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

 
We decided that the Plan does not have to pre-approve lumbar radiofrequency ablation (RFA). 
 
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 RFA 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 the enrollee has low back pain due to 
lumbar facet arthropathy. He has only had one set of diagnostic medial branch blocks (MBBs) and has not 
undergone prior RFA at the same level. The criteria for coverage are not met and the services are 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 lumbar radiofrequency ablation (RFA).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the cervical 
spine (72141). 
 
You asked the Plan to pre-approve an MRI of the cervical spine. You say that you have been seeing a 
chiropractor for your neck pain who has been noticing some changes, and would like you to have an MRI of 
your neck. The Plan denied your request. The Plan says there is no indication of failure of conservative therapy, 
or that you are being considered for invasive therapy. The Plan also says that the notes indicate you had 
adjustments with a chiropractor and that you responded well. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of the cervical spine. Our 
reviewer says that the MRI is not medically reasonable and necessary. Our physician reviewer found there are 
notes of a single chiropractic adjustment on March 14, 2022, and a notation that you received physical therapy 
in the past, but no notes document this treatment. Our reviewer found that there is no neurological exam in the 
chart, and no x-ray report. Our physician reviewer also found that without these documents and evidence of 
prior treatment, the medical necessity for the requested MRI of the cervical spine has not been established. 
 
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 MRI of the cervical spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the cervical spine (72141).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (66984) provided on November 9, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service is not 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 66984 is not supported in the medical record. Specifically, the records show that this 
code was processed and paid by the Plan with modifier -54. As this code has already been paid with modifier -
54, the global procedure code is not separately payable. Based on this information, we decided that Medicare 
rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay 
for the services (66984) provided on November 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Athena Diagnostics Myotonic Syndrome Panel. 
 
You asked the Plan to pre-approve Athena Diagnostics Myotonic Syndrome Panel. You say that the services 
are necessary. The Plan denied your request. The Plan says medical necessity has not been established. 
Therefore, coverage criteria have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that molecular pathology procedures are 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 Athena Diagnostics Myotonic 
Syndrome Panel. Our reviewer says that the services are not medically necessary. Our physician reviewer 
found there is no documentation demonstrating how the results of the requested testing will directly impact 
treatment. The review has determined that the enrollee does not meet the coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Athena Diagnostics Myotonic Syndrome Panel have not been met. Therefore, 
we decided that the Plan does not have to pre-approve Athena Diagnostics Myotonic Syndrome Panel.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FANCC genetic testing rendered on November 30, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that FANCC genetic testing is non-covered. 
 
We looked at the file and Medicare rules. The testing at issue is FANCC genetic testing. Therefore, we decided 
that the Plan does not have to pay for the FANCC genetic testing rendered on November 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections. 
 
You asked the Plan to pre-approve epidural steroid injections. You say that the requested epidural steroid 
injections are medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for the requested epidural steroid injections. 
 
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 epidural steroid injections. Our 
reviewer says that the enrollee does not meet criteria for the requested epidural steroid injections (ESIs). Our 
physician reviewer found the documentation does not reveal that the enrollee has had at least 50% of sustained 
improvement in pain relief and/or improvement in function measured from baseline using the same scale for at 
least three months from prior injection. There is no evidence that the repeated epidural steroid injection will be 
performed using a different approach, level and/or medication with the rationale and medical necessity for the 
second epidural steroid injection (ESI) documented in the medical record.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural steroid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve epidural steroid injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction provided on January 26, 2022. 
 
You asked the Plan to pay for the refraction. You say that this was an eye exam to check for diabetes and the 
eye exam and refraction were covered last time. You say that you had no notice that this was not in your 
coverage. The Plan denied your request. The Plan says eye refractions are only covered if performed by a 
participating vision provider and performed as a routine screening.  Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan only covers this service during a routine exam with a participating vision care provider. 
 
We looked at the file and the Plan's rules. Specifically, the refraction was not performed with a routine eye 
exam. Based on this information, we decided that the Plan's rules for coverage of the refraction have not been 
met. Therefore, we decided that the Plan does not have to pay for the refraction provided on January 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says it is not necessary for 
you to be admitted into an Acute Rehabilitation Facility at this time. The Plan also says that the treatment you 
need can be provided in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer 
found that 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. Our 
physician reviewer also found that 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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the clinical 
documentation does not show that the enrollee's care cannot be provided at a lower level. 
 
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 complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer 
found that 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. Our 
physician reviewer also found that 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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the IRF services you 
are requesting do not meet the requirements for approval. 
 
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 complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer 
found that 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. Our 
physician reviewer also found that 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. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the requested Intracept procedure is 
considered experimental in nature, as more research is needed to show its efficacy. 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 an Intracept procedure.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that 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 
services are not medically necessary. Our physician reviewer found the enrollee did not require skilled therapy 
to establish a safe and effective maintenance program. As a practical matter, the enrollee did not require any 
skilled services on an inpatient basis, at a SNF level of care at the time of discharge from the hospital. 
 
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 skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says medical studies have not proven that this service is helpful for the treatment of the 
health problem. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this 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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept intraosseous basivertebral artery ablation. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this should be allowed to treat the 
enrollee's symptoms. The Plan denied your request. The Plan says this is an experimental treatment at this time. 
 
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 intraosseous basivertebral artery ablation.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occupational therapy services provided by an occupational 
therapy assistant on October 22, 2021. 
 
You asked the Plan to pay for occupational therapy services. You say that the medical records required to 
reprocess the denied claim are attached. The Plan denied your request. The Plan says the code is not 
appropriate for the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of an occupational therapy assistant 
(OTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, 
because they do not meet the qualifications of a therapist.  
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of occupational therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner, and not a licensed therapist. As such, OTA services cannot be paid incident to this provider's 
professional services. Therefore, we decided that the Plan does not have to pay for occupational therapy 
services provided by an occupational therapy assistant on October 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy (99183, G0277). 
 You asked the Plan to pre-approve hyperbaric oxygen therapy. You say that the enrollee's hearing is at risk for 
being lost if not treated with hyperbaric oxygen therapy. The Plan denied your request. The Plan says the 
requested HBO therapy does not meet requirements for approval. 
 
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 hyperbaric oxygen therapy. 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 the standard of care suggests a trial of oral and 
injected steroids. Oral steroids were tried and failed by the enrollee and plans for steroid perfusion were made 
but no report of its effect was provided to justify HBO therapy at this time. Also, there is insufficient high-
quality evidence for HBO in the setting of hearing loss. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hyperbaric oxygen therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve hyperbaric oxygen therapy (99183, G0277).