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

 
We decided that the Plan does not have to pre-approve a Cala Trio device and monthly supplies. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is insufficient evidence in the 
peer-reviewed medical literature to support the use of the requested Cala Trio device for the treatment of 
essential tremor. The device is not the standard of care and not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Cala Trio device and monthly supplies.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Spravato Sol. 
 
You asked the Plan to pre-approve Spravato Sol. You say that the records provided support the need for the 
drug in dispute. The Plan denied your request. The Plan says the enrollee does not have a pharmacy benefit 
under this contract. The Plan says that the enrollee has TRS-CARE MA which provides its own pharmacy 
benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Spravato Sol.  
 Benefits for Spravato Sol may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the National Comprehensive Cancer 
Network (NCCN) guidelines do not address proton therapy for breast cancer. There is no actual planning 
comparison in the submitted records and therefore no demonstration with quantifiable dosimetric measures that 
proton therapy is needed. Routine use of proton therapy for breast cancer is not the standard of care. The 
services are therefore not reasonable or medically necessary.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve proton beam therapy.
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 you disagree with the denial. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. 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 medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital with respiratory failure and hypoxia following a prolonged hospitalization for COVID-19 pneumonia. 
He is now medically stable with no complex nursing or rehabilitation needs. He does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While he has a need for physical and/or occupational therapy, there is no documentation of a 
need for an intensive rehabilitation program. There is not a reasonable expectation that the 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Remicade. 
 
You asked the Plan to pre-approve Remicade. You say that the medication is necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 Remicade. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found the record does not indicate that the 
enrollee has 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 Remicade have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Remicade.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture (D5212). 
 
You asked the Plan to pre-approve the mandibular partial denture. You say that you need help paying for the 
bottom denture so you can get them because you cannot afford them. The Plan denied your request. The Plan 
says this service exceeds the maximum count allowed per period. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, mandibular partial denture (D5212) is 
limited to one procedure every five plan years. The record shows that you received a mandibular partial denture 
(D5212) on August 24, 2020 and your mandibular partial denture (D5212) benefit has been exhausted. 
Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture (D5212).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets the Medicare criteria 
for acute inpatient LTACH that cannot be accomplished at a lower level of care. The Plan denied your request. 
The Plan says authorization denied because LTACH 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 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 documentation shows that the enrollee is receiving appropriate care at the present 
acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care 
hospital where they are currently receiving care. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. 
The Plan says rules for SNF care have not been met. 
 
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 is a 70-year-old female with a 
past medical history of diabetes, hyperlipidemia, hypertension and osteoarthritis who presented to the acute 
hospital on April 1, 2022, with a fall resulting in a left hip fracture. In this case, there is no documentation that 
the patient requires skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled 
professional nurse are not required to safely and effectively provide medically necessary and reasonable 
treatment. Records do not document the need for intravenous medications, new tube feeding or ostomy care or 
daily complex wound care. While this patient does require skilled therapy services, i.e., the specialized skill, 
knowledge and judgment of a qualified therapist are required to safely and effectively provide medically 
necessary and reasonable treatment, these services are not required on a daily basis. In conclusion, there is no 
documentation that the patient requires 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 admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95957-26, 95909-26, and 84775-26 (x2) 
billed for date of service February 11, 2021. 
 
You asked the Plan to pay for procedure codes 95957-26, 95909-26, and 95886-26 (x2). You say that you have 
provided medical records to support payment of these codes. The Plan denied your request. The Plan says these 
codes are not supported in the medical record. 
 
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 95957 is Digital analysis of electroencephalogram (EEG) 
during nonintracranial surgery (eg, carotid surgery). The CPT code definition of code 95909 is Nerve 
conduction studies; 5-6 studies. The definition of CPT code 95886 is needle electromyography, each extremity, 
with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity 
study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels 
(list separately in addition to the code for primary.  
We asked our coder 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 procedure codes 95957-26, 95909-26, and 95886-26 (x2). 
Our reviewer says that these codes are not supported in the medical record. Our reviewer found for CPT code 
95957, the documentation submitted was reviewed, and does not meet criteria.  The technical report does not 
include documentation of digital analysis of EEG during nonintracranial surgery.  Any additional EEG testing 
is inclusive to the intraoperative neuromonitoring procedure code. For CPT code 95909, the technical report 
describes pedicle screw stimulation.  Nerve conduction studies would not be reported for the procedure 
documented.  Nerve conduction studies, latency, amplitude and conduction velocity are measured, which are 
not supported by the documentation. For CPT code 95886, the technical report does not include documentation 
of a complete needle electromyography, per each extremity with related paraspinal areas when performed, done 
with nerve conduction, amplitude and latency/velocity study, for five or more muscles studies, innervated by 
three or more nerves or four or more spinal levels. The narrative of the technical note does not describe a 
complete needle electromyography done with nerve conduction. The requested procedure code is not 
sufficiently supported by documentation in the technical report. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 95957-26, 95909-26, and 95886-26 (x2) have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 95957-26, 95909-26, and 84775-
26 (x2) billed for date of service February 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus gene panel provided on July 24, 2021. 
 
You asked the Plan to pay for the panel testing. You say that the testing will be useful at initial diagnosis or for 
refractory disease. The Plan denied your request. The Plan says the test was not approved by the ordering 
provider. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and the rules. We find that the gene panel is not supported in the medical records. The 
records do not show that the enrollees physician ordered the testing as part of the treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the panel testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the Tempus gene panel provided on July 24, 2021.
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 you are able to tolerate three hours of therapy a day 
with the goal of returning home to be as independent as possible with the assistance of your spouse. The Plan 
denied your request. The Plan says authorization denied because the IRF admission is not medically necessary 
and your needs can be met at a lower level of care, such as a skilled nursing facility (SNF), on an intermittent 
basis at home with home health care, or in a long-term care 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 your medical problems are stable and 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 you have a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program.  
 
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 epidural steroid injections. 
 
You asked the Plan to pre-approve epidural steroid injections. You say that the injections are medically 
necessary. The Plan denied your request. The Plan says your records show you have had an injection before. 
Your Plan requires you have at least 50% pain relief for at least 3 months to approve a repeat injection. Your 
records show your previous injection relieved your pain by 25%. This pain relief lasted for 2 months. You do 
not meet criteria. This treatment is not medically necessary. 
 
The Plan follows Medicare rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve epidural steroid injections. Our 
reviewer says that the requested epidural steroid injections do not meet the Medicare coverage criteria.  Our 
physician reviewer found CMS Guidelines support a repeat injection if the patient received at least 50% pain 
relief from a prior epidural injection with evidence of functional improvement. The records indicate that you 
received 25% pain relief from the October 2021 injection. In this case, the degree of pain relief from the prior 
injection of October 2021 was insufficient to support a repeat procedure. Therefore, your clinical condition 
does not meet the CMS (Medicare) Clinical Guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural steroid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve epidural steroid injections.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the ultrasound (76641), digital breast 
tomosynthesis (DBT) screening (77063), and screening mammography (77067) provided on October 20, 2021. 
 
You asked the Plan to reimburse you for the diagnostic services. You say that these services should have been 
covered as they were preventive. You say that you understand that the provider does not accept Medicare 
insurance. You also say that this should be processed as out of network. The Plan denied your request. The 
Plan says payment cannot be made for services received by a provider that has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care.  
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for 
the ultrasound (76641), digital breast tomosynthesis (DBT) screening (77063), and screening mammography 
(77067) provided on October 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Methocarbamol 500mg tablets. 
 
You asked the Plan to pre-approve Methocarbamol 500mg tablets. You say that you would like to continue the 
low dose Robaxin at this time for pain and function. You also say that the enrollee has tolerated this in the 
recent past and you are not comfortable switching to Flexeril or Tizanidine with higher side effect risk of 
drowsiness which increases the enrollee's fall risk. The Plan denied your request. The Plan says this medication 
falls under Part D coverage and the enrollee does not have Part D pharmacy (drug) benefit administered by the 
Plan. The Plan also says that drugs covered under Part D are not eligible for coverage under Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Methocarbamol 500mg 
tablets.   
Benefits for Methocarbamol 500mg tablets may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.