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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will benefit most from placement in an 
IRF and cannot receive the appropriate care in a lower level. The Plan denied your request. The Plan says the 
criteria for admission to an IRF are not met. The enrollee's needs can be safely met in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollees nursing, medical and rehabilitation needs do not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. The enrollee does continue to need skilled therapy with 
ongoing safety concerns and a potential for functional improvement; however, the documentation does not 
support that the criteria for admission to an acute inpatient rehabilitation facility are met. There is no indication 
that the enrollee would require a minimum of 15 hours per week of skilled rehabilitation services in an IRF 
under the supervision of a physician with at least three physician visits weekly to regain or maintain functional 
status. The enrollee can receive further services 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 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 an implantable loop recorder. 
 
You asked the Plan to pre-approve an implantable loop recorder. You say that the requested implantable loop 
recorder is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria 
for the requested implantable loop recorder. 
 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 an implantable loop recorder. Our 
reviewer says that the enrollee does not meet criteria for the requested implantable loop recorder. Our physician 
reviewer found there is no documentation provided to suggest a history of syncope or any other apparent 
indication for an ILR.  In summary, there is insufficient documentation to support the medical necessity for 
insertion of an ILR in this enrollees clinical management. 
 
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 implantable loop recorder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an implantable loop recorder.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667) for the 
enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no trial of a standard device. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found as the records do not document at least four weeks of regular, daily, multiple-hour home usage of a 
standard pump (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, then it cannot be said that the enrollee has 
unique characteristics that would indicate the segmental pump over a standard pump. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device (E0652, E0667) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Volara system - high frequency oscillation lung 
expansion device 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not covered for use in the home. 
 
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 system. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is insufficient evidence to support that the Volara high frequency oscillation lung expansion 
system is more efficacious than standard respiratory care in the management of bronchiectasis. 
 
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 system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Volara system - high frequency oscillation lung expansion device
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intercept procedure. 
 
You asked the Plan to pre-approve Intercept 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 Intercept 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 has history of ongoing lower back pain for several years. The Intracept 
procedure is experimental. More research is needed. 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 Intercept procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Intercept procedure.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomographic angiography (CTA) of the 
neck (70498). 
 
You asked the Plan to pre-approve a CTA of the neck. The Plan denied your request. The Plan says the 
necessity criteria is not met for requested CTA of the neck. 
 
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 CTA of the neck. Our reviewer says 
that a CTA of the neck is not medically reasonable and necessary. Our physician reviewer found the enrollee 
does not have significant enough stenosis noted on imaging to warrant a follow-up CTA. Our reviewer also 
found that a follow-up CTA is reserved for those who are candidates for carotid revascularization, which this 
enrollee is not, according to the provided documentation. 
 
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 CTA of the neck have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a computed tomographic angiography (CTA) of the neck (70498).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift. 
 
You asked the Plan to pre-approve a seat lift. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
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 a seat lift. Our reviewer says that a seat 
lift is not medically reasonable and necessary in this case. Our physician reviewer found that the documentation 
does not indicate that the enrollee has severe neuromuscular disease, arthritis of the hips or knees, or that he is 
incapable of standing up from a regular armchair or any chair in his home. 
 
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 seat lift have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a seat lift.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is medically necessary 
for the enrollee's condition. The Plan denied your request. The Plan says this procedure is considered 
experimental/investigational. 
 
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 Vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is experimental. More research is needed before coverage can be 
approved. 
 
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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 9, 2022, billed with 
codes 81227, 81230, 81231, 81232, 81306, 81335, 81355, 0031U, 0032U, and 0033U. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the testing 
was billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 9, 2022, billed with codes 81227, 81230, 81231, 81232, 81306, 81335, 81355, 0031U, 0032U, and 
0033U.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories. 
 You asked the Plan to pre-approve the wheelchair. You say that the records provided support the need for the 
requested items which will help make the enrollee's daily life better. The Plan denied your request. The Plan 
says the items being requested are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 wheelchair. Our reviewer says that 
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found that there is 
no documentation that the group 3 power wheelchair with multiple power options (power tilt and recline, 
power seat elevation system) and accessories at issue in this case meet Medicare criteria for medically 
reasonable and necessary. The requested power seat elevation feature is statutorily non-covered as it serves no 
primary medical purpose. Although there is a reported history of a pressure ulcer from March 2022 there is no 
support in the record that the enrollee is unable to perform a functional weight shift as required by the Local 
Coverage Determination (LCD) - Wheelchair Options/Accessories - L33792. You are reported to be able to 
ambulate short distances with an assistive device. The records do not document that you perform bladder self-
catheterization and are unable to transfer independently or that you have increased muscle tone or spasticity as 
required by the LCD.  
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 3 power wheelchair and accessories.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you need to be in skilled nursing facility as you 
need more care and will not receive the care at home. The Plan denied your request. The Plan says skilled 
nursing facility services do not meet the requirements for approval. 
  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 that you do not have documented skilled nursing or skilled therapy needs. Your needs 
are custodial and can 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 SNF care.
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 the service requested is not supported based on the records received. 
 
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 enrollee does not require the intensity of services provided at an 
IRF.  Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (62323). 
 
You asked the Plan to pre-approve the repeat injection. You say that this injection provides relief for you. You 
also say that without it, your ability to function and your quality of life will decrease. The Plan denied your 
request. The Plan says the requested injection is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that if a patient fails to respond well to the initial ESI, a 
repeat ESI after 14 days can be performed, using a different approach, level and/or medication if appropriate, 
with the rationale and medical necessity for the second ESI documented in the medical record. 
 
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 injection. Our reviewer says 
that a repeat injection is not medically necessary. Our physician reviewer found there is no indication in the 
progress notes, or the request itself for a different approach, or any rationale given for the medical necessity of 
a second injection after a failed first injection. Therefore, the reviewer found that the requested injection is not 
medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the repeat injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a repeat epidural steroid injection (62323).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (64483), bilateral. 
 
You asked the Plan to pre-approve the repeat injection. You say that the injection is necessary for the enrollee. 
The Plan denied your request. The Plan says the documentation does not indicate that the enrollee's pain relief 
lasted at least three months. 
 
The Plan follows Medicare rules. Medicare rules say that repeat epidural steroid injection (ESI) may be 
considered medically reasonable and necessary when the medical record documents at least 50% of sustained 
improvement for at least three months. 
 
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 injection. Our reviewer says 
that a repeat injection is not medically necessary. Our physician reviewer found there is no documentation of 
50% pain relief for 3 months. Therefore, the reviewer found that the requested repeat injection is not medically 
reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the repeat injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a repeat epidural steroid injection (64483), bilateral.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman procedure. 
 
You asked the Plan to pre-approve the Minuteman procedure. You say that this procedure is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the use of this device as a 
stand-alone procedure has not been shown to be safe and effective in long term studies. 
 
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 Minuteman procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the Minuteman procedure is experimental. More research is needed before 
coverage can be approved. 
 
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 Minuteman procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Minuteman procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 13, 2022, billed with 
codes 81162, 81201, 81292, 81295, 81298, and 81317. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the testing 
was billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 13, 2022, billed with codes 81162, 81201, 81292, 81295, 81298, and 81317.