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

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve a portable ventilator. You say that the ventilator is to be used for the 
treatment of COPD. The Plan denied your request. The Plan says the request for a home mechanical ventilator 
set in PS with Safety Tidal Volume that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 
 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 portable ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found you were recently hospitalized twice 
with acute hypoxic respiratory failure, and ABG was consistent with chronic hypercarbic respiratory failure, 
although this has not been documented with an ABG as an outpatient while stable. There is a diagnosis of 
COPD, but there are no pulmonary function tests to confirm the diagnosis and assess severity. You have 
HFpEF, OSA untreated, and likely obesity-hypoventilation syndrome. You may benefit from bipap during 
sleep, with or without the AVAPS mode. Medicare does not cover a ventilator when used as BiPAP. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation system 
(HFCWO). 
 
You asked the Plan to pre-approve an HFCWO. You say that pulmonary therapy to clear the enrollee's lungs 
and airways is essential to their overall health. The Plan denied your request. The Plan says the requested 
service is not covered by Medicare or the health plan. 
 
The Plan follows Medicare rules. Medicare rules say that if all of the criteria listed in the Medicare rules 
section of this letter are not met, the claim will be denied as not reasonable and 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 an HFCWO. Our reviewer says that an 
HFCWO is not medically necessary. Our physician reviewer found this enrollee has COPD with chronic cough. 
There is no diagnosis of cystic fibrosis, bronchiectasis, or neuromuscular disease. Our reviewer also found that 
there is inadequate evidence that a HFCWO is beneficial in the treatment of COPD. 
 
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 HFCWO have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation system (HFCWO).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99484) provided on January 12, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
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 99484 is "Care management services for behavioral 
health conditions, at least 20 minutes of clinical staff time, directed by a physician or other qualified health care 
professional, per calendar month, with the following required elements: initial assessment or follow-up 
monitoring, including the use of applicable validated rating scales, behavioral health care planning in relation 
to behavioral/psychiatric health problems, including revision for patients who are not progressing or whose 
status changes, facilitating and coordinating treatment such as psychotherapy, pharmacotherapy, counseling 
and/or psychiatric consultation, and continuity of care with a designated member of the care team". 
 
We find that CPT code 99484 is not supported in the medical record. Specifically, the records do not show that 
20 or more minutes of care management services were provided on the date of service in question. 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 services (99484) provided on January 12, 2022.
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 your doctor is recommending more therapy and your 
current doctor cannot provide the level of care needed. The Plan denied your request. The Plan says 
authorization denied because the IRF care is not medically necessary, and your needs can be met at a lower 
level of care such as a skilled nursing facility (SNF). 
 
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 there is no indication that you would require skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, under the supervision of a physician with at least three 
visits weekly to regain or maintain your functional status.  
 
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 the IRF care is medically necessary. The Plan denied 
your request. The Plan says authorization denied because the IRF care is not medically necessary, and the 
enrollee's needs can be met at a lower level of care such as a skilled nursing facility (SNF). 
 
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 specifically, the enrollee is not shown to require, or to be able to tolerate, fifteen hours per week of rehabilitative services with regular physician evaluation.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacral nerve stimulator. 
 
You asked the Plan to pre-approve a sacral nerve stimulator. You say that the requested sacral nerve stimulator 
is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested sacral nerve stimulator.  
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 a sacral nerve stimulator. Our reviewer 
says that the enrollee does not meet criteria for the requested sacral nerve stimulator. Our physician reviewer 
found all of the coverage criteria have not been met. Specifically, the records show that the enrollee has 
persistent stress incontinence and urinary obstruction due to prior sling placement has not been ruled out. 
 
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 sacral nerve stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a sacral nerve stimulator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intraosseous ablation of the basivertebral nerve 
(Intracept Procedure). 
 
You asked the Plan to pre-approve Intracept Procedure. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested 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 Intracept Procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee diagnoses of low back pain, unspecified and vertebrogenic low back 
pain. The Intracept procedure is considered experimental. More research is needed to support the necessity of 
this service. Therefore, the enrollee does not meet criteria for the requested 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 Intracept Procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve intraosseous ablation of the basivertebral nerve (Intracept Procedure).
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 the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an epidural steroid injection. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has not 
had a 3 months or longer sustained improvement in pain relief and/or improvement in function of at least 50% 
measured from baseline using same scale before a repeat epidural steroid injection. Therefore, he does not meet 
the criteria for another epidural steroid injection, and it is deemed 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the home ventilator is necessary. The Plan 
denied your request. The Plan says the request for a home mechanical ventilator set in intelligent volume-
assured pressure support (iVAPS) mode with Auto-EPAP (AE) that could be delivered by bilevel positive 
airway pressure (BiPAP) is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our physician 
reviewer found the provided primary source documentation does not contain sufficient detailed information in 
the medical record to justify the treatment selected. You could be treated with a BiPAP machine with AVAPS 
capability. The Plan has indicated coverage for such a device is available upon request. The elements of the 
coverage criteria are not satisfied. The requested service cannot be recommended. 
 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction of nerve or branch by neurolytic agent. 
 
You asked the Plan to pre-approve destruction of nerve or branch by neurolytic agent. You say that the enrollee 
suffers from left knee pain, and it is recommended that nerves be treated with cryoneurolysis. You say that this 
therapy is reasonable and necessary. The Plan denied your request. The Plan says medical studies do not show 
this procedure works better than others. 
 
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 destruction of nerve or branch by 
neurolytic agent. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found that cryoneurolysis remains experimental for the 
treatment of extremity nerve pain. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of destruction of nerve or branch by neurolytic agent have not been met. 
Therefore, we decided that the Plan does not have to pre-approve destruction of nerve or branch by neurolytic 
agent.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve IGRT (CPT code(s): 77387 and G6002). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says that the enrollee's doctor wants to give the enrollee radiation and the Plan approved that. 
The Plan states the enrollee's doctor wants to give the enrollee many days of radiation and the Plan approved 
that also. The Plan states the enrollee's doctor wants to use a special type of radiation and this was approved 
too. The Plan states the enrollee's doctor wants daily scans and their Health Plan has reviewed published 
guidelines and the Plan found daily scans are not necessary. The Plan states they have approved weekly scans; 
therefore, the prior denial for IGRT is upheld. 
 
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 the services. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found IGRT could be necessary as daily set up can potentially be compromised without IGRT. As this 
appears to be an exceptional circumstance, our physician reviewer's decision is favorable as IGRT would be 
furnished in accordance with accepted standards of medical practice. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve IGRT (CPT code(s): 77387 and G6002).  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you are unable to lift your head due to neck muscle 
and you need physical and occupational therapy. You also say that you need assistance moving around, getting 
in and out of bed, and going to the bathroom. The Plan denied your request. The Plan says the member has no 
skilled nursing needs and no daily skilled therapy needs. 
 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 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have documented skilled nursing needs or skilled therapy needs. 
Our physician reviewer also found that the enrollee's care needs, custodial and intermittent, can as a practical 
matter, be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the epidural steroid injection (CPT code 62323). 
 
You asked the Plan to pre-approve the epidural steroid injection. You say that the injection is necessary. The 
Plan denied your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the epidural steroid injection have not been met. The enrollee 
received four (4) ESIs in the last 12 months; therefore, the enrollee does not qualify for this requested ESI 
injection. Therefore, we decided that the Plan does not have to pre-approve the epidural steroid injection (CPT 
code 62323).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (81161, 81286, 81413, 81414, 81442 and 
81479) provided on December 3, 2021.  
You asked the Plan to pay for laboratory services. You say that these services were necessary and were billed 
appropriately by a recognized facility. The Plan denied your request. The Plan says there is insufficient 
information available in order to process this claim. In addition, the Plan is unable to verify the provider's 
license. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of laboratory services have been met. 
Specifically, no medical records or physician order were submitted for review. Without evidence that a test has 
been ordered by a physician who is treating an enrollee, these services must be denied as not reasonable and 
necessary. Therefore, we decided that the Plan does not have to pay for laboratory services (81161, 81286, 
81413, 81414, 81442 and 81479) provided on December 3, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the step therapy criteria have not been met. 
 
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 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 Evenity.