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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs an IRF admission. The Plan 
denied your request. The Plan says the enrollee does not require the intensity of services provided at an IRF 
and does not require full-time access to a doctor or rehabilitation nurse. The enrollee's needs can be met at 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 that the complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the member has not 
met the required coverage criteria to be admitted into the Inpatient Rehabilitation Facility. 
 
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 that the enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee does not require fifteen hours per week of rehabilitative services and regular 
physician evaluation. The enrollees care needs can be met at a lower level of 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 IRF admission and services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Eylea (J0178). 
 
You asked the Plan to pre-approve Eylea. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step therapy rules for the requested drug 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 Eylea. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of Avastin before they will approve the requested drug. The requested drug is a new 
start. The provided records do not indicate that the enrollee has tried and failed the Plan's preferred step-one 
alternative. The record does not indicate that the enrollee has a contraindication to, or would have an adverse 
effect from, the Plan's preferred step-one alternative. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Eylea (J0178).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (99221) provided on October 30, 2021. 
 
You asked the Plan to pay for initial hospital care. You say that the providers in these claims have different 
specialties, and therefore both hospital care services should be paid. The Plan denied your request. The Plan 
says this service was billed on the same date 99233 was billed for this enrollee at this facility. The providers in 
this case both have the same specialty, and the hospital care codes in this case are "per diem" services which 
may only be reported once per day by physicians of the same specialty from the same group practice. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Medicare rules say that both Initial Hospital Care (CPT codes 99221 - 99223) and Subsequent Hospital Care 
codes are "per diem" services and may be reported only once per day by the same physician or physicians of 
the same specialty from the same group practice. We find that CPT code 99221 is not supported in the medical record. Specifically, we were able to verify that 
both providers in this case have a primary taxonomy/specialty of 207RH0003X - Internal Medicine 
Hematology & Oncology, and they are part of the same group practice. Code 99233 was billed on the same 
date as 99221, with one service reported by each of these providers. Based on this information, we decided that 
Medicare rules for coverage of initial hospital care have not been met. Therefore, we decided that the Plan does 
not have to pay for initial hospital care (99221) provided on October 30, 2021.
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 fell and were on the floor for 4 days where your 
muscles atrophied and became extremely weak. You said you are in the hospital but not getting adequate 
therapy to get you mobile again. The Plan denied your request. The Plan says you are significantly 
deconditioned and would not be able to participate in 3 hours of therapy daily, 5x per week. A skilled nursing 
facility setting is more appropriate at this time. 
 
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 do not require the intensity of services provided at an IRF.  Specifically, you are 
not shown to require, or to be able to tolerate, fifteen hours per week of rehabilitative services and regular 
physician evaluation. 
 
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 special anesthesia service (99100) provided on July 13, 
2021. 
 
You asked the Plan to pay for the special anesthesia service (99100). You say that you are submitting the 
medical records and Waiver of Liability for reprocessing of the claim. The Plan denied your request. The Plan 
says procedure code 01214 has been overturned and procedure code 99100 remains denied as bundled services 
are not eligible for separate payment. 
 
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 99100 is anesthesia for patient of extreme age, younger 
than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure). 
  We find that CPT code 99100 is not supported in the medical record. Specifically, CPT code 99100 has a status 
indicator of B. This means that CPT code 99100 is considered bundled and not separately payable. Based on 
this information, we decided that Medicare rules for coverage of the special anesthesia service (99100) have 
not been met. Therefore, we decided that the Plan does not have to pay for the special anesthesia service 
(99100) provided on July 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drug provided in an outpatient setting 
on September 27, 2021. 
 
You asked the Plan to pay for the self-administered drug. You say that you should be reimbursed. The Plan 
denied your request. The Plan says the drug you received is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drug 
you received is not covered under Medicare Part B. 
 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drug 
provided in an outpatient setting on September 27, 2021.  
 
Benefits for the self-administered drug may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 7, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab 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 provided on September 7, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay the full cost for the eyeglass frames (V2020) purchased on June 11, 2021. 
 
You asked the Plan to pay the full cost for the frames. You say that you were told that these eyeglasses would 
be covered in full, and you specifically chose frames from the specified eyewear collection. The Plan denied 
your request. The Plan says that the frames purchased in this case are not part of the specified eyewear 
collection. If you choose frames that are not part of this collection, you have a $50 allowance to use toward the 
cost of the non-collection frames. The total cost of the frames you chose was $113. The Plan covered $50, and 
you were given an additional discount on the remaining cost, leaving you responsible for $50.40. 
 
The Plan must follow Medicare rules. The rules 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 Plans rules also state that one set of prescription lenses and one set of frames from a specified 
eyewear collection are covered every year. If you choose frames from outside the specified collection, you will 
receive a $50 allowance toward the cost of the frames, and you will be responsible for the remaining cost. 
 
 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 produced any documentation to show that the 
frames in question are not part of the specified collection, including any documentation that the Plan used to 
verify this statement when making payment. Therefore, we decided that the Plan has to pay the full cost for the 
eyeglass frames (V2020) purchased on June 11, 2021.  
 
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 the insertion of stabilization device (22869). 
 
You asked the Plan to pre-approve the insertion of stabilization device (22869). You say that the Vertiflex is a 
better procedure than the laminectomy. You say that the laminectomy is too dangerous, and your health will be 
affected. The Plan denied your request. The Plan says there are not enough studies on Vertiflex Superion to 
show it is safe and effective. 
 
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 insertion of stabilization device 
(22869). Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that current evidence based medical guideline and peer 
reviewed literature do not fully support the spinal decompression device procedure over the standard lumbar 
laminectomy. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception to guidelines. 
  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 insertion of stabilization device (22869) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the insertion of stabilization device (22869).
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 would like to return to being independent as 
quickly as possible. The Plan denied your request. The Plan says criteria for admission to the IRF setting have 
not been met. Your ongoing skilled therapy and nursing needs can be provided at 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 that the complexity of your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for 
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric visit (90791), provided on October 30, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychiatric visit. You say that the service should be covered. The Plan denied 
your request. The Plan says prior authorization must be obtained. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue.  We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that 
the Plan does not have to pay for the psychiatric visit (90791), provided on October 30, 2021, by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) 
joint. 
 
You asked the Plan to pre-approve RFA of the SI joint. You say that you are in extreme pain constantly and 
need this procedure. The Plan denied your request. The Plan says RFA of the SI joint for the treatment of SI 
joint mediated pain is 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 RFA of the SI joint. Our reviewer says 
that RFA of the SI joint is not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is insufficient literature to support the use of the requested service in your clinical 
situation.  The record as provided is insufficient to establish the medical necessity and reasonableness, as 
defined by Medicare rules, of the requested service.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of RFA of the SI joint have not been met. Therefore, we decided that the Plan does 
not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Radiologic examination (71045) provided on November 
7, 2021. 
 
You asked the Plan to pay for code 71045. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 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 71045 
is a column II code to column I code 77001. 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 the Radiologic examination (71045) provided on November 7, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of stabilization device (22869). 
 
You asked the Plan to pre-approve the insertion of stabilization device (22869). You say that the enrollee has 
suffered from this condition for many years and has failed several years of conservative approaches to 
treatment. You say that you recommend this minimally invasive procedure when conservative treatment has 
failed and as a safer alternative to a laminectomy or spinal fusion procedure. The Plan denied your request. The 
Plan says there are not enough studies on Vertiflex Superion to show it is safe and effective. 
 
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 insertion of stabilization device 
(22869).  Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that interspinous process devices are 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 insertion of stabilization device (22869) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the insertion of stabilization device (22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the electronic connection (E2311). 
 
You asked the Plan to pre-approve the electronic connection. You say that the item is medically necessary. The 
Plan denied your request. The Plan says the item is not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that items 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 electronic connection. Our reviewer 
says that the item is not medically necessary. Our physician reviewer found the patient's upper extremity 
strength and function with independence in eating support that the patient can control any power options 
through their own switches. 
 
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 electronic connection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the electronic connection (E2311).