Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intra-articular (into the joint space) corticosteroid 
injections for the hip. 
 
You asked the Plan to pre-approve the intra-articular hip joint injections. You say that you have been having 
hip pain that keeps you from sleeping, and the medications you have tried do not work. You feel that this 
should be covered so you can avoid taking oxycodone due to the potential for addiction. The Plan denied your 
request. The Plan says this treatment is not shown to be medically necessary due to a lack of a trial of physical 
therapy or other treatments. 
 
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 intra-articular hip joint injections. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the records show that the enrollee is a male with a history of hip pain. X-
rays demonstrate mild joint space narrowing with subchondral sclerosis. He has been treated with anti-
inflammatory medication.   
 There is inadequate evidence in the medical literature to show that intra-articular hip corticosteroid injections 
are useful for painful hip osteoarthritis. There is some evidence to show that it can hasten the progression of the 
osteoarthritis. There is some evidence that it is no better than saline injection. Due to these findings, this type of 
injection is not considered 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 the intra-articular hip joint injections have not been met. Therefore, we decided 
that the Plan does not have to pre-approve intra-articular (into the joint space) corticosteroid injections for the 
hip.
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 this is medically necessary. The Plan denied your 
request. The Plan says care could be received in another setting. 
 
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 
epidural and psoas muscle abscess and were discharged to skilled nursing on 3/21/22. 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 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 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: 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 this is medically necessary. The Plan denied your 
request. The Plan says this 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  The enrollee was admitted for surgical management of a hematoma at previous below the knee amputation site. 
Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical 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 enrollee 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing visits. 
 
You asked the Plan to pre-approve home health services. You say that the services are medically necessary. 
The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 
 
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 home health services. Our reviewer 
says that the requested home health services are not medically necessary. Our physician reviewer found the 
provided documentation does not indicate that the enrollee has skilled nursing needs. Therefore, the reviewer 
found that the requested home health services are 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve skilled nursing visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on September 27, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code.  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 pay for the genetic testing services provided on September 
27, 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 LTACH care is medically necessary for 
the patient. The Plan denied your request. The Plan says LTACH is not medically necessary and the patient can 
be managed at the current acute care 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 there is no documentation provided indicating medical necessity for admission to a 
LTACH. The patient is receiving appropriate care at the present acute care hospital. The patient does not 
require services at the LTACH that are not available at the acute care hospital where they are currently 
receiving care. There are no services available at the LTACH that the patient requires that are not available at 
the health care setting being offered by the health plan. 
 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for five (5) units of intravascular ultrasound (noncoronary 
vessel) during diagnostic evaluation and/or therapeutic intervention (37253) provided on September 9, 2021. 
 
You asked the Plan to pay for the ultrasound services. You say that these services are supported in the record. 
The Plan denied your request. The Plan says the documentation does not support that five units of this service 
were provided on this date. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
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 ultrasound services Our reviewer says 
that these services are not supported as billed. Our physician reviewer found the medical records do not support 
that 5 units of CPT 37253 were provided on September 9, 2021.  
 
We looked at this physician's review, the file, and Medicare rules. The written note on the medical record that 
was submitted with the appeal also indicates that only three (3) units of 37253 were provided on the date in 
question. Based on this information, we decided that Medicare rules for coverage of five (5) units of 37253 have not 
been met. If the provider determines that a billing error has been made, a corrected claim may be submitted 
directly to the Plan. Therefore, we decided that the Plan does not have to pay for five (5) units of intravascular 
ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention (37253) provided 
on September 9, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says the requested continued SNF care does not 
meet criteria. 
 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 daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not have a need for 
intravenous medications, new tube feeding, ostomy care or daily complex wound care. After three weeks of 
daily skilled therapy services, the enrollee appears to have plateaued with his treatment and records document 
he has been anxious, confused and delusional in the facility and difficult to re-direct and educate. Part time 
therapy services now appear indicated. The enrollee does not require the services on an inpatient basis, only in 
a skilled nursing facility setting. Services in the home with home health care or in a long-term care facility on a 
part time basis appear appropriate in this case. 
 
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 continued skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat lumbar epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve the repeat ESI. You say that this should be allowed to see if improved pain 
control can be achieved. The Plan denied your request. The Plan says a repeat ESI is not reasonable and 
necessary at this time. 
 
The Plan follows Medicare rules. Medicare rules say that repeat ESIs are considered reasonable and necessary 
only when there is at least 50% pain relief for at least three months from prior injection. 
 
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 repeat ESI. Our reviewer says that 
the requested ESI is not considered medically necessary. Our physician reviewer found the enrollee is a 65-
year-old female with a history of chronic low back pain due to severe lumbar stenosis and scoliosis. She has 
tried a home exercise program, NSAIDS, muscle relaxants, Tramadol, and activity limitations. Physical exam 
was positive for increased lower back pain at all extremes of motion. She had a lumbar epidural steroid 
injection on 1/28/2022 which provided 65% pain relief for only a few days. No rationale for a repeat injection 
or different approach is documented in the record. 
 
 
 
 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 repeat ESI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat lumbar epidural steroid injection (ESI).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transurethral waterjet ablation of the prostate. 
 
You asked the Plan to pre-approve the transurethral waterjet ablation of the prostate. You say that it is felt that 
this procedure would be beneficial for the enrollee and that all criteria are met. The Plan denied your request. 
The Plan says only patients 80 years old or younger are covered for this procedure. 
 
The Plan follows Medicare rules. Medicare rules say that the requested water jet ablation of the prostate is 
covered only when the criteria listed in the Medicare rules section 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 the transurethral waterjet ablation of the 
prostate. Our reviewer says that the requested treatment is not medically necessary. Our physician reviewer 
found the enrollee is over 80 years old with a symptom severity score of 9. In addition, the maximum flow rate 
is not documented. For these reasons, the criteria from the LCD 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 the transurethral waterjet ablation of the prostate have not been met. Therefore, 
we decided that the Plan does not have to pre-approve transurethral waterjet ablation of the prostate.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the exercise equipment (A9300) purchased January 1, 2021. 
 
You asked the Plan to pay for the exercise equipment. You say that someone in customer service told you that 
the exercise equipment would be covered. The Plan denied your request. The Plan says this item is not covered 
under the enrollee's wellness benefit, and the Plan was unable to locate any phone call where misinformation 
was provided. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
The Plans rules for coverage of gym benefits have not been met because exercise equipment is not listed as a 
covered item under the enrollees Wellness Allowance. Therefore, we decided that the Plan does not have to 
pay for the exercise equipment (A9300) purchased January 1, 2021.  
 Your complaint about potentially receiving misinformation from a plan representative is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
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 LTACH care is medically necessary. The 
Plan denied your request. The Plan says LTACH is not medically necessary. The patient can be managed at a 
lower level of 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 reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted with an intracranial hemorrhage in the setting of a history 
of brain tumor.  The record indicates that the enrollee is improving. 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 she is 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: 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 this is medically necessary. The Plan 
denied your request. The Plan says the services can be safely received in another setting, such as a skilled 
nursing 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 enrollee was admitted with dyspnea in the setting of interstitial pneumonitis and 
exacerbation of congestive heart failure. The record indicates that the enrollee is improving but still requires 
intravenous medication and has a rising white blood cell count, requiring ongoing acute care services 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 he is not currently receiving but that would be available at the 
LTACH facility. 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: 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 LTACH care is medically necessary for 
the enrollee. The Plan denied your request. The Plan says LTACH is not medically necessary and the enrollee's 
care can be managed at their current acute care 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 enrollee was admitted with left foot cellulitis and acute on chronic kidney failure. 
The record indicates that the enrollee underwent an operative procedure and requires ongoing acute care 
services. 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 he is 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.