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

 
We decided that the Plan does not have to pre-approve the Rialto SI Fusion System coded as 27279 and 61783. 
 
You asked the Plan to pre-approve the Rialto SI Fusion System. You say that prior sacroiliac joint injections 
have worked 90% but were short lasting. You feel the enrollee is a candidate for left sacroiliac joint fusion. The 
Plan denied your request. The Plan says this service is considered investigational as the Rialto SI Fusions 
system, which is a cylindrical implant device and not an FDA-approved titanium triangular implant as required 
by criteria. 
 
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. Criteria states minimally invasive fusion/stabilization of the 
sacroiliac joint for the treatment of back pain presumed to originate from the sacroiliac joint is considered 
investigational under all other conditions including but not limited to when Criterion III is not met or when a 
non-FDA approved device is used. Based on this information, we decided that Medicare rules for coverage of 
the Rialto SI Fusion System have not been met. Therefore, we decided that the Plan does not have to pre-
approve the Rialto SI Fusion System coded as 27279 and 61783.
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 meets criteria for an IRF admission, 
physical and occupational therapy for assisted ambulation is medically necessary. The Plan denied your 
request. The Plan says the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitative care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the current functional level, the enrollee does not need intensive therapies consisting 
of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach 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: 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 mother is being referred and recommended to 
IRF, to be assessed both medically and functionally in regard to their functional capacity to determine your 
mother may benefit from a rehabilitation level of care. The Plan denied your request. The Plan says your 
mother's records do not show the need for an intensive team for your care, medically necessary care may be 
provided safely in a different level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup, including any pins when required for teeth 
#6, #8 (D2950), retainer crown - porcelain fused to high noble metal, teeth #6, #8 (D6750) and pontic-porcelain 
fused to high noble metal, tooth #7 (D6240). 
 
You asked the Plan to pre-approve the dental services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says your benefit for the pontic and crowns has already been exhausted. 
Because the crowns are denied, the core buildup is also denied. 
 
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, certain limitations apply. The record 
shows your benefit for the crowns and pontic was exhausted on date of service November 30, 2021. Additionally, theres no reason for a core buildup (D2950) for crowns (D6750) that cannot be approved due to 
the benefit being exhausted. Therefore, we decided that the Plan does not have to pre-approve core buildup, 
including any pins when required for teeth #6, #8 (D2950), retainer crown - porcelain fused to high noble 
metal, teeth #6, #8 (D6750) and pontic-porcelain fused to high noble metal, tooth #7 (D6240).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy visits. 
 
You asked the Plan to pre-approve home health services. You say that the enrollee will benefit from therapeutic 
exercise, balance training, and pain management. The Plan denied your request. The Plan says there is no 
active or acute on chronic condition that would necessitate a new program. 
 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 home health services. Our physician 
reviewer found that the enrollee does not have documented skilled therapy needs. The enrollee is functioning at 
a level commiserate with a lower level of care (i.e., home exercise program, outpatient therapy, layperson 
supervision). As such, the requested services are not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health physical therapy visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex device. 
 
You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically 
necessary. The Plan denied your request. The Plan says the requested Vertiflex device 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 Vertiflex device. Our reviewer says 
that the requested Vertiflex device is not medically necessary. Our physician reviewer found the enrollee was 
being treated for spinal stenosis of the lumbar region with neurogenic claudication. He presented with 
continued bilateral radicular leg pain with neurogenic claudication. He has moderate-severe impaired physical 
function with buttock/lower leg pain and weakness with lumbar extension but has relief on flexion of the 
lumbar spine. The exam reveals pain, paresthesia, and decreased sensation in the bilateral legs in the L4-5 and 
L5-S1 dermatome distribution. Strength in the bilateral legs is 4+/5. However, current evidence based medical 
guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 
gold standard of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees medical condition. There is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Therefore, the requested Vertiflex Superion interspinous spacer at L4-5 and L5-S1, 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 a Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Vertiflex device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ferric gluconate intravenous (IV). 
 
You asked the Plan to pre-approve Ferric gluconate IV. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Ferric gluconate IV. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the review has determined that the 
documentation does not support that the Ferric gluconate IV is medically reasonable and necessary for the 
enrollee. The documentation does not support that the Ferric gluconate IV is safe and effective 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 Ferric gluconate IV have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Ferric gluconate intravenous (IV).
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says that the admission to an IRF is 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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to be able to tolerate fifteen hours per week of rehabilitative services 
with regular physician evaluations. The enrollees care needs can be met at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing for the F2 (prothrombin, coagulation 
factor II) and F5 (coagulation factor V) genes (81240, 81241). 
 
You asked the Plan to pre-approve genetic testing. You say that these tests are medically reasonable and 
necessary. The Plan denied your request. The Plan says the criteria for these tests are not met as the enrollee is 
not currently pregnant and has no family history or prior risk factors for venous thromboembolism (VTE). 
 
The Plan must follow Medicare rules. Medicare rules say that testing for FVL and F2 G20210A mutations is 
indicated for pregnant patients who have a history of personal venous thromboembolism (VTE) associated with 
a non-recurrent (transient) risk factor who are not otherwise receiving anticoagulant prophylaxis. There is no 
Medicare benefit for assessment of thrombosis risk in asymptomatic patients (aka screening for inherited 
thrombophilia) or in asymptomatic individuals whose relatives have documented inherited thrombophilia. 
 
We looked at the file and Medicare rules. 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 for the F2 (prothrombin, coagulation factor II) and F5 (coagulation factor V) genes 
(81240, 81241).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gene analysis (alpha globin 1 and alpha globin 2) for 
common deletions or variant (81257). 
 
You asked the Plan to pre-approve gene analysis (alpha globin 1 and alpha globin 2) for common deletions or 
variant. You say that this testing is medically necessary. The Plan denied your request. The Plan says this test is 
not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this 
information, we decided that Medicare rules for coverage of gene analysis (alpha globin 1 and alpha globin 2) 
for common deletions or variant have not been met. Therefore, we decided that the Plan does not have to pre-
approve gene analysis (alpha globin 1 and alpha globin 2) for common deletions or variant (81257).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skin substitute services (procedure code 15275) provided to 
the enrollee on August 26, 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 CPT 15275 is listed as a high-cost skin substitute application procedure which is billed without 
an appropriate high-cost skin substitute product code. 
 
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 15275 is "Application of skin substitute graft to face, 
scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area 
up to 100 sq cm; first 25 sq cm or less wound surface area." 
 
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 procedure report describes 
Epifix was used with an application procedure.  When reporting CPT 15275, a high-cost skin substitute should be reported. In this case, provider reported a high-cost application procedure code with a low-cost skin 
substitute HCPCS Q4100 Skin substitute, nos. A more appropriate HCPCS code should be reported to support 
the service provided. 
 
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 skin substitute services (procedure code 15275) provided to the enrollee on August 26, 2022.
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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 documentation does not support necessity for admission to an IRF and the 
complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitative care. While the enrollee may benefit from 
physical and occupational theray, the enrollee's rehabilitation needs can be provided in a lower intensity and 
alternate setting. 
 
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 Functional Electrical Stimulator (E0770). 
 
You asked the Plan to pre-approve the Functional Electrical Stimulator. You say that this device is 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 coverage of Functional Electrical Stimulation to treat 
muscle atrophy is limited to the treatment of disuse atrophy where nerve supply to the muscle is intact, 
including brain, spinal cord and peripheral nerves, and other non-neurological reasons for disuse atrophy. 
 
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 Functional Electrical Stimulator. 
Our reviewer says that this device is not medically necessary. Our physician reviewer found the patient does 
not have disuse atrophy where nerve supply to the muscle is intact, including brain, spinal cord and peripheral 
nerves, or other non-neurological reasons for disuse atrophy. 
 
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 Functional Electrical Stimulator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Functional Electrical Stimulator (E0770).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve a power wheelchair. You say that the requested power wheelchair is 
medically necessary. The Plan denied your request. The Plan says the requested power wheelchair is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a power wheelchair. Our reviewer says 
that the requested power wheelchair is not medically necessary. Our physician reviewer found the enrollee has 
Friedrich's ataxia and impaired ambulation. The record does not include his physical therapy evaluation. The 
record does not support his safety with wheelchair or that home is accessible. It is not clear the enrollee 
requires a power wheelchair to perform mobility related activities of daily living.  
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 power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a combination sit to stand frame/table system, any size 
including pediatric, with seat lift feature, with or without wheels (E0637). 
 
You asked the Plan to pre-approve a sit to stand frame/table system. You say that you disagree with the denial. 
You feel the requested item is medically necessary for your plan of care. The Plan denied your request. The 
Plan says the requested item is not covered by Medicare or your Plan. They are a convenience item and not 
primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a combination sit to stand frame/table system, any size 
including pediatric, with seat lift feature, with or without wheels (E0637).