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

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve, 
including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (CPT code 64628). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to 
insufficient evidence of efficacy. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found basivertebral nerve ablation is experimental. More research is needed. 
 
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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve thermal destruction of intraosseous 
basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (CPT code 
64628).
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says you are medically stable and records do not show a need for an intensive program. 
Your needs can be met at a lower level of care. 
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
respiratory failure, pneumonia, and congestive heart failure and your medical problems are stable. There are no 
complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a 
need for physical and/or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ozempic 
 
You asked the Plan to pre-approve Ozempic. You say that You did not provide an argument for coverage with 
your appeal request. The Plan denied your request. The Plan says this drug is not covered under the enrollee's 
medical benefits. 
 
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 Ozempic  
 Benefits for Ozempic may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right carpal tunnel release for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied 
your request. The Plan says that there is no clear documentation of paresthesias in the median nerve 
distribution and there is lack of documentation of conservative treatment to include night splinting. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Detailed 
documentation is not evident regarding trial and failure of recent, reasonable, and comprehensive less invasive 
conservative care measures. There are limited large-scale, long-term references showing the safety and efficacy 
of the requested surgery in this clinical setting without failure of conservative treatments. Our physician 
reviewer found that the enrollee's condition does not meet criteria for coverage of these services. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve right carpal tunnel release for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the X-ray exam of the spine (72050) and office visit 
(99213) provided from September 2, 2021, through September 29, 2021. 
 
You asked the Plan to pre-approve the X-ray exam of the spine and office visit. You say that you would like 
this claim reprocessed and approved for payment. The Plan denied your request. The Plan says these services 
are not covered when rendered by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulations of the spine. Therefore, we decided 
that the Plan does not have to pre-approve the X-ray exam of the spine (72050) and office visit (99213) 
provided from September 2, 2021, through September 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient post-stabilization care provided from May 13, 
2021 at 10:48am, to May 18, 2021 
 
You asked the Plan to pay for the inpatient post-stabilization care. You say that the enrollee's associated high 
risk of clinical decompensation warranted inpatient care. You also say that the enrollee could not have been 
treated appropriately and safely in any other setting. The Plan denied your request. The Plan says all inpatient 
care was unauthorized post-stabilization care and correctly denied. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 inpatient post-stabilization care. Our 
reviewer says that the post-stabilization care was not medically reasonable and necessary. Our physician 
reviewer found as of May 14, 2021, the enrollee was clearly stable for ambulance transportation with 
monitoring to a Plan facility because hemoglobin remained stable without further blood transfusions, her 
hypotension resolved, and her nausea and vomiting had resolved. There were no reports of hemodynamic 
decline. Our reviewer found that there was no documentation provided indicating medical necessity for the 
post-stabilization care services provided from May 13, 2021 at 10:48am, to May 18, 2021 at the non-Plan 
facility. Our physician reviewer also found that the treating physician did not document (in the physician notes, 
on a form, or in an order) that the patient was not stable for transfer on any dates of service. 
 
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 inpatient post-stabilization care have not been met. Therefore, we decided 
that the Plan does not have to pay for the inpatient post-stabilization care provided from May 13, 2021 at 
10:48am, to May 18, 2021
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 It will be dangerous for the member to be alone after 
his surgery and needs to be admitted to an inpatient rehabilitation level of care. The Plan denied your request. 
The Plan says IRF services are not medically necessary, and the patient can be managed at a lower level of care 
 
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 patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for hydropneumothorax, aortic stenosis, and cirrhosis and their medical problems are stable. There are 
no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the patient has a need for physical and/or occupational therapy, there is no documentation of a need for 
an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 an ultrasonic bone growth stimulator. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a bone growth stimulator is covered when 
specific criteria are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show that you have a 
fracture of the fifth toe base on your left foot. You reported improvement in pain and swelling with use of a rigid soled shoe. The records do not clearly show that the foot fracture has not healed over the past 90 days 
with conservative treatment to justify a bone growth stimulator. 
 
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 an ultrasonic bone growth stimulator.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xifaxan Tab 550mg. 
 
You asked the Plan to pre-approve Xifaxan Tab 550mg. You say that this drug is medically necessary since the 
patient has been hospitalized for hepatic encephalopathy. The Plan denied your request. The Plan says this drug 
is not covered under the patient's medical benefits. 
 
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 Xifaxan Tab 550mg.  
 Benefits for Xifaxan Tab 550mg may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sterile water, saline and/or dextrose, diluent/flush, 
10ML (CPT code A4216), and wound cleansers (CPT code A6260). 
 
You asked the Plan to pre-approve the items. You say that cleaning your wound is a vital part of your dressing 
changes. You state you are a high risk for re-hospitalization for infection and/or amputation; therefore, it is 
necessary for your wound care supplies, including sterile water and/or wound cleanser to be covered. The Plan 
denied your request. The Plan says the items are not covered by Medicare. 
 
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 items have not been met. Wound cleansers and solutions used 
to moisten gauze (e.g., saline) are non-covered under the surgical dressing benefit because they do not meet the 
statutory definition of a dressing. Therefore, we decided that the Plan does not have to pre-approve sterile 
water, saline and/or dextrose, diluent/flush, 10ML (CPT code A4216), and wound cleansers (CPT code 
A6260).
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 would like this denial to be reconsidered so the 
enrollee can receive intensive therapy in an inpatient rehabilitation setting. The Plan denied your request. The 
Plan says the documentation does not say that the enrollee needs at least two kinds of therapy or that a doctor 
needs to see them at least 3 times per week. The Plan also says that the documentation does not say that the 
enrollee can do therapy at least 3 hours a day, 5 days in a row, or for at least 15 hours a week, 7 days in a row. 
 
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 patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer 
found that the patient does not require at least 3 hours a day, 5 days a week, or 15 hours over 7 consecutive 
days, of therapy services. Our physician reviewer also found that there is not a reasonable expectation that this 
patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
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: 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 enrollee is not clinically appropriate 
for a lower level of care. The Plan denied your request. The Plan says the enrollee is receiving appropriate 
inpatient acute 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 physician 
reviewer found that the enrollee was admitted to the acute care hospital with a urinary tract infection and 
decubitus ulcer. She does not complex daily wound care needs. She is receiving appropriate care at the present 
acute care hospital. There are no services available at the LTACH that she requires that are not available at the 
health care setting being offered by the health plan. The requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT 
code 22869). 
 
You asked the Plan to pre-approve the service. You say that this is to treat lumbar spinal stenosis with 
neurogenic claudication. You state the enrollee has suffered from this condition for too long and has impacted 
their quality of life and functionality. The Plan denied your request. The Plan says unproven and not medically 
necessary procedures are not covered by Medicare due to insufficient evidence of efficacy. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy.  
 
 
 
 
 
 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a patient lift chair (E0635), provided on July 14, 2021. 
 
You asked the Plan to pay for a patient lift chair. You say that the item is medically necessary. The Plan denied 
your request. The Plan says this item was obtained through a provider that is not enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a patient lift chair (E0635), provided on 
July 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an eye exam provided on November 17, 
2021. 
 
You asked the Plan to waive the deductible for an eye exam. You say that you do not have a deductible policy. 
The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1,000 deductible which applies to vision care.  
 
Vision care includes services for the diagnosis and treatment of diseases and injuries of the eye. The item or 
service you asked the Plan to waive the deductible for falls within the Vision Care benefit category. The 
services you received are not covered under your supplemental benefits. The Plan has followed Medicare rules 
by clearly disclosing in the contract that there is a $1,000 deductible which applies to vision care. This cost 
sharing is a contractual obligation that had not been met at the time an eye exam was received on November 
17, 2021. Therefore, we decided that the Plan does not have to waive the deductible for an eye exam provided 
on November 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 24, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.  
 
We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which 
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based 
on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for the lab services provided on June 24, 2021.