Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation of the sacroiliac (SI) joint. 
 
You asked the Plan to pre-approve radiofrequency ablation of the SI joint. You say that radiofrequency ablation 
of the SI joint is medically necessary. The Plan denied your request. The Plan says radiofrequency ablation of 
the SI joint 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 radiofrequency ablation of the SI joint. 
Our reviewer says that the requested radiofrequency ablation of the SI joint is not considered medically 
reasonable and necessary. Our physician reviewer found that radiofrequency ablation of the SI joint is 
considered experimental/investigational because of the wide variation of efficacy reported in the literature. 
Therefore, the request is deemed not medically 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 radiofrequency ablation of the SI joint have not been met. Therefore, we 
decided that the Plan does not have to pre-approve radiofrequency ablation of the SI joint.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99222) rendered on 
September 5, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services 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. 
 
In this case, the CPT Code Manual definition of code 99222 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) 
requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's 
hospital floor or unit." 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the enrollee presented with atrial 
fibrillation on coumadin with middle cerebral artery (MCA) stroke, thrombectomy, computed tomography 
(CT) evidence and symptoms of intracranial hemorrhage. The right pupil was fixed and dilated. The Glasgow 
Coma Scale (GCS) score was 9. The history and physical examination was focused and only neurological, 
without evidence of comprehensive history and physical in the documentation. The documentation did support 
medical decision making of moderate complexity, but not high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for initial hospital care (procedure code 99222) rendered on September 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the therapy is desperately needed for your general 
health. You must use a walker to get around. The Plan denied your request. The Plan says the request is not 
medically necessary, the services you need can be provided safely in other settings, for example, a skilled 
nursing facility. 
 
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. There is no documented need for intensive rehabilitation services and 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 IRF admission and services.
Appeal type: Step-Therapy
Decision: Favorable

 
We decided that the Plan has to pre-approve Orencia. 
 
You asked the Plan to pre-approve Orencia. You say that the services are necessary. The Plan denied your 
request. The Plan says that 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 Orencia. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found there is no indication that the enrollee has 
tried and failed the required drugs. Based on the medical records provided and the Medicare-approved major 
drug compendia there is indication that the plan's required drugs may be more likely to have adverse effects for 
the enrollee. The prescriber indicates concern with regard to the enrollee's risk for infection on the required 
drugs and the enrollee was recently hospitalized for an abscess while on methotrexate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orencia have not been met. Therefore, we decided that the Plan has to pre-
approve Orencia.  
 
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: 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. The Plan denied your request. The Plan says the enrollee's current 
care may be rendered at a lower level of care and may benefit from an acute rehabilitation admission in the 
future when able to participate at least 3 hours per day in therapy. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Stereotactic Body Radiation Therapy (SBRTx5). 
 
You asked the Plan to pre-approve SBRT. You say that the enrollee has a history of bilateral breast cancer and 
prior lumpectomy. She has multiple sclerotic bone lesions as well as scattered pulmonary nodules throughout 
the chest. This is the best treatment for the enrollee. The Plan denied your request. The Plan says the request 
does not meet the Medicare or health plan coverage criteria. 
 
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 SBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found for metastatic disease, SBRT/HIGRT is generally indicated for enrollees with oligometastatic 
disease or for those undergoing palliation after prior radiation to the same site. Oligometastases are defined as a 
state of metastatic disease with metastases few in number and extent. Emerging data and NCCN guidelines also 
support SBRT in the setting of oligoprogression. SBRT is only necessary if it can be safely delivered when 
encompassing all sites of disease, which for this enrollee would imply with treatment of 2 lung lesions in the 
setting of widespread disease. Non-SBRT approaches could be considered. The decision is unfavorable as the 
treatment (selectively treating 2 metastases) in the setting of widespread metastases is not furnished in 
accordance with accepted standards, and the case file does not provide any guidelines or studies to suggest 
otherwise (the referenced SABR COMET study only enrolled enrollees with limited metastatic/oligometastatic 
disease). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Stereotactic Body Radiation Therapy (SBRTx5).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom shoe supports (A5500, A5513) to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve custom shoe supports to be provided by an OON provider. You say that the 
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able 
to provide these services. Therefore, coverage criteria have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
custom shoe supports (A5500, A5513) to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve knee arthroscopy. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there was no x-ray to show an overgrowth of bones or narrowing of the joint space. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that detailed documentation is not evident regarding a trial and failure of recent, reasonable, 
comprehensive less invasive conservative care measures. Additionally, the magnetic resonance imaging (MRI) 
and x-rays of the left knee corroborate degenerative changes. There are limited large-scale, long-term 
references showing the safety and efficacy of the requested surgery in this clinical/imaging setting. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested a knee arthroscopy with meniscectomy (medial OR lateral 
including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty) same or 
separate compartment(s), in this case, 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve knee arthroscopy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home delivered prepared meals. 
 
You asked the Plan to pre-approve home delivered prepared meals. You say that you are low income and need 
home delivered meals. The Plan denied your request. The Plan says home delivered meals is not covered by 
Medicare, the plan provides it as a supplementary service only if you meet certain criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that immediately following discharge from a hospital 
as an inpatient due to congestive heart failure, we cover up to two meals per day in a consecutive four-week 
period, once per calendar year. 
 
Though the Plan offers a supplemental benefit in excess of Medicare coverage, the requested home delivered 
prepared meals is not covered under Original Medicare. Therefore, we decided that the Plan does not have to 
pre-approve home delivered prepared meals.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint fusion. 
 
You asked the Plan to pre-approve the sacroiliac joint fusion. You say that this service is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 sacroiliac joint fusion. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no evidence of Sacroiliac joint instability, fracture, or lesion. Sacroiliac joint 
fusion for degenerative back pain remains 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 the sacroiliac joint fusion have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a sacroiliac joint fusion.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this service is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this procedure is considered experimental. More research is needed to show safety 
and efficacy. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99226 provided on August 17, 2022. 
 
You asked the Plan to pay for procedure code 99226. You say that the medical records support the billing of 
code 99226. The Plan denied your request. The Plan says the medical records do not support the billing of code 
99226. 
 
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 99226 is Subsequent observation care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit.  
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 code 99226. Our reviewer says that the medical 
records do not support the billing of code 99226. Our reviewer found a detailed interval history requires 4+ 
elements or 3+ chronic conditions in the history of present illness, 2-9 review of systems and 1 pertinent 
element of past, family, and social history. Provided records in this case do not document 4+ elements or 3+ 
chronic conditions in the history of present illness and 1 pertinent element of past, family, and social history. A 
detailed examination requires 2-7 organ systems. Provided records in this case document a detailed 
examination. Medical decision making of high complexity requires an extensive number of diagnoses or 
management options, an extensive amount and complexity of data reviewed and high risk of complication. 
Provided records in this case do not document an extensive number of diagnoses or management options, an 
extensive amount and complexity of data reviewed and high risk of complication. 
 
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 code 99226 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99226 provided on August 17, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 
You asked the Plan to pre-approve Feraheme. You say that Feraheme is medically necessary. The Plan denied 
your request. The Plan says a trial of Infed or Venofer 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 Feraheme. Our reviewer says that this 
drug is not medically necessary. Our physician reviewer found the records show no trial of the plan preferred 
drugs or any reason they would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme.
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 from IRF care. 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.