Persius/hicric huggingface dataset:
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 it is felt that you would benefit from IRF care. The 
Plan denied your request. The Plan says IRF criteria are met as the enrollee is not likely to be able to participate 
in three hours of daily 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 enrollee was admitted to an acute hospital on 9/8/22 with severe acute on chronic anemia. Therapy notes show that she requires minimal assistance with bed mobility and transfers, and she was 
able to ambulate 45 feet with contact guard assistance with a quad cane. 
 
The enrollee does not have acute rehabilitation or nursing needs. At 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. She will not likely tolerate the intensity with severe anemia. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vectra testing. 
 
You asked the Plan to pre-approve the testing. You say that Vectra testing will help gauge the enrollee's 
response to therapy and see if their diagnosis is controlled. The Plan denied your request. The Plan says the 
enrollee does not meet the Plan's 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 the testing. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found it has not been demonstrated that Vectra testing is medically reasonable and necessary for the 
enrollee in this case and will likely impact their management and outcome. 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 testing have not been met. Therefore, we decided that the Plan does not have to pre-approve Vectra testing.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are requesting SNF services for the enrollee so 
they can get back to baseline before going home. 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found daily skilled services are not necessary. Our physician reviewer found that the 
medical records do not document that you require services on an inpatient basis, only in a skilled nursing 
facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 9, 
2021. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical lumbar spine fusion procedure (CPT 
code(s): 22842, 22853 x3, 22633, 22634 x2). 
 
You asked the Plan to pre-approve the procedure. You say that the services are necessary. The Plan denied 
your request. The Plan says the enrollee's records do not show that they have a spinal fracture, spinal stenosis, 
spondylolisthesis, adjacent segment disease pseudarthrosis or are having a planned decompression surgery. 
 
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 procedure. 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 lumbar instability, fracture, or lesion. Lumbar fusion is not medically 
needed. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the surgical lumbar spine fusion procedure (CPT code(s): 22842, 22853 x3, 22633, 22634 
x2).
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 enrollee's recovery will be adversely affected if 
required to wait the standard timeframe and acute inpatient rehabilitation is further delayed. The Plan denied 
your request. The Plan says rules for IRF care have 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 there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultra-lightweight manual wheelchair with power 
assist. 
 
You asked the Plan to pre-approve an ultra-lightweight manual wheelchair. You say that the power wheelchair 
is in house use even though it is portable, and it cannot get wet. During your physical therapy assessment, the 
therapist recommended a manual wheelchair. You also say you can go out in the rain with a manual 
wheelchair. You say you need to be free and need to have fun with friends and family outside. The Plan denied 
your request. The Plan says the requested ultra-lightweight manual wheelchair with power assist is not 
medically necessary. Your current new wheelchair meets all of your mobility needs, is functioning correctly, 
can be transported in a family's car, and is built and designed to be water resistant. 
 
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 an ultra-lightweight manual wheelchair. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the requested ultralightweight manual wheelchair with power assist 
exceeds your medical needs and is not medically necessary for the diagnosis, treatment of illness or injury, or 
to improve the functioning of a malformed body member. The documentation indicates you were approved for 
a power wheelchair in the past and this particular wheelchair was chosen due to portability. The requested 
wheelchair would serve a similar purpose as the prior wheelchair and this is not 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 an ultra-lightweight manual wheelchair have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an ultra-lightweight manual wheelchair with power assist.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diagnostic medial branch blocks (MBBs). 
 
You asked the Plan to pre-approve diagnostic MBBs. You say that the requested diagnostic MBBs are 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested diagnostic MBBs. 
 
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 diagnostic MBBs. Our reviewer says 
that the enrollee does not meet criteria for the requested diagnostic MBBs. Our physician reviewer found the 
enrollee has chronic low back pain. The enrollee has tried physical therapy. The enrollee takes Oxycodone, 
Zanaflex and Lyrica for pain. The enrollee underwent Right L2-L5 medial branch radiofrequency ablation 
(RFA) more than two years ago with good effect, so diagnostic procedures must be repeated. However, the 
case file does not contain documentation that there is currently no non-facet pathology per clinical assessment 
or radiology studies that could explain the source of the pain, including but not limited to fracture, tumor, 
infection, or significant deformity. The documentation does not include a physical examination of the back or 
radiology studies to determine whether non-facet pathology is present. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of diagnostic MBBs have not been met. Therefore, we decided that the Plan does 
not have to pre-approve diagnostic medial branch blocks (MBBs).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair, group 4 standard, single power 
option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (CPT code K0877). 
 
You asked the Plan to pre-approve the power wheelchair. You say that you cannot use a regular wheelchair due 
to health issues. The Plan denied your request. The Plan says the documentation does not support the Medicare 
criteria of medical necessity. 
 
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 the power wheelchair. Our physician 
reviewer found there is no documentation that the group 4 power wheelchair at issue in this case meets 
Medicare criteria for medically reasonable and necessary. Provided records do not document the power 
wheelchair is for use in the home (as opposed to use in the community) and records do not include an 
assessment of your home to assure that the power wheelchair will safely fit and be maneuverable within your 
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 power wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve power wheelchair, group 4 standard, single power option, sling/solid seat/back, 
patient weight capacity up to and including 300 pounds (CPT code K0877).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Libre 2 reader. 
 
You asked the Plan to pre-approve the CGM. You say that the CGM is necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
There is no documentation that the current monitor is damaged. The criteria have not been met for replacement 
of your CGM as it has not exceeded it's reasonable useful lifetime, which is not less than 5 years. Therefore, the 
requested replacement is not approved. Therefore, we decided that the Plan does not have to pre-approve the 
Freestyle Libre 2 reader.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a medical vision exam with imaging 
provided on April 14, 2022. 
 
You asked the Plan to waive the deductible for a medical vision exam with imaging. You say that you would 
like the claim to be reviewed because someone in customer service informed you that the $500 deductible had 
already been met prior to March 14, 2022. The Plan denied your request. The Plan says the deductible applied 
is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $500 deductible which is the amount you have to pay out-of-pocket 
before we will pay our share for your covered medical services.  
 
The item or service you asked the Plan to waive the deductible for falls within the Vision Care and Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit category. The Plan has followed Medicare 
rules by clearly disclosing in the contract that there is a $500 deductible which applies to a medical vision exam 
with imaging. This cost sharing is a contractual obligation that had not been met at the time a medical vision 
exam with imaging was received on April 14, 2022. Therefore, we decided that the Plan does not have to waive 
the deductible for a medical vision exam with imaging provided on April 14, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 18 physical therapy visits. 
 
You asked the Plan to pre-approve therapy visits. You say that additional therapy is medically necessary. The 
Plan denied your request. The Plan says these services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found you have had extensive prior therapy and the documentation does not 
reveal that you require the unique skills of a professional therapist to provide treatment safely and effectively. 
You have been instructed in a home exercise 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 therapy visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 18 physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pneumatic compressor, segmental home model with 
calibrated gradient pressure (CPT code E0652) and segmental pneumatic appliance for use with pneumatic 
compressor, full leg (E0667). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the DME have not been met. Review of the file shows that the 
enrollee has swelling only in the enrollee's legs. The rules say a PCD coded as E0652 used to treat lymphedema 
not extending onto the chest, trunk and/or abdomen or CVI is not eligible for reimbursement. Therefore, we 
decided that the Plan does not have to pre-approve pneumatic compressor, segmental home model with 
calibrated gradient pressure (CPT code E0652) and segmental pneumatic appliance for use with pneumatic 
compressor, full leg (E0667).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genetic testing (PALB2 ANALYSIS) (CPT) code 
81307). 
 
You asked the Plan to pre-approve the genetic testing. You say that the testing is necessary. The Plan denied 
your request. The Plan says you do not have a diagnosis of cancer; therefore, the test is not medically 
necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the genetic testing. Our physician 
reviewer found you have no cancer history; therefore, you do not meet criteria for genetic testing. 
 
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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the genetic testing (PALB2 ANALYSIS) (CPT) code 81307).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
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 Botox is coverd for specific indications only. 
 
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 enrollee has had choking episodes. 
A mildly prominent cricopharyngeus was reported on a swallowing study in October of 2021. The doctor 
would like to offer an injection of the cricopharyngeal muscle with Botox. This is not an indication for which 
Botox is covered by the Medicare criteria. 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 Botox.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a microprocessor knee and foot. 
 
You asked the Plan to pre-approve the prostheses. The Plan denied your request. The Plan says the coverage 
criteria are not met. 
 
The Plan follows Medicare rules. Medicare rules say that microprocessor prostheses are covered for the 
indications established 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 prostheses. Our reviewer says that 
the requested microprocessor knee and foot are not medically reasonable and necessary. Our physician 
reviewer found that although the microprocessor knee and foot are requested in this case, the provided records 
from the enrollee's treating physician do not explain why a mechanical K3 level knee and foot would not meet 
the enrollee's needs. The records do not document trial and failure of a new mechanical K3 level knee and foot. 
 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 prostheses have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a microprocessor knee and foot.