Persius/hicric huggingface dataset:
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 service is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of a LTACH 
admission. 
 
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 that in this case the enrollee was admitted with acute hypoxic respiratory failure in 
the setting of Covid-19 pneumonia and severe sepsis. The record indicates that the enrollee has ongoing acute 
medical issues and still requires 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. 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 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 you were admitted for a head injury after a fall. 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT), of the abdomen and pelvis; 
without contrast material (74176). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this service is not medically necessary. 
 
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 this service. Our reviewer says that this 
service is not medically necessary. Our physician reviewer found that in this case, the record indicates that you 
have abdominal pain. The records provided do not support the medical necessity of the requested test at this 
time. The provided records do not indicate the medical necessity or reasonableness, as defined by Medicare 
rules, of the requested service. 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 this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve computed tomography (CT), of the abdomen and pelvis; without contrast material (74176).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gastrointestinal tract imaging, intraluminal (eg, capsule 
endoscopy), esophagus through ileum, with interpretation and report (CPT code 91110). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been 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 service. Our physician reviewer 
found available records neither support high suspicion of GI blood loss nor meet coverage criteria for WCE 
after a negative esophagogastroduodenoscopy (EGD) and colonoscopy. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve gastrointestinal tract imaging, intraluminal (eg, capsule endoscopy), esophagus through 
ileum, with interpretation and report (CPT code 91110).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation, nerves innervating the 
sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography) (64625). 
 
You asked the Plan to pre-approve the outpatient procedure. You say that the enrollee has had this same 
procedure in the past with positive results. Please reconsider the original denied decision. The Plan denied your 
request. The Plan says radiofrequency nerve ablation of the sacroiliac joint is considered experimental, 
investigational or unproven. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient procedure have not been met. Therefore, we decided that the Plan does not have to 
pre-approve radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (ie, 
fluoroscopy or computed tomography) (64625).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing with codes 81173, 81201, 81295, 81307, 
81351, 81400, 81401, 81403, 81404, 81405, 81406, 81407, 81408, 81479. 
 
You asked the Plan to pre-approve genetic testing. You say that the enrollee was recently diagnosed with stage 
IV squamous cell carcinoma of the right lung. The requested testing is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the genetic testing can be approved if requested with a single 
panel code (not multiple procedure codes as submitted). The enrollee does not meet criteria for the requested 
testing. 
 
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 genetic testing have not 
been met. Therefore, we decided that the Plan does not have to pre-approve genetic testing with codes 81173, 
81201, 81295, 81307, 81351, 81400, 81401, 81403, 81404, 81405, 81406, 81407, 81408, 81479.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency transportation billed using procedure 
code A0130. 
 
You asked the Plan to pre-approve procedure code A0130. You say that the enrollee needs transportation to 
dialysis. The Plan denied your request. The Plan says the code is not covered by Medicare. 
 
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 A0130 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code A0130 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code A0130 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve non-emergency transportation billed using procedure code A0130.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a heart sac incision (33025) provided on March 20, 2022. 
 
You asked the Plan to pay for a heart sac incision. You say that this is supported in the records. The Plan 
denied your request. The Plan says this cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that when treatment for complications requires a 
return trip to the operating room, physicians must bill the code that describes the procedure(s) performed with modifier -78. To report an unrelated procedure by the same physician during a postoperative period, 
physicians should use modifier -79. 
 
We looked at the file and Medicare rules. The records show that this service was performed in the 90-day 
global period of the coronary artery bypass (33533) provided on March 1, 2022, but it was not billed with 
modifier -78 or -79. Based on this information, we decided that Medicare rules for coverage of a heart sac 
incision have not been met. Therefore, we decided that the Plan does not have to pay for a heart sac incision 
(33025) provided on March 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a OneTouch Verio Flex Meter. 
 
You asked the Plan to pre-approve a OneTouch Verio Flex Meter. You say that the requested device is not 
medically necessary. The Plan denied your request. The Plan says the requested device is a non-preferred brand 
and is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and may limit the DME to only those preferred brands and manufacturers as long as the enrollee 
retains access to all medically necessary items. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a OneTouch Verio Flex Meter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a OneTouch Verio Flex Meter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lupron. 
 
You asked the Plan to pre-approve Lupron. You say that Lupron is medically necessary. The Plan denied your 
request. The Plan says a trial of Eligard is required before alternatives can be considered. 
 
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 Lupron. Our reviewer says that Lupron 
is not medically necessary. Our physician reviewer found the record shows no trial of the plan preferred drug or 
any reason it is unsafe or ineffective 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 Lupron have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Lupron.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme (CPT code Q0138). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says you do not have any stated contraindications to the preferred products, you have 
not tried any of the preferred agents and the provider does not provide a rationale for use of the non-preferred 
product for safety or efficacy. 
 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 provided records do not indicate that you have tried and failed the Plan's preferred step one 
alternative. The record does not indicate that you have a contraindication to or would have an adverse effect 
from the Plan's preferred step one alternative. 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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Feraheme (CPT code Q0138).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of a permanent cardiac pacemaker. 
 
You asked the Plan to pre-approve cardiac pacemaker. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says the enrollee has asymptomatic resting bradycardia, so a 
pacemaker is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules state that cardiac pacemakers are only covered for certain 
conditions. 
 
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 cardiac pacemaker. Our reviewer says 
that the enrollee does not meet the Medicare criteria for a cardiac pacemaker. Our physician reviewer found 
while the enrollee has a history of sinus bradycardia, there is no documentation of symptomatic bradycardia. 
As such, there is insufficient documentation to support the medical necessity for insertion of a pacemaker in the 
enrollee's 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 cardiac pacemaker have not been met. Therefore, we decided that the Plan does 
not have to pre-approve insertion of a permanent cardiac pacemaker.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the ventilator is medically necessary. The 
Plan denied your request. The Plan says the request for a home mechanical ventilator set in iVAPS mode with 
Auto-EPAP (AE) 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found there is documentation that you have 
chronic respiratory failure consequent to chronic obstructive pulmonary disease. Provided records document 
that the home ventilator is being requested for use in intelligent volume assured pressure support (IVAPS) 
mode with auto-titration which could be provided by a BiPAP device with AVAPS and a back-up rate. As 
stated in the Local Coverage Determination (L33800): Claims for ventilators used to provide CPAP or bi-level 
CPAP therapy for conditions described in this RAD policy will be denied as not reasonable and 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99255 billed for date of service January 7, 
2022. 
 
You asked the Plan to pay for procedure code 99255. The Plan denied your request. The Plan says the billed 
code is invalid for Medicare purposes. 
 
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 99255 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99255 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99255 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99255 billed for date of service January 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the brain 
(78608). 
 
You asked the Plan to pre-approve a PET scan of the brain. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the service is not covered by Medicare of the health plan. 
 
The Plan follows Medicare rules. Medicare rules say that an FDG PET scan is only covered when there is a 
need to separate a differential diagnosis of frontotemporal dementia and Alzheimers disease. 
 
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 PET scan of the brain. Our reviewer 
says that the enrollee does not meet coverage criteria. Our physician reviewer found the record indicates that 
the enrollee has cognitive deficits and is undergoing neuropsychological testing. The records provided do not 
document that the enrollee meets the diagnostic criteria of both Alzheimer's disease and frontotemporal 
dementia. The records provided do not document that the study requested is being performed in the context of a 
clinical trial. 
 
   
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 PET scan of the brain have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a positron emission tomography (PET) scan of the brain (78608).
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 additional inpatient rehab. The Plan 
denied your request. The Plan says the request is not medically necessary. 
 
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 daily skilled services are not required. There is no documentation that you require 
services on an inpatient basis, only in a skilled nursing facility setting. You are tolerating your current therapy. 
You can complete your current treatment course before being transferred to 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Libre System. 
 
You asked the Plan to pre-approve the Freestyle Libre System. You say that due to recent episodes of 
hypoglycemia, it is medically necessary that the enrollee use the Freestyle Libre system to manage blood 
glucose levels better and be alerted to avoid any need for immediate medical attention. The Plan denied your 
request. The Plan says there is no documentation that the enrollee is on an insulin treatment regimen requiring 
frequent adjustments, therefore, the enrollee does not meet the criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan.  
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the Freestyle Libre System have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the Freestyle Libre System.