Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for long term acute care hospital (LTACH) services. 
 
You asked the Plan to pay for the LTACH services. You say that he deteriorated some so he does need a lot of 
care. You also say that you need someone to check on him every day. The Plan denied your request. The Plan 
says based on Medicare guidelines and the information they have; the enrollee does not meet all the 
requirements. 
 
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 pay for 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 patient appears to be stable and improving, and should only require short-term additional 
acute care services that can safely be administered at the current facility until more appropriate for a lower level 
of care. Our physician reviewer also found that there are no services at the LTACH that the patient requires that 
are not already available and covered at the current facility. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pay for long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Coflex device for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of the Coflex interspinous 
device in the setting of lumbar stenosis has 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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. There is imaging 
evidence of 7mm of anterolisthesis of L4 on L5, with no discussion of spinal instability on flexion/extension 
films. There is imaging evidence of exaggerated lordosis of the lumbar spine, with no documentation of the 
Cobb angle. There is no discussion indicating that a DEXA scan has demonstrated the lack of significant 
osteoporosis in this patient. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception to guidelines. 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 the Coflex device for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IsoTis Mozaik Putty allograft and bone marrow aspirate 
for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of the IsoTis Mozaik Putty 
Allograft in the setting of spinal fusion surgery has 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 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 a specific indication provided to support the request for bone marrow 
aspirate for the approved surgery. There is no compelling rationale presented or extenuating circumstances 
noted to support the medical necessity of IsoTis Mozaik Putty allograft and bone marrow aspiration in 
conjunction with the lumbar surgery performed. There is a lack of large volume, long-term peer-reviewed 
outcome studies to support the use of IsoTis Mozaik Putty allograft and bone marrow aspirate for this 
enrollee's medical condition. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Our physician reviewer found that the enrollee's 
condition does not meet criteria for 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 IsoTis Mozaik Putty allograft and bone marrow aspirate for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing the denied admission to IRF with 
medical records. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria 
for admission to an IRF. Care can be received at a lower level such as skilled nursing facility which may be 
approved if requested. 
 
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 enrollee's nursing medical and rehabilitation needs may require 
physician and nursing oversight. The enrollee may have the medical complexity requiring physician and 
nursing oversight but this does not need to occur in the acute inpatient rehabilitation setting since her medical 
and rehabilitation needs do not require the intensive interdisciplinary approach provided on acute inpatient 
rehabilitation. 
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program at least 3 hours a day and 5 days a week, or 15 hours 
over 7 consecutive days. The documentation indicates that the enrollee would likely not be able to tolerate 3 
hours of therapy per day. The enrollee does not meet the requirements for intensive rehabilitation therapy 3 
hours a day and 5 days a week or 15 hours over 7 consecutive days. Therefore, the enrollee does not require the 
intensive therapies provided in the acute inpatient rehabilitation 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services requested are medically necessary. The 
Plan denied your request. The Plan says the member does not appear to meet Medicare criteria for an IRF 
admission. 
 
The Plan must follow Medicare rules. The rules say that an 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 Document does not support the medical necessity for admission to 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ubrelvy for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
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 Ubrelvy for the enrollee.  
 
Benefits for this drug 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rotary wing air mileage (A0436) and rotary wing air 
transport (A0431) provided on May 13, 2021. 
 
You asked the Plan to pay for the rotary wing air mileage and transport. You say that the physician in charge 
said an air ambulance was your only option. The Plan denied your request. The Plan says ground transportation 
(land vehicles) was approved, and records did not show the need for air transport. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
 
  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 rotary wing air mileage and transport. 
Our reviewer says that the elements of the coverage rules are not satisfied, and the requested service cannot be 
recommended. Our physician reviewer found the record provided does not indicate that other means of 
transportation were contraindicated or that you were transported to the nearest facility capable of providing the 
needed care. The provided record is insufficient to determine whether the coverage criteria are satisfied. 
 
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 rotary wing air mileage and transport have not been met. Therefore, we 
decided that the Plan does not have to pay for the rotary wing air mileage (A0436) and rotary wing air transport 
(A0431) provided on May 13, 2021.
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 admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 you appear to be somewhat unstable and require additional short-term acute care 
services that can be safely administered at the current facility until you are more stable and appropriate for a 
lower 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 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 continuation off care with an out of network (OON) 
provider. 
 You asked the Plan to pre-approve the continuation of care with an OON provider. You say that the enrollee 
wishes to continue care with the provider she has been seeing. The Plan denied your request. The Plan says the 
records received do not indicate that the enrollee has an emergent or urgent medical condition or is in need of 
specialized service(s) that are not available in the network. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for 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 continuation of care with an OON 
provider. Our reviewer says that the criteria for coverage of OON care have not been met. Our physician 
reviewer found the record indicates that the enrollee has a a diagnosis of peripheral arterial disease.  The record 
indicates that the enrollee is being treated with observation and a walking program. The enrollee is not 
receiving active treatment, as defined by Medicare rules, that would make transferring her care and medical 
management to another provider medically inappropriate and/or contraindicated 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 continuation of care with an OON provider have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a continuation off care with an out of network (OON) 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150), and treatment 
of root canal obstruction (D3331) to be performed by an endodontist. 
 
You asked the Plan to pre-approve a comprehensive oral evaluation and treatment of root canal obstruction to 
be performed by an endodontist. You say that the requested services are medically necessary. The Plan denied 
your request. The Plan says the services at issue are not covered unless they are performed by a participating 
general dentist. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a comprehensive oral evaluation and treatment of root canal obstruction to be performed by an 
endodontist have not been met. Specifically, the services at issue are not covered unless they are performed by 
a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve a 
comprehensive oral evaluation (D0150), and treatment of root canal obstruction (D3331) to be performed by an 
endodontist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic parenteral drug (D9610). 
 
You asked the Plan to pre-approve the dental service. You say that you want this to be covered. The Plan 
denied your request. The Plan says therapeutic parenteral drug is not listed as a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a therapeutic 
parenteral drug (D9610).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an apicoectomy (D3410) and retrograde filling (D3430). 
 
You asked the Plan to pre-approve the dental services. You say that you have a tooth infection. You say that 
you are in pain. You also say that you need to have this apicoectomy done to remove the infection. The Plan 
denied your request. The Plan says the requested services are not listed as covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
apicoectomy (D3410) and retrograde filling (D3430).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the aortography services coded 75625 provided on 
November 1, 2021. 
 
You asked the Plan to pay for the aortography services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 75625 is aortography, abdominal, by serialography, 
radiological supervision and interpretation. 
 
We find that CPT code 75625 is not supported in the medical record. Specifically, the operative report did not 
include documentation of radiological supervision and interpretation of an abdominal aortography by 
serialography; therefore, code 75625 cannot be verified. Based on this information, we decided that Medicare 
rules for coverage of the aortography services have not been met. Therefore, we decided that the Plan does not 
have to pay for the aortography services coded 75625 provided on November 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that inpatient admission is medically 
necessary. The Plan denied your request. The Plan says there is no documentation provided to support the 
expectation the enrollee will require a greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the enrollee is approved for facility fees, and anesthesia to be associated 
with elective extraction of teeth, alveoloplasty, and tori removal for dentures. The record does not document 
that the treating physician has a reasonable expectation of a length of stay spanning 2 or more midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transit wheels for a wheelchair. 
 
You asked the Plan to pre-approve transit wheels. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested items are not a covered benefit. 
 The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. In addition, the 
requested items are for use for outside of the home. These items are not covered. Therefore, we decided that the 
Plan does not have to pre-approve transit wheels for a wheelchair.