billed with code 99223. 
 
You asked the Plan to pay for the EM services as billed. You say that the records support the code selected for 
these services. The Plan denied your request. The Plan says the billed code is 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 99223 is Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. 
 
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 EM services as billed. Our reviewer says 
that the documentation does not support the billed code in this case. Our reviewer found the enrollee was seen 
in the hospital due to generalized weakness, with a history of thrombocytopenia and myelodysplastic 
syndrome. The evaluation and management code billed requires a medically appropriate history and/or 
examination and high level of medical decision making. In this case, the medical records submitted did not 
support a medical decision making of high complexity. 
 
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 EM services as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the inpatient evaluation and management (EM) services provided on July 14, 
2022, billed with code 99223.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connector (E2311). 
 
You asked the Plan to pre-approve an electronic connector. The Plan denied your request. The Plan says that 
the connector device is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that an electronic connection device is covered when it is 
medically necessary to control the power options through the joystick. 
 
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 an electronic connector. Our reviewer 
says that the coverage criteria has not been met. Our physician reviewer found that you have use of the upper 
extremities and can operate and control the power options using the switches that are included in the basic 
wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connector have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connector (E2311).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the Healthy Food Allowance. 
 
You asked the Plan to pre-approve the Healthy Food Allowance. You say that you have diabetes and you used 
to have the produce box benefit last year. The Plan denied your request. The Plan says that your doctor did not 
confirm you meet criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations, 
premiums and cost-sharing, and any other conditions associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Healthy Food Allowance have been met. Specifically, the only clinical information provided to 
us by the Plan was a form from the prescribing physician that states you have hypertension and mixed 
hyperlipidemia. These are cardiovascular disorders. The Plan has not substantiated their denial reason that you 
do not have a qualifying condition for the Healthy Food Allowance. Therefore, we decided that the Plan has to 
pre-approve the Healthy Food Allowance.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet block injections (64493, 64494). 
 
You asked the Plan to pre-approve facet block injections. 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 therapeutic facet joint procedures are considered 
medically reasonable and necessary for patients who meet specific criteria. 
 
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 facet block injections. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the records show that the 
enrollee did not have two medically reasonable and necessary diagnostic facet joint procedures with each one 
providing a consistent minimum of 80% relief of primary pain (with the duration of relief being consistent with 
the agent used). The review has determined that the enrollee does not meet the coverage criteria detailed in the 
LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet block injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet block injections (64493, 64494).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an attendant control feature (E2331). 
 
You asked the Plan to pre-approve attendant control feature. You say that the requested Group 3 power 
wheelchair and all recommended components are necessary to meet the enrollee's mobility, medical and 
functional needs. The Plan denied your request. The Plan says the requested feature is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that an attendant control provided in addition to a 
beneficiary-operated drive control system will be denied as non-covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of attendant control feature have not been met. Specifically, the file indicates that the Plan has 
approved a beneficiary operated drive-control system. Therefore, we decided that the Plan does not have to pre-
approve an attendant control feature (E2331).