Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the 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 LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found you are presently receiving appropriate services in the short-term acute care setting. 
Continued care in the short-term acute care hospital is appropriate until you are stable to transfer to a lower 
level of care such as an inpatient rehabilitation facility, a sub-acute rehabilitation facility or 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on May 2, 
2022. 
 
You asked the Plan to pay for the CT scan. You say that you are unable to see if the place of service is correct. 
The Plan denied your request. The Plan says it is inappropriate to bill an outpatient place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
 We looked at the file and the rules. The claim at issue was billed with an outpatient place of service. The 
enrollee was receiving inpatient care at the time the services were provided. Based on this information, we 
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have 
to pay for the computed tomography (CT) scan provided on May 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a radiofrequency ablation procedure of the sacroiliac-
joint nerves (64625). 
 
You asked the Plan to pre-approve a radiofrequency ablation. 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 radiofrequency ablation. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the requested procedure is considered experimental/investigational because of 
the wide variation in efficacy as published in the peer-reviewed literature. 
 
 
  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 radiofrequency ablation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a radiofrequency ablation procedure of the sacroiliac-joint nerves (64625).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you were admitted to the hospital for altered mental status and leg ulcers. You are 
now medically stable with no complex nursing or rehabilitation needs. You do not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. There is not a reasonable expectation that you 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat transforaminal epidural steroid injection 
(TFESI) (64483 x 2). 
 
You asked the Plan to pre-approve repeat TFESI. You say that the enrollee had 90% relief for at least weeks 
with their last injection. You also say that the enrollee still has relief since their injection on June 23, 2022. The 
Plan denied your request. The Plan says a repeat injection is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat epidural steroid injection (ESI) when the first 
injection directly and significantly provided improvement of the condition being treated may be considered 
medically reasonable and necessary when the medical record documents at least 50% of sustained 
improvement in pain relief and/or improvement in function measured from baseline using same scale for at 
least three months. 
 
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 repeat TFESI. Our reviewer says that 
the requested repeat TFESI is not medically necessary. Our physician reviewer found the provided 
documentation does not indicate that the enrollee had 50% pain relief for 3 months after the previous TFESI. 
Therefore, the requests repeat injection 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 repeat TFESI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat transforaminal epidural steroid injection (TFESI) (64483 x 2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two nerve blocks provided along with anesthesia on June 
2, 2022. 
 
You asked the Plan to pay for the nerve blocks. You say that these nerve blocks are separately payable as they 
were performed for post-operative pain management. The Plan denied your request. The Plan says the 
documentation does not show these blocks were used for postoperative pain. 
 The Plan must follow Medicare rules. Medicare rules say that nerve blocks may be paid separately in addition 
to anesthesia when ordered by the surgeon when general anesthesia, subarachnoid injection, or epidural 
injection is used, and the adequacy of the intraoperative anesthesia is not dependent on the peripheral nerve 
block injection. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the nerve blocks have not been met. Specifically, there is no documentation that these injections 
were requested by the surgeon for postoperative pain management. In addition, the records show that 
monitored anesthesia care (MAC) was provided and not general anesthesia. The records do not clearly indicate 
that these blocks were not required for the adequacy of the intraoperative anesthesia. Therefore, we decided 
that the Plan does not have to pay for the two nerve blocks provided along with anesthesia on June 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laser therapy. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that laser therapy is covered when specific criteria are 
met. 
 
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 you have a diagnosis of rosacea. The 
records do not document complicating symptoms that warrant medical intervention or that there is diagnostic 
uncertainty. The records do not establish that the requested laser therapy is reasonable or medically necessary 
at this time. 
 
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 laser therapy.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for FoundationOne CDx (F1CDx) testing (0037U) billed for date of 
service May 31, 2022. 
 
You asked the Plan to pay for F1CDx testing. You say that this test was necessary and is supported in the 
medical record. The Plan denied your request. The Plan says that the date of service for a clinical laboratory 
test or the technical component of physician pathology service must be the date the specimen was collected. 
The specimen in this case was collected on May 5, 2022, rather than the billed date of service May 31, 2022. 
 
The Plan must follow Medicare rules. The rules say that generally, laboratory services should be reported with 
the date of specimen collection as the date of service; however, there are three exceptions to this rule. The rules 
also 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. Specifically, the Plan has not acknowledged nor addressed the exceptions to the 
applied rule. The sample in this case was a piece of live tissue which was collected as part of a biopsy 
procedure performed in a hospital setting. It is very likely that an exception was met in this case, which would 
mean that the date the testing was performed (May 31, 2022) would be the correct date to report in this case. 
Therefore, we decided that the Plan has to pay for FoundationOne CDx (F1CDx) testing (0037U) billed for 
date of service May 31, 2022.  
 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 spinal cord stimulator implantation. 
 
You asked the Plan to pre-approve spinal cord stimulator implantation. The Plan denied your request. The Plan 
says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a spinal cord stimulator is 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 spinal cord stimulator implantation. Our 
reviewer says that the requested spinal cord stimulator is not medically reasonable and necessary. Our 
physician reviewer found that the enrollee does not have an evidence-based indication, and she has not had a 
surgical consultation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of spinal cord stimulator implantation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve spinal cord stimulator implantation.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orencia (J0129). 
 
You asked the Plan to pre-approve Orencia. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy requirements have 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 
requirements for coverage of Orencia have not been met. Our physician reviewer found the Plan requires a trial 
of Remicade, infliximab, Inflectra, or Simponi Aria before they will approve the requested drug. In this case, 
the enrollee has not tried and failed the required drugs. There is no documentation provided indicating that the 
required drugs would likely be less effective or  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 Orencia have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Orencia (J0129).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on May 3, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that this laboratory does not have 
a contractual agreement with the dialysis facility for payment. The Plan denied your request. The Plan says 
Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on May 3, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 27, 2022. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the testing 
was billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repairs to a power mobility device. 
 
You asked the Plan to pre-approve power mobility device repairs. You say that your power scooter is not 
working properly. The Plan denied your request. The Plan says the cumulative cost of repairs to your power 
scooter exceeds the estimated cost for replacement, so the requested repairs are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that if the expense for repairs exceeds the estimated 
expense of purchasing or renting another item of equipment for the remaining period of medical need, no 
payment can be made for the amount of the excess.  
 
We looked at the file and Medicare rules. Your power scooter has received prior repairs with a cumulative cost 
of $1,468.82. The Plan estimates that the allowable amount for a replacement would be $958.19. Therefore, 
your power scooter has already exceeded the expense of acquiring a new power scooter and Medicare will not 
pay for these exceed repair costs. Please contact the Plan regarding coverage for a new power mobility device 
which meets your needs. Based on this information, we decided that Medicare rules for coverage of power 
mobility device repairs have not been met. Therefore, we decided that the Plan does not have to pre-approve 
repairs to a power mobility device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the hip injection services to be billed with CPT code 
27096. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says an 
incorrect code cannot be covered. 
 
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 27096 is injection procedure for sacroiliac joint, 
anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed. 
 
We find that CPT code 27096 is not supported in the medical record. There is a more comprehensive code to 
describe the intra-articular cortisone injection your provider recommended. The file does show that the Plan 
would approve code 20611 if requested. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve the hip injection 
services to be billed with CPT code 27096.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the 4-wheeled walker with seat and brakes (CPT code 
E1399). 
 
You asked the Plan to pre-approve the walker. You say that the walker is medically 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 walker have not been met. The LCA states: When code E1399 
is billed, the claim must include the manufacturer name and the product name/number. Criteria has not been 
met. There is no submitted documentation which includes the manufacturer and the product name/number. The 
provider is requesting coverage for an unlisted code when there is a more appropriate code for this service. A 
review of CMS guidelines states an unlisted code cannot be covered if there is an appropriate code for the 
requested service. Unlisted codes should be reported only if no other specific codes adequately describe the 
procedure or service. Therefore, we decided that the Plan does not have to pre-approve the 4-wheeled walker 
with seat and brakes (CPT code E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for re-evaluation - limited, problem focused (D0170) provided 
on February 8, 2022. 
 
You asked the Plan to pay for dental services. You say that you were in a lot of pain, and you cannot afford to 
pay out-of-pocket for this service. The Plan denied your request. The Plan says this service is not covered 
under your Plan. 
 
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. Re-evaluation - limited, 
problem focused (D0170) is not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested re-evaluation - limited, 
problem focused (D0170) is not among those covered under this benefit. Therefore, we decided that the Plan 
does not have to pay for re-evaluation - limited, problem focused (D0170) provided on February 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro myoelectric orthosis (L8702). 
 
You asked the Plan to pre-approve the orthosis. You say that the enrollee has been referred by their family 
nurse practitioner for myoelectric orthotic restoration. The Plan denied your request. The Plan says the MyoPro 
Orthosis is still being studied to establish clinical effectiveness and long-term safety of the device. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve 
the MyoPro myoelectric orthosis (L8702).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental service (D0150) on June 8, 2022. 
 
You asked the Plan to pay for the dental service (D0150). You say that the services provided were medically 
necessary. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
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 requested item or service was exhausted on date of service November 23, 2020. 
Therefore, we decided that the Plan does not have to pay for the dental service (D0150) on June 8, 2022.