Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient lumbar spinal fusion procedure. 
 
You asked the Plan to pre-approve a lumbar spinal fusion. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
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 a lumbar spinal fusion. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no evidence of spinal instability, fracture or lesion. 
 
 
  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 lumbar spinal fusion have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an inpatient lumbar spinal fusion procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve F2 (prothrombin, coagulation factor II) gene analysis 
(81240) and F5 (coagulation factor V) gene analysis (81241). 
 
You asked the Plan to pre-approve F2 and F5 gene analysis. You say that these tests are medically necessary. 
The Plan denied your request. The Plan says these tests are considered experimental/investigational in all 
patients other than those who are pregnant. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing for the F2 and F5 genes is non-
covered except in pregnant patients.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of F2 and F5 gene analysis have not been met. Specifically, the enrollee is not pregnant. Therefore, 
we decided that the Plan does not have to pre-approve F2 (prothrombin, coagulation factor II) gene analysis 
(81240) and F5 (coagulation factor V) gene analysis (81241).
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 need the IRF admission approved. The Plan 
denied your request. The Plan says the IRF services requested do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary care can 
be provided in a different 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are in need of rehabilitation. You say you can't 
walk at all unassisted, and you are unable to care for yourself in the home setting as you have one prosthetic leg 
and have had reconstructive surgery on the other. The Plan denied your request. The Plan says that the IRF 
services requested do not meet the requirements for approval. 
 
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 found to be medically reasonable and necessary. Our physician reviewer found the 
complexity of your nursing, medical and rehabilitation needs does require an acute hospital inpatient stay with 
an interdisciplinary approach to rehabilitation care. You do require treatment by multiple therapies, including 
either physical therapy or occupational therapy, and an intensive rehabilitation therapy program at least three 
hours a day and five days a week, or 15 hours over seven consecutive days. You have had a decline from your 
baseline level of function, and you would benefit from the intensity of therapies provided on acute inpatient 
rehabilitation given your pre-existing right sided transtibial amputation. Therefore, the acute inpatient 
rehabilitation admission is 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute IRF admission and services.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of a permanent cardiac contractility 
modulation system. 
 
You asked the Plan to pre-approve the insertion of a permanent cardiac contractility modulation system. You 
say that this is medically necessary. The Plan denied your request. The Plan says this is experimental. 
 
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 insertion of a permanent cardiac 
contractility modulation system. Our reviewer says that the requested services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found cardiac contractility modulation systems 
remain the subject of multiple studies examining long-term efficacy, as well as randomized, controlled, double-
blinded trials to quantify clinical efficacy. Until such statistically rigorous studies are completed, it is premature 
to presume clinical outcomes and benefit. 
 
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 insertion of a permanent cardiac contractility modulation system have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a permanent 
cardiac contractility modulation system.
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 admission to IRF is medically necessary to help the 
enrollee return to independent living. The Plan denied your request. The Plan says the requested IRF services 
do not meet the requirements for approval. 
 
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 does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair. 
 
You asked the Plan to pre-approve the wheelchair. The Plan denied your request. The Plan says the coverage 
criteria are not met. 
 
The Plan follows Medicare rules. Medicare rules say that a manual wheelchair is covered when the criteria are 
met in the applicable LCD. 
 
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 manual wheelchair is not medically reasonable and necessary. Our physician reviewer found that 
there is not evidence submitted indicating the enrollee's condition cannot be met with a walker or cane, or that a 
wheelchair is necessary for the 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 the wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a manual wheelchair.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a core build-up (D2950), extractions (D7210), retainer crowns 
(D6740), and pontics (D6245) 
 
You asked the Plan to pre-approve the dental services. You say that these dental services are medically 
necessary. The Plan denied your request. The Plan says that the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has failed to provide dental-rays. Therefore, we decided that the Plan 
has to pre-approve a core build-up (D2950), extractions (D7210), retainer crowns (D6740), and pontics 
(D6245)  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan injections. 
 
You asked the Plan to pre-approve the Hyalgan. You say that the repeat injections are medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that repeat viscosupplement treatments are considered 
medically necessary for patients being treated for osteoarthritis of the knee when the previous set of injections 
provided significant improvement. 
 
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 Hyalgan. Our reviewer says that the 
repeat injections are not medically necessary. Our physician reviewer found the medical records do not 
document significant improvement in knee pain and known improvement in functional capacity from the 
previous series of injections. 
 
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 Hyalgan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Hyalgan injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies provided on August 24, 2022. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says the documentation 
does not contain a proof of delivery. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for the supplies provided on August 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar fusion. 
 
You asked the Plan to pre-approve a lumbar fusion. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is 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 a lumbar fusion. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found dynamic flexion/extension films are not provided in order to potentially assess the amount of 
movement (instability) at the requested surgical level. Detailed documentation is not evident regarding 
potential impending/inevitable temporary intra-operative instability. There is no compelling rationale presented 
or extenuating circumstances noted to support the medical necessity of this request as an exception. 
 
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 lumbar fusion have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a lumbar fusion.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on April 29, 2019, to 
May 2, 2019, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code N17.0, described as acute 
kidney failure with tubular necrosis. We asked our physician reviewer to carefully review the case file and 
apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the 
inpatient hospital services at the DRG originally billed. Our reviewer says that documentation does not support 
the billed code. Our physician reviewer found the diagnosis billed was not supported in the documentation, nor 
was it listed in the assessment section of the progress notes provided for this admission. The enrollee did not 
have evidence of a significant enough rise in creatine level beyond baseline to meet criteria.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on April 29, 2019, to May 2, 2019, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home health evaluation. 
 
You asked the Plan to pre-approve a home health evaluation. You say that you have not located any 
occupational therapists which will evaluate you at your home. You also say that an evaluation at a facility does 
not evaluate your ability to perform tasks in your household The Plan denied your request. The Plan says the 
services are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home health evaluation. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the request for 
driving evaluation and other documentation does not show that you are home-bound, and thus would not 
require a home health occupational therapy 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 a home health evaluation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home health evaluation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) fusion with allograft. 
 
You asked the Plan to pre-approve SI fusion with allograft. You say that you have quality of life issues. The 
Plan denied your request. The Plan says the clinical value and effectiveness of this procedure have not been 
demonstrated. 
 
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 SI fusion with allograft. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documented SI joint instability, fracture, or lesion. SI joint fusion for 
degenerative back pain is experimental. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SI fusion with allograft have not been met. Therefore, we decided that the Plan 
does not have to pre-approve sacroiliac (SI) fusion with allograft.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections (77002, 20610, J7324) provided on November 15, 
2022. 
 
You asked the Plan to pay for the injections. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 77002, 20610, & J7324 are not supported in the medical record. Specifically, the 
laterality modifiers billed do not match the diagnosis codes billed. A LT modifier cannot be billed for a right 
side diagnosis code. A RT modifier cannot be billed for a left side diagnosis code. Based on this information, 
we decided that Medicare rules for coverage of the injections have not been met. Therefore, we decided that the 
Plan does not have to pay for injections (77002, 20610, J7324) provided on November 15, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the injectafer (J1439). 
 
You asked the Plan to pre-approve the injectafer. You say that the drug is medically necessary. The Plan denied 
your request. The Plan says the enrollee has not met the step therapy requirements. 
 
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 injectafer. Our reviewer says that 
the drug is not medically necessary. Our physician reviewer found the patient 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 injectafer have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the injectafer (J1439).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory panel rendered on September 10, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that respiratory panels with more than five (5) respiratory 
pathogens performed in the Part B outpatient setting are not medically necessary. 
 
We looked at the file and Medicare rules. The file shows that more than 5 respiratory panels were tested. 
Therefore, we decided that the Plan does not have to pay for the respiratory panel rendered on September 10, 
2021.