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 enrollee meets criteria for IRF. The Plan denied 
your request. The Plan says the enrollee's 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 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 
does not require treatment by multiple therapies. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says you do not need an 
intensive team for 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 physician reviewer found 
that you were admitted to the acute care hospital for vertebral and rib fractures after a fall. Medical problems 
are stable. You do not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. 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 requested LTACH care is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says medical-necessity rules for LTACH 
care have 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 short-term acute care hospital can provide for all of the enrollee's inpatient 
care needs and the enrollee is receiving an appropriate level of care in the present setting. The Plan has stated 
that continued care in the short-term acute care hospital will be covered as medically indicated. 
 
 
  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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Optimizer Smart device (CCM) (CPT code(s): 
0408T and C1824). 
 
You asked the Plan to pre-approve the services. You say that the enrollee has suffered from dyspnea and 
shortness of breath and fatigue and has tried the more conservative methods for their heart failure and 
cardiomyopathies. The Plan denied your request. The Plan says the Medicare guidelines say that this item or 
service is not medically necessary because a scientific assessment of the technique has not been completed and 
its safety and efficacy has not been established. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found while the clinical studies led to Food and Drug Administration (FDA) approval in 2019, CCM 
remains the subject of multiple studies examining long-term efficacy, as well as randomized, controlled, 
double-blinded trials to quantify clinical efficacy. Until such statistically rigorous studies are completed, it is 
premature to presume clinical outcomes and benefit. At the current time, our physician reviewer would not 
consider the CCM system to be medically necessary in this 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Optimizer Smart device (CCM) (CPT code(s): 0408T and C1824).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 75726-59, 75774-59, and 99153 provided 
on October 19, 2021. 
 
You asked the Plan to pay for procedure codes 75726-59, 75774-59, and 99153. You say that you would like 
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not 
covered 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, we have confirmed that code 75726 and 75774 are column II codes to column I code 37244; 
however, 75726 and 75774 were billed with a modifier.  
 
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 procedure codes 75726-59, 75774-59, and 99153. Our 
reviewer says that the medical records do not support the services billed. Our reviewer found, although, these 
codes are supported in the procedure report, these procedures would not be reported separately, as an 
intervention was performed and reported with CPT 37244 which (per CPT code description) "inclusive of all 
radiological supervision and interpretation".  Therefore modifier -59 is not supported in this case for codes 
75726 and 75774. 
 
Furthermore, the review shows that the medical records provided represent professional charges; however, 
procedure code 99153 was provided in a facility with a place of service code of 21. Procedure code 99153 has a 
PC/TC Modifier Status of 3, which specifies a Technical Component only code. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 75726-59, 75774-59, and 99153 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 75726-59, 75774-59, and 99153 provided on 
October 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a right shoulder rotator cuff repair and decompression. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
service is not supported. 
 
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 services. Our physician 
reviewer found that the enrollee is being treated for impingement syndrome of right shoulder. She presented 
with right shoulder pain. The documentation is not evident regarding trial and failure of recent, reasonable, and 
comprehensive less invasive conservative care measures (outside of cortisone injections) without 
documentation of results of those injections. Additionally, there are no recent objective examination findings 
provided. There are limited large-scale, long-term references showing the safety and efficacy of the requested 
surgery in this clinical setting. There is no compelling rationale presented or extenuating circumstances noted 
to support the medical necessity of this request as an exception to guidelines. Therefore, the requested right 
shoulder rotator cuff repair and decompression, in this case, is not medically reasonable or 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a right shoulder rotator cuff repair and decompression.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that the enrollee is in severe pain and is 
almost bedridden. The Plan denied your request. The Plan says the denial of authorization for this service is 
correct, because the enrollee had previous blocks that did not provide sufficient pain relief. 
 
The Plan follows Medicare rules. Medicare rules state that repeat facet joint injections are only covered if 
certain 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 facet joint injections. Our reviewer says 
that the enrollee does not meet the Medicare criteria for the requested facet joint injections. Our physician 
reviewer found the enrollee did not have 80% relief of primary pain after the first diagnostic facet joint 
procedure. Therefore, this is not considered medically reasonable or 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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated mandibular advancement oral 
appliance (E0486) used to treat obstructive sleep apnea (OSA). 
 You asked the Plan to pre-approve a custom fabricated mandibular advancement oral appliance. You say that 
this is medically necessary for your condition. The Plan denied your request. The Plan says the criteria for 
coverage have not been satisfied. 
 
The Plan must follow Medicare rules. Medicare rules say that the beneficiary must have an in-person clinical 
evaluation by the treating practitioner prior to the sleep test to assess the beneficiary for obstructive sleep apnea 
testing. 
 
We looked at the file and Medicare rules. In this case, the documentation confirms that the sleep test referenced 
was completed in 2018 which was prior to the in-person clinical evaluation by the treating practitioner. Based 
on this information, we decided that Medicare rules for coverage of a custom fabricated mandibular 
advancement oral appliance have not been met. Therefore, we decided that the Plan does not have to pre-
approve a custom fabricated mandibular advancement oral appliance (E0486) used to treat obstructive sleep 
apnea (OSA).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Fundus Photography provided on February 28, 2022. 
 
You asked the Plan to pay for Fundus Photography. You say that you saw the ophthalmologist because you 
needed to get pictures done as well as an evaluation and you were not informed that the imaging would not be 
covered. The Plan denied your request. The Plan says Fundus Photography is not a covered benefit. 
 
The Plan follows Medicare rules. Medicare rules say Fundus Photography is not covered for routine screening.  
We looked at the file and the Medicare rules. Medicare says that Fundus Photography is not covered for routine 
screening. Therefore, we decided that the Plan does not have to pay for Fundus Photography provided on 
February 28, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve Intraperitoneal Nutrition (IPN) (B4185, B4189, B4193, B4197, 
B4199, B4224). 
 
You asked the Plan to pre-approve IPN. You say that the requested nutrition is medically necessary. The Plan 
denied your request. The Plan says that the records do not show that the enrollee has a permanent impairment 
that impedes absorption of nutrients. The clinical value and effectiveness of IPN, in the setting of chronic 
malnourishment and protein calorie malnutrition have not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 IPN. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee qualifies for IPN. The enrollee is under the care of a registered dietician. He has 
failed increasing protein in diet and oral supplements. He has a documented malabsorption. IPN is indicated 
due to the negative risk and high mortality associated with his malnutrition, which is severe. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IPN have been met. Therefore, we decided that the Plan has to pre-approve 
Intraperitoneal Nutrition (IPN) (B4185, B4189, B4193, B4197, B4199, B4224).  
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer (CPT code J1439). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessity for the 
enrollee's treatment for iron deficiency anemia and chronic kidney disease stage 4. The Plan denied your 
request. The Plan says the enrollee has not tried and failed the preferred step therapy drug(s) Infed (iron 
dextran) and Venofer (iron sucrose). The Plan states there is no indication their preferred drug(s) would likely 
be: less effective, and/or cause adverse effects for the enrollee. 
 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 the medication. Our physician reviewer 
found the Plan requires a trial of drug Infed (iron dextran) and Venofer (iron sucrose) before they will approve 
the requested drug. In this case, the enrollee has not tried and failed the required drug(s). There is no 
documentation provided indicating that the Plans required drug(s) 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Injectafer (CPT code J1439).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve SNF care. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of authorization for SNF care is correct. 
 
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 SNF care. Our reviewer says that the 
enrollee does not meet the Medicare criteria for SNF care. 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. 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) admission.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve total shoulder arthroplasty surgery. 
 
You asked the Plan to pre-approve shoulder surgery. You say that the enrollee has tried conservative treatment 
without relief. The Plan denied your request. The Plan says the denial of authorization for this service is 
correct, because the enrollee has failed 2 prior attempts at repair that has been unresponsive to treatment with 
medication and physical therapy. 
 
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 shoulder surgery. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation is not evident regarding trial and failure of recent, reasonable, and 
comprehensive less-invasive conservative care measures. There is limited literature showing this request to be 
an effective and/or safe treatment for the noted pathology. There is no compelling rationale or extenuating 
circumstance noted to support the necessity of this request as an exception to guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of shoulder surgery have not been met. Therefore, we decided that the Plan does 
not have to pre-approve total shoulder arthroplasty surgery.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve VIA Disc allograft intervertebral disc augmentation 
procedure (CPT code 0627T). 
 
You asked the Plan to pre-approve the surgery. You say that the surgery is necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of the VIA Disc allograft intervertebral disc 
augmentation in the setting of lumbar spondylosis have not been demonstrated in the peer-reviewed literature. 
 
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 surgery. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there were no diagnostic imaging studies provided for the lumbar spine. Regardless, there is 
limited published, large-scale, long-term peer-reviewed literature that shows VIA Disc intervertebral disc 
augmentation to be an effective and/or safe treatment for the noted pathology. There is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Therefore, the requested VIA disc allograft intervertebral disc augmentation in the setting of lumbar 
spondylosis, in this case, is not medically reasonable or 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 the surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve VIA Disc allograft intervertebral disc augmentation procedure (CPT code 0627T).