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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 the enrollee appears to be improving but is still somewhat unstable and should only 
require short-term additional acute care services that can be safely administered at the current facility until 
more appropriate for a lower level of care. There are no services at the LTACH that the enrollee requires that 
are not already available and covered at the current facility. Transfer to a lower level of care may be considered 
when treatment has completed. 
 
 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 
You asked the Plan to pre-approve Evenity. You say that the drug is necessary. The Plan denied your request. 
The Plan says the enrollee has not tried and failed the required drugs, Prolia (denosumab) or IV zoledronic 
acid. 
 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 Evenity. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
that the enrollee has tried and failed the plan's required drug, Prolia (denosumab) or IV zoledronic acid. The 
reviewer also found that the provided documentation does not support that the plan's required drugs would 
likely be less effective, and/or would likely have adverse effects for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extracapsular cataract removal with insertion of 
intraocular lens prosthesis and anterior segment aqueous drainage device. 
 
You asked the Plan to pre-approve the cataract services. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says the criteria for coverage have not been satisfied. 
 
The Plan must follow Medicare rules. Medicare rules say that the requested procedure requires the enrollee to 
currently be treated with an ocular hypotensive medication. 
 
We looked at the file and Medicare rules. In this case, the most recent medical records that have been submitted 
indicate that the enrollee is currently not being treated with an ocular hypotensive medication. Based on this 
information, we decided that Medicare rules for coverage of an extracapsular cataract removal have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an extracapsular cataract removal with 
insertion of intraocular lens prosthesis and anterior segment aqueous drainage device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided to the enrollee on 
October 29, 2021. 
 
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 provider must attempt to consult the attending or primary care physician about the services 
furnished and document the consent or declination date to consultations, and the date of consultations in the 
enrollees medical record 
 The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for outpatient mental health services provided to the 
enrollee on October 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the PBRT (CPT code 77523). 
 
You asked the Plan to pre-approve the PBRT. You say that proton therapy is beneficial for prostate cancer. The 
Plan denied your request. The Plan says a review of the literature indicates that PBRT is not the standard of 
care for prostate cancer and Proton Beam therapy for primary treatment of prostate cancer should only be 
performed within the context of a prospective clinical trial. 
 
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 PBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found proton therapy would arguably exceed need for this enrollee. Proton therapy may or may not be 
better than intensity-modulated radiation therapy (IMRT)/image-guided radiation therapy (IGRT).  
 
 
 
 
 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 PBRT have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the PBRT (CPT code 77523).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve low dose computed tomography (LDCT) scan for lung 
cancer screening for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says a screening examination in the setting of signs and/or symptoms of lung cancer is not 
appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 scan. Our reviewer says that the 
requested screening is not medically reasonable or necessary. Our physician reviewer found the record 
indicates that the enrollee is a lifelong smoker and has a five month history of shortness of breath and 
cough. The enrollee is not asymptomatic. The elements of the coverage criteria are not satisfied. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve low dose computed tomography (LDCT) scan for lung cancer screening for the enrollee.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve transcatheter insertion or replacement of permanent leadless 
pacemaker, right ventricular, including imaging guidance (eg, fluoroscopy, venous ultrasound, 
ventriculography, femoral venography) and device evaluation (eg, interrogation or programming), when 
performed (CPT code 33274). 
 
You asked the Plan to pre-approve the service. You say that the enrollee's life is at risk. The Plan denied your 
request. The Plan says that your request is not a covered benefit because the enrollee's records do not document 
their participation in the necessary FDA approved study. 
 
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 service. Our physician reviewer 
found at issue is the medical appropriateness and necessity of implanting a leadless pacemaker, instead of a 
traditional pacemaker with an intravascular lead, in a patient who is felt to require permanent pacing. The 
advantage of the leadless pacemaker is avoidance of an intravascular lead, while the limitation is the inability 
to allow pacing in the atrium, as well as the inability to remove and replace the generator at the time of battery 
depletion, roughly every ten (10) years, with a need to place a new unit at time of battery depletion. However, 
this enrollee has atrial fibrillation, and the physician does not feel that an atrial lead is mandatory. Advanced 
age also makes the patient a suitable candidate, as opposed to a young person, for which a leadless pacemaker 
might not be appropriate. Therefore, use of a leadless pacemaker would be at the physicians discretion and 
considered medically appropriate and reasonable in this enrollees clinical management. 
 
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 service have been met. Therefore, we decided that the Plan has to pre-
approve transcatheter insertion or replacement of permanent leadless pacemaker, right ventricular, including 
imaging guidance (eg, fluoroscopy, venous ultrasound, ventriculography, femoral venography) and device 
evaluation (eg, interrogation or programming), when performed (CPT code 33274).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transport chair (E1038) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a transport chair. You say that you would like this claim reprocessed and 
approved for payment based on medical necessity. The Plan denied your request. The Plan says there are in-
network providers that are available to provide the equipment in question. 
 
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 
a transport chair (E1038) to be provided by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on  
November 6, 2020. 
 
You asked the Plan to pay for an emergency department visit. The Plan denied your request. The Plan says 
Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to 
the members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on November 3, 2020. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for an emergency 
department visit provided on November 6, 2020.
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 appear to be more stable and improving and should only require short-term 
additional acute care services including additional weaning that can be safely administered at the current 
facility. There are no services at the LTACH that you require that are not already available and covered at the 
current facility. Transfer to a lower level of care may be considered when treatment has completed. 
 
 
 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 pre-approve CT scan of the soft tissue of the neck for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says there has been no exam of the back of the throat. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found the record indicates that 
the enrollee has a history of chronic sinus infections and multiple sinus surgeries who complains of hoarseness 
following intubation for gallbladder surgery. Subsequent endoscopies revealed thrush and right vocal cord 
partial paralysis. The record reveals a normal neck examination otherwise. The record does not indicate that 
repeat endoscopy to evaluate the abnormal findings has been performed. The provided records do not indicate 
the medical necessity or reasonableness, as defined by Medicare rules, of the requested service. The elements 
of the coverage criteria are not satisfied. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve CT scan of the soft tissue of the neck for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hot or cold packs therapy (97010) provided on June 1, 
2021, and June 9, 2021. 
 
You asked the Plan to pay for the hot or cold packs therapy (97010). The Plan denied your request. The Plan 
says coverage is limited to manual manipulation of the spine to correct subluxation. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
  We looked at the case file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the hot or cold packs therapy (97010) have not been met. Specifically, the only chiropractic service 
Medicare covers is manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay 
for the hot or cold packs therapy (97010) provided on June 1, 2021, and June 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (CPT code 64628). 
 
You asked the Plan to pre-approve the intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of the intracept procedure in the setting 
of chronic low back pain have not been demonstrated in the peer-reviewed literature. The Plan states more 
research is needed to show safety and efficacy of the procedure. 
 
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 items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the intracept procedure is experimental. More research is 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 intracept procedure have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the intracept procedure (CPT code 64628).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cranial prosthesis. 
 
You asked the Plan to pay for a cranial prosthesis. You say that the items should be covered. The Plan denied 
your request. The Plan says the items were obtained from a provider who is not under contract with the health 
plan, is not certified for Medicare and was not authorized with the plan 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a cranial prosthesis.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT 
code 22869). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says a review of the current medical literature indicates that this service is considered 
experimental and investigational as it is not identified as widely used and generally accepted for the proposed 
use as reported in nationally recognized peer-reviewed medical literature published in the English language. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertiflex device is 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat. 
 
You asked the Plan to pre-approve a raised toilet seat. You say that this is medically necessary. The Plan 
denied your request. The Plan says this device is not covered by Medicare or by the Plan. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic activities (97530) provided on April 19, 2021. 
 
You asked the Plan to pay for therapeutic activities. You say that these services were billed appropriately and 
should be paid. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) 
Procedure to Procedure (PTP) edit exists between 92526 and 97530. This PTP edit has a modifier indicator of 
1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with 
this PTP code edit. This service was not billed as required by Medicare coding regulations. 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 97530 
is a column II code to column I code 92526. 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 therapeutic activities (97530) provided on April 19, 2021.