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

 
We decided that the Plan does not have to pre-approve repeat facet joint injection services. 
 
You asked the Plan to pre-approve facet joint injection services.. You say that this injection service is 
medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage have 
not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a second confirmatory diagnostic facet joint 
procedure is considered medically reasonable and necessary in patients when after the first diagnostic facet 
joint procedure, there must be a consistent positive response of at least 80% relief of primary (index) pain. 
 
We looked at the file and Medicare rules. In this case, the documentation clearly demonstrates that the response 
to the first injection was 75% relief of primary pain, not the required 80%. Based on this information, we 
decided that Medicare rules for coverage of facet joint injection services. have not been met. Therefore, we 
decided that the Plan does not have to pre-approve repeat facet joint injection 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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee can safely receive the services he needs in other settings. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for right sided weakness 
and slurred speech. The enrollees medical problems are stable. There are no complex nursing or rehabilitation 
needs. The patient does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical 
and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There 
is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition 
does not meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair with custom fabricated seat 
cushion and back cushion. 
 
You asked the Plan to pre-approve the wheelchair. You say that this si medically necessary. The Plan denied 
your request. The Plan says the enrollee is a resident at a nursing facility. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the wheelchair is being requested for use in a SNF or hospital. Therefore, we decided that 
the Plan does not have to pre-approve a manual wheelchair with custom fabricated seat cushion and back 
cushion.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve F2 and F5 genetic testing services (81240, 81241). 
 
You asked the Plan to pre-approve F2 and F5 genetic testing services. You say that this genetic testing is 
medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage for 
the requested testing have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing for the F2 and F5 genes for all 
risk factors, signs, symptoms, diseases, or conditions, including cardiovascular risk assessment, are non-
covered except for pregnant patients. Based on this information, we decided that Medicare rules for coverage 
of F2 and F5 genetic testing services have not been met. Therefore, we decided that the Plan does not have to 
pre-approve F2 and F5 genetic testing services (81240, 81241).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the enrollee would benefit from a CGM. The Plan 
denied your request. The Plan says the criteria for this device are not 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. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily administrations. The records show the enrollee uses only one insulin injection at nighttime. Based on this information, we decided that Medicare rules for coverage of the CGM have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
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 medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital for a fall, gastrointestinal bleeding, and anemia. He is now medically stable with no complex nursing 
or rehabilitation needs. He does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While he has a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not 
a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine provided on January 18, 2022. 
 
You asked the Plan to pay for the shingles vaccine. You say that the doctor stated the shingles shot you 
received in 2009 was no longer in effect and prescribed another vaccine shot as a preventive measure. You say 
that the second shot was not covered at no cost and preventive medicine has always been covered. The Plan 
denied your request. The Plan says Medicare only covers the shingles vaccine under Medicare Part D. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the shingles 
vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine provided on January 
18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) to be provided at 
the in-network benefit level by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve MRI. You say that there are no other sites available for this testing to be 
done. The Plan denied your request. The Plan says the denial of authorization for in-network benefits for this 
testing is correct, because this provider is out-of-network with the Plan and this test can be performed by an in-
network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that enrollees may choose to receive care from out-of-network providers, but the share for covered 
services may be higher. 
 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 at the in-network benefit level. The enrollee may choose to receive 
service from this provider at the out-of-network benefit level. Therefore, we decided that the Plan does not 
have to pre-approve magnetic resonance imaging (MRI) to be provided at the in-network benefit level by an 
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the requested acute inpatient 
hospital care is medically necessary. The Plan denied your request. The Plan says the requested acute inpatient 
hospital care does not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
 
 
 
 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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for acute inpatient hospital care are met 
in this case. Our physician reviewer found the enrollee has no prior allergic reaction to the chemotherapy. The 
review has determined that the record did not show that at the time of inpatient admission the admitting 
physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
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 medically necessary. Our physician reviewer found you have a history of oxygen-
dependent chronic obstructive pulmonary disease (COPD), anxiety, depression, and high blood pressure and 
are living at home. You are 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 you have a need for physical and/or occupational therapy, there 
is no documentation of a need for an intensive rehabilitation program. 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pulmonary ventilation and perfusion imaging (78582). 
 
You asked the Plan to pre-approve pulmonary ventilation and perfusion imaging. You say that this is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve pulmonary ventilation and perfusion 
imaging. 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 documentation that the pulmonary ventilation 
and perfusion imaging at issue in this case meets Medicare criteria for medically reasonable and necessary. 
Provided records document that the enrollee had a computed tomography angiogram (CTA) of the chest in 
May 2022 that did not show a pulmonary embolus. CTA is the test of first choice in diagnosing pulmonary 
embolus. Provided records do not clarify what additional information the pulmonary ventilation and perfusion 
imaging would show that the CTA did not show or why a repeat CTA is contraindicated if there is ongoing 
concern for a pulmonary embolus.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of pulmonary ventilation and perfusion imaging have not been met. Therefore, we 
decided that the Plan does not have to pre-approve pulmonary ventilation and perfusion imaging (78582).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve limited bilateral noninvasive physiologic studies of 
upper or lower extremity arteries (CPT code 93922) and complete bilateral noninvasive physiologic studies of 
upper or lower extremity arteries (CPT code 93923). 
 
You asked the Plan to pre-approve the services. You say that your previous ultrasound was inconclusive and 
this provider wants to be present when the ultrasound is done in the provider's office. The Plan denied your 
request. The Plan says while this provider is contracted for other services, the provider you requested is not 
contracted to provide an upper/lower extremity arterial study. The Plan states they will approve this service 
with another radiology center. 
 
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 provider you requested is not contracted to provide an upper/lower extremity arterial study. Therefore, we 
decided that the Plan does not have to pre-approve limited bilateral noninvasive physiologic studies of upper or 
lower extremity arteries (CPT code 93922) and complete bilateral noninvasive physiologic studies of upper or 
lower extremity arteries (CPT code 93923).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of leadless pacemaker (33274). 
 
You asked the Plan to pre-approve insertion of leadless pacemaker. You say that this is medically necessary for 
the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been 
met for the requested device. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare covers leadless pacemakers when 
procedures are performed in Food and Drug Administration (FDA) approved studies. 
 
We looked at the file and Medicare rules. In this case, there is no evidence that the enrollee is currently 
participating in an FDA approved study. Based on this information, we decided that Medicare rules for 
coverage of insertion of leadless pacemaker have not been met. Therefore, we decided that the Plan does not 
have to pre-approve insertion of leadless pacemaker (33274).
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 is currently undergoing treatment at an ACH. He is not 
intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As 
LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the 
enrollee to the LTACH. He can remain at the current ACH until such time no acute services are required. The 
enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 
 
 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve evaluation and management services with a 
chiropractor. 
 
You asked the Plan to pre-approve the evaluation and management services with a chiropractor. You say that 
the records provided support the need for the requested chiropractic services. The Plan denied your request. 
The Plan says the requested services are not covered by Medicare or under this contract. 
 
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.  
 
The records show that the service at issue is not manual manipulation of the spine.  Therefore, we decided that 
the Plan does not have to pre-approve evaluation and management services with a chiropractor.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Vyvgart. 
 
You asked the Plan to pre-approve Vyvgart. You say that this is the least invasive treatment. The Plan denied 
your request. The Plan says that this is not medically necessary. 
 
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 Vyvgart. Our reviewer says that the 
requested use of Vyvgart is not supported. Our physician reviewer found the record indicates that the enrollee 
has a diagnosis of myasthenia gravis, anti-acetylcholine receptor (AChR) antibody positive.  The Food and 
Drug Administration has stated that the requested drug is indicated for the enrollee's condition. The requested 
service is recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vyvgart have been met. Therefore, we decided that the Plan has to pre-approve 
Vyvgart.  
 
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 vacuum erectile aid device kit. 
 
You asked the Plan to pre-approve a vacuum erectile aid device kit. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that vacuum erection devices are non-covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a vacuum erectile aid device kit have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a vacuum erectile aid device kit.