Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the chronically ill (SSBCI) supplemental benefit. 
 
You asked the Plan to pre-approve the chronically ill (SSBCI) supplemental benefit.. You say that the items are 
medically necessary. The Plan denied your request. The Plan says there is no documentation that the member 
meets criteria for the requested service. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the durable medical equipment have not been met. Specifically, there is no documentation 
confirming that you have one of the eligible conditions listed in the Evidence of Coverage. Therefore, we 
decided that the Plan does not have to pre-approve the chronically ill (SSBCI) supplemental benefit.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you have more than one health issue and need IRF 
services to further progress in your treatment. The Plan denied your request. The Plan says criteria for 
admission to an IRF have not been met. 
 
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 documentation does not support the necessity for admission to an IRF. The 
complexity of your nursing and medical needs does not require an acute hospital inpatient rehabilitation stay with an interdisciplinary approach to rehabilitative care. While you may benefit from physical therapy and/or 
occupational therapy, your rehabilitation needs can be provided in a lower intensity and alternate setting such 
as in a skilled nursing 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 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan. 
 
You asked the Plan to pre-approve a computed tomography (CT) scan. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the criteria for 
approval have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a computed tomography (CT) scan. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the ordered CT of the 
neck, (70490) is a soft tissue neck exam and intended for the evaluation of the soft tissues of the neck such as 
lymph nodes, masses etc. The patient has symptoms of cervical spondylosis, and the correct exam would be CT 
cervical spine, (72125).  The denial for the exam requested is upheld. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a computed tomography (CT) scan have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a computed tomography (CT) scan.
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 requires extensive skilled 
services that would be offered in a LTACH. The Plan denied your request. The Plan says the enrollee is 
receiving medically necessary acute care in the current facility. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee is improving but still requires acute care 
services before transitioning to a lower level of care. The enrollee continues to receive acute care services, and 
these have not been denied. The medical record does not indicate that the enrollee requires services that they 
are not currently receiving but that would be available at the LTACH 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 pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Tecentriq. 
 
You asked the Plan to pre-approve Tecentriq. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says Tecentriq is 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 Tecentriq. Our reviewer says that the 
enrollee does not meet criteria for Tecentriq. Our physician reviewer found Tecentriq is not Food & Drug 
Administration (FDA) approved for the enrollee's diagnosis. This use is not supported by one of the major drug 
compendia or by clinical research appearing in a Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Tecentriq have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Tecentriq.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the partial psychiatric hospitalization. 
 
You asked the Plan to pre-approve the partial psychiatric hospitalization. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the patient can be safely managed on an outpatient 
basis with increased frequency of visits with her psychiatrist for review/optimization of pharmacotherapy and 
psychological treatment to cope with psychosocial stressors and management of her family reality. Currently, 
the patient has no acute symptoms or psychosocial factors that pose imminent risk or potential for imminent 
risk to herself, others, or property. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.   
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 partial psychiatric hospitalization. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the patient is not 
showing any perceptual disturbance, psychosis or aggressive behaviors nor does she have any suicidal or 
homicidal thoughts or behavioral disturbance. Her symptomatology could be treated at 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 partial psychiatric hospitalization have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the partial psychiatric hospitalization.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF services are necessary because you need 
physical therapy and occupational therapy to regain mobility to go home. The Plan denied your request. The 
Plan says an IRF admission is not medically necessary. 
 
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 the clinical documentation does not specify any active medical comorbidities or 
complex functional impairments. Thus, the complexity of your documented nursing, medical, and rehabilitation needs would not be expected to require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. IRF criteria are not met. 
 
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 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 member's condition is too complex 
for a lower level of care. The Plan denied your request. The Plan says the member's medical needs are being 
met in the current facility. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee has ongoing acute medical issues and still 
requires acute care services before transitioning to a lower level of care. The enrollee continues to receive acute 
care services, and these have not been denied. The medical record does not indicate that the enrollee requires 
services that they are not currently receiving but that would be available at the LTACH facility. The requested 
service cannot be recommended as the elements of the coverage rules are not 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 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve a positron emission tomography (PET) scan. You say that you would like to 
request reconsideration of the denied authorization. The Plan denied your request. The Plan says the criteria for 
approval have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a positron emission tomography (PET) 
scan. Our reviewer says that the service is not medically necessary. Our physician reviewer found that the 
patient has no behavioral issues to suggest frontotemporal dementia (FTD).  In order for a PET scan to be 
covered a differential diagnosis of Alzheimer's disease vs. FTD must be present.  No other neurocognitive 
diagnoses are covered indications.  Since there is no discussion of possible FTD, criteria for PET/CT are not 
met. The requested PET/CT is denied. 
 
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 positron emission tomography (PET) scan have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the crutch substitute (E0118). 
 
You asked the Plan to pre-approve the crutch substitute. You say that because of ongoing lower back problems, 
you cannot use a wheelchair because of lower back pain when you sit so you would like to have a knee scooter 
approved. The Plan denied your request. The Plan says The crutch substitute is on the list of non-covered 
Durable Medical Equipment (DME). There is insufficient published clinical literature demonstrating safety and 
effectiveness. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the crutch substitute have not been met. Therefore, we decided that the Plan does not have to pre-
approve the crutch substitute (E0118).
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 you require medical and rehabilitation 
that cannot be provided at a lower level of care. The Plan denied your request. The Plan says criteria for an 
LTACH admission has 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 the record indicates that you have ongoing acute medical issues and still require acute 
care services before transitioning to a lower level of care. You continue to receive acute care services, and these 
have not been denied. The medical record does not indicate that the enrollee requires services that they are not 
currently receiving but that would be available at the LTACH facility. The requested service cannot be 
recommended as the elements of the coverage rules are not 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and sleeves 
(E0656, E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the items are medically 
necessary. The Plan denied your request. The Plan says your records do not show that you failed a 4 week trial 
of a E0650 or E0651 device or that you have truncal edema on physical exam. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that you have failed at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and sleeves (E0656, E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that an epidural steroid injection is 
medically necessary. The Plan denied your request. The Plan says an epidural steroid injection is not medically 
necessary. 
 
The Plan follows Medicare rules.  
 
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 epidural steroid injection. Our 
reviewer says that an epidural steroid injection is not medically necessary in this case. Our physician reviewer 
found in this case, there is no documentation of radiculopathy, no advanced imaging obtained, and no 
documentation of a failure of conservative therapy such as physical therapy, home exercise program, or 
chiropractic care. The other issue is the provider ordered an epidural of the cervical/thoracic region and there is 
no documentation of any symptoms related to that particular area. The review has determined that the requested 
cervical/thoracic epidural steroid injection is not medically necessary or reasonable.  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 epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone morphogenic protein (BMP) allograft. 
 
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 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 services are not medically necessary. Our physician reviewer found that the BMP allograft is not Food and 
Drug Administration (FDA)-approved for use in the posterior cervical spine. More research is needed to show 
its safety and efficacy. The allograft is therefore 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 a bone morphogenic protein (BMP) allograft.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Prolia (J0897). 
 
You asked the Plan to pre-approve the Prolia. You say that the drug is medically necessary. The Plan denied 
your request. The Plan says you did not meet the step therapy requirements. 
 
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 looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Prolia have not been met. Specifically, the documentation submitted indicates you have not 
tried and failed the Plan's preferred drugs and that there is no reason why you cannot try them first. Therefore, 
we decided that the Plan does not have to pre-approve the Prolia (J0897).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty scooter (K0801). 
 You asked the Plan to pre-approve a heavy-duty scooter. You say that the item is medically necessary. The 
Plan denied your request. The Plan says the member does not meet the weight requirement for a heavy-duty 
scooter. 
 
The Plan must follow Medicare rules. Medicare rules say that the beneficiarys weight is less than or equal to 
the weight capacity of the POV that is provided and greater than or equal to 95% of the weight capacity of the 
next lower weight class POV. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a heavy-duty scooter have not been met. Specifically, the member does not meet the required 
weight restrictions for the requested heavy-duty scooter. Therefore, we decided that the Plan does not have to 
pre-approve a heavy-duty scooter (K0801).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service August 5, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code 99100 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service August 5, 2022.