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

 
We decided that the Plan does not have to pre-approve a bilateral medial branch block. 
 
You asked the Plan to pre-approve a bilateral medial branch block. You say that a bilateral medial branch block 
is medically necessary. The Plan denied your request. The Plan says a bilateral medial branch block is not 
medically necessary. 
 
The Plan follows Medicare rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a bilateral medial branch block. Our 
reviewer says that a bilateral medial branch block is not medically necessary. Our physician reviewer found 
that in this case, the enrollee's MRI showed foraminal stenosis which may be contributing/causing the back 
pain and it is a contraindication for MBB. There also should be documentation of the failure of conservative 
measures prior to the procedure for at least 4-6 weeks. The review has determined that the requested facet joint 
injections are not medically reasonable or necessary according to the coverage criteria established in the above 
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 a bilateral medial branch block have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a bilateral medial branch block.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0100). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the enrollee relies on 
transportation services to take her to and from provider appointments. This is critical for her to maintain these 
services to keep her chronic medical conditions under control. The Plan denied your request. The Plan says the 
enrollee has used all the 100 allotted trips under the 2022 benefit for transportation and has zero one-way trips 
remaining, therefore, the transportation benefit has been exhausted. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 100 trips per year.  We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips (A0100).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that your provider has sent in the request for a prior 
authorization multiple times. The Plan denied your request. The Plan says medically necessary care is available 
in-network. 
 
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 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CxBladder Detect test (0012M) provided on March 15, 2022. 
 
You asked the Plan to pay for CxBladder testing. You say that this test was reasonable and necessary. The Plan 
denied your request. The Plan says this service is considered unproven and is not covered by Medicare. 
 
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 pay for CxBladder testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found CxBladder is not considered a screening test for urothelial cancer. Cystoscopy, ureteroscopy, 
possible biopsy and upper tract imaging will still be necessary regardless of the results of Cxbladder testing. 
Urinary biomarker tests such as CxBladder give significant false-negative results in patients with urothelial 
cancer and are subject to false-positive results in others. Accuracy is poor for low-stage and low-grade tumors. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CxBladder testing have not been met. Therefore, we decided that the Plan does 
not have to pay for CxBladder Detect test (0012M) provided on March 15, 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. You say that the enrollee requires the level of care provided by an 
IRF. The Plan denied your request. The Plan says criteria for IRF are not met. 
 
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 enrollee was admitted to an acute hospital after a fall sustaining multiple thoracic 
spine fractures. She was also found to have pneumonia and new onset atrial fibrillation. No acute rehab nursing 
needs identified or documented. At the current functional level, the enrollee does not need intensive therapies consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach in an 
IRF. While the enrollee may benefit from continued physical and occupational therapy, the enrollee's rehab 
needs can be safely provided in a lower intensity and alternate setting 
 
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. You say that this is medically necessary. The Plan denied your 
request. The Plan says the inpatient rehabilitation facility (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 that you are deconditioned from chronic illness and has a below-knee amputation. You are non-ambulatory at this time. You do not require intensive or complex rehabilitation services. You have 
routine wound care needs and need PT and OT support and direction as you regain your strength. You do not 
require frequent physiatry oversight, and you do not have complex needs. Your medical management is at an 
outpatient level. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair and wall rail. 
 
You asked the Plan to pre-approve a shower chair and wall rail. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested items are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature. Medicare rules also state that grab bars are not covered because they are not 
primarily medical in nature. 
 
While a shower chair and wall rail 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 shower chair and wall 
rail.
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 these services are medically necessary. The Plan 
denied your request. The Plan says the criteria for admission to an IRF are not met. The services you need can 
be provided in a less intensive setting. 
 
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 documentation provided does not support that the complexity of your nursing, medical and rehabilitation needs requires an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. The documentation does not support that you require at least three hours per day of therapy 
for five days per week, or fifteen hours over seven consecutive days of therapy services. The criteria in this 
case are not met. 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve unlimited round trips through the end of the year. 
 
You asked the Plan to pre-approve unlimited round trips. You say that the enrollee is in need of unlimited 
transportation due to seizure disorder, uncomplicated opioid dependence, and type 2 diabetes mellitus. The 
Plan denied your request. The Plan says the enrollee's benefit has been exhausted. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve unlimited round trips through the end of the year.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with single power 
option with power tilt seating system and other accessories. 
 
You asked the Plan to pre-approve the Group 3 single power option PWC. You say that you feel that the 
requested PWC is medically necessary. The Plan denied your request. The Plan says the specific type of PWC 
base does not meet criteria for coverage in this case. 
 
The Plan follows Medicare rules. Medicare rules say that a single power option PWC may be covered for 
enrollees who meet the criteria for a power tilt or power recline seating system.  
 
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 Group 3 single power option PWC. 
Our reviewer says that the criteria for the requested type of PWC are not met. Our physician reviewer found 
per the relevant LCD, the enrollee does not meet criteria for this PWC because she is not at high risk for skin breakdown and does not use intermittent catheterization. 
 
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 Group 3 single power option PWC have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with single power 
option with power tilt seating system and other accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dermatology consultation to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a dermatology visit. You say that the in-network dermatologists are 
scheduling over a year out or are over 50 miles away. You say you need an in-person visit and you are unable 
to pay out-of-pocket. The Plan denied your request. The Plan says your medical needs can be met in-network. 
The Plan also provided information for an in-network dermatologist who is accepting new patients. 
 
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 dermatology consultation to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve scooter ramp installation. 
 
You asked the Plan to pre-approve scooter ramp installation. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve scooter ramp installation.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a breast MRI (magnetic resonance imaging) (77049). 
 
You asked the Plan to pre-approve a breast MRI. You say that this is medically necessary. The Plan denied 
your request. The Plan says that this is not supported for the enrollee's situation. 
 
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 a breast MRI. Our reviewer says that 
the requested MRI is medically necessary. Our physician reviewer found the Food and Drug administration 
recommends an MRI at 3 years post-implant. The exam will also allow for evaluation of the suspicious area 
noted in the upper outer quadrant of the right breast. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a breast MRI have been met. Therefore, we decided that the Plan has to pre-
approve a breast MRI (magnetic resonance imaging) (77049).  
 
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 pneumatic compression device (PCD) and full leg 
sleeve from an out-of-network (OON) provider. 
 
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 available from network providers. 
 
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 pneumatic compression device (PCD) and full leg sleeve from an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ophthalmology visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve an ophthalmology visit. You say that you need cataract surgery, but you 
speak very limited English. You say you wish to see a doctor who speaks Vietnamese, and you are not 
comfortable seeing a provider who doesnt speak Vietnamese. The Plan denied your request. The Plan says 
there is a network provider available that can provide the requested service. 
 
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 
an ophthalmology visit to be provided 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 rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs intensive therapy for his 
condition. The Plan denied your request. The Plan says the criteria for IRF care are not met. 
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient's medical status does not require intensive physician and nursing oversight in an IRF. While the patient may 
benefit from additional multiple therapies, including physical and occupational therapy, the documentation 
does not reveal that the patient requires or can tolerate this therapy on an intensive IRF level. The 9/14/22 
therapy note indicated he tolerated under 20 seconds of standing with support. The patient's functional and 
medical needs can safely and effectively 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 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. You say that it is felt that IRF care is needed to allow the enrollee 
to regain strength. The Plan denied your request. The Plan says criteria for IRF care have not been met. 
 
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 enrollee was treated in the hospital for exacerbation of C. diff colitis. She is 
deconditioned but able to walk up to 160 feet with standby/contact guard assistance. She is walking at nearly a community level and is functioning with home care rehabilitation. She does not require intensive rehabilitation, 
and her care needs may reasonably 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 inpatient rehabilitation facility (IRF) admission and services.