Persius/hicric huggingface dataset:
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 you are requesting reconsideration for the denial of 
a continued SNF stay. The Plan denied your request. The Plan says the request for extended skilled services in 
a SNF does not meet Medicare criteria. 
 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 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. Transition to part 
time therapy services now appears to be appropriate. You do not require daily skilled nursing and/or skilled 
therapy on an inpatient basis in a skilled nursing facility (SNF) setting. The records support that services in the 
home or an assisted living facility with home health care or in a long-term care facility on a part time basis are 
appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: 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 enrollee has multiple on-going 
medical issues that require daily physician involvement and treatment. The Plan denied your request. The Plan 
says the member is receiving appropriate inpatient acute care and does not require transfer to LTACH. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. The health 
plan has approved ongoing care in the current acute care 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spine surgery (22558, 22585, 22853, 20930). 
 
You asked the Plan to pre-approve spine surgery. 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 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 spine surgery. 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 compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the requested 2-stage surgery with stage 1 being 
lateral lumbar L2-3, L3-4, and L4-5 discectomies and interbody arthrodesis and stage 2- posterior thoracic T10-
pelvis instrumentation and arthrodesis, in this case, is not medically reasonable or 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 spine surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve spine surgery (22558, 22585, 22853, 20930).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve block of the genicular nerves and Cooled 
radiofrequency ablation (RFA) of the nerves. 
 
You asked the Plan to pre-approve the genicular nerve blocks and the Cooled RFA services. You say that the 
records provided support the request for the services in dispute. The Plan denied your request. The Plan says 
the requested 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 the genicular nerve blocks and the 
Cooled RFA services. Our reviewer says that the requested services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found this is considered an experimental therapy and it is the 
subject of ongoing clinical trials. 
 
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 genicular nerve blocks and the Cooled RFA services have not been met. Therefore, we decided that the Plan does not have to pre-approve block of the genicular nerves and Cooled 
radiofrequency ablation (RFA) of the nerves.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological examination services, including a barium 
swallow study, provided on August 23, 2022. 
 
You asked the Plan to pay for radiologic services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says the services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that procedure requiring the administration of a substance 
to the enrollee are not covered under the portable x-ray benefit.  
 
We looked at the file and Medicare rules. We find that the radiological services provided included a swallow 
study, which requires a substance to be administered to the enrollee. As such, this cannot be covered under the 
portable x-ray benefit. Based on this information, we find that the Medicare rules for the radiological services 
provided have not been met. Therefore, we decided that the Plan does not have to pay for radiological 
examination services, including a barium swallow study, provided on August 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuroplasty from an out-of-network 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 neuroplasty from an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endoskeletal ankle foot system, microprocessor-
controlled feature, dorsiflexion and/or plantar flexion control, includes power source (L5973). 
 
You asked the Plan to pre-approve the K3 microprocessor foot. You say that the enrollee is in need of a new 
foot due to the current prosthesis being 5 years old and the foot is failing. The Plan denied your request. The 
Plan says the K3 microprocessor foot does not meet Medicare criteria as reasonable and 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 the K3 microprocessor foot. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the nurse practitioner progress notes do not clearly indicate why the 
enrollee requires a microprocessor foot over a mechanical foot. The request exceeds the enrollee's medical 
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 K3 microprocessor foot have not been met. Therefore, we decided that the 
Plan does not have to pre-approve endoskeletal ankle foot system, microprocessor-controlled feature, 
dorsiflexion and/or plantar flexion control, includes power source (L5973).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says criteria for admission to the IRF 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 complexity of the enrollees nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical therapy and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. 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 an IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Perjeta. 
 
You asked the Plan to pre-approve Perjeta. You say that Perjeta is medically necessary. The Plan denied your 
request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Perjeta. Our reviewer says that Perjeta 
is not medically necessary. Our physician reviewer found the use of this drug is not supported by one of the 
major drug compendia or by clinical research for the enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Perjeta have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Perjeta.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an insertion of new or replacement of permanent 
pacemaker with transvenous electrode(s); atrial and ventricular (33208). 
 
You asked the Plan to pre-approve a cardiac implantable device. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the device is not medically necessary at this time. The records do not 
indicate the enrollee has had symptoms such as fainting spells due to a slow heartbeat. 
 
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 a cardiac implantable device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found at issue is the medical appropriateness and necessity of implantation of a 
prophylactic pacemaker in this enrollee whose provider anticipates symptomatic bradycardia following planned 
cardioversion. Symptomatic bradycardia has not been documented.  As such, the evidence provided would not 
meet criteria for a pacemaker implant. In summary, there is insufficient documentation to support the medical 
necessity for the requested cardiac pacemaker in this enrollee's clinical management. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a cardiac implantable device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an insertion of new or replacement of permanent pacemaker with 
transvenous electrode(s); atrial and ventricular (33208).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is necessary. The Plan 
denied your request. The Plan says the request for a home mechanical ventilator set in average volume-assured 
pressure support (AVAPS) mode with Auto-expiratory positive airway pressure (EPAP) (AE) that could be 
delivered by bilevel positive airway pressure (BiPAP) is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our physician 
reviewer found there is no arterial blood gas (ABG), done while stable, to document chronic carbon dioxide 
(CO2) retention. If this enrollee does have chronic CO2 retention, may benefit from BiPAP with AVAPS 
during sleep. There is no documentation that this has been tried and failed as an outpatient.  Medicare does not 
cover a home ventilator when used at settings that can be provided with BiPAP.  
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) 
sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre 2 CGM sensor. You say that you have diabetes and are 
requesting the sensor because your fingers and hands are full of arthritis, and you take insulin weekly. You 
need a better way to test your sugar and you already have the reader. The Plan denied your request. The Plan 
says a CGM is not covered under Medicare if you are not on three or more daily injections of insulin. 
 
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 injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre 2 CGM sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre 2 continuous glucose monitor (CGM) sensor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested IRF services are medically necessary. 
The Plan denied your request. The Plan says criteria for admission to the IRF setting 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 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. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you may have a need for physical therapy and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. 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 an IRF admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 77066, 76642, and G0279 billed for date of 
service October 13, 2022. 
 
You asked the Plan to pay for procedure codes 77066, 76642, and G0279. You say that the claim was billed 
correctly and should be paid. The Plan denied your request. The Plan says the number of units billed exceeds 
the maximum allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 77066, 76642, and G0279 is 1. The MAI value for this code is 2. You 
billed 2 units of this code, exceeding the MUE. Specifically, you billed one line item of codes 77066 and 76642 
with the LT modifier and one line item of this code with the RT modifier instead of billing one line item with 
the bilateral modifier as is required. G0279 was also billed with an incorrect modifier. Based on this 
information, we decided that Medicare rules for coverage of procedure codes 77066, 76642, and G0279 have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 77066, 76642, and 
G0279 billed for date of service October 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that the device is medically necessary. The Plan 
denied your request. The Plan says the enrollee must have a congenital or acquired neuromuscular interfering 
with respiration. Medicare recognizes the presence of the genetic condition of cystic fibrosis as an indication 
for high frequency chest wall oscillation systems. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
 
 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 HFCWOD. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the record indicates that the enrollee has 
chronic obstructive pulmonary disease in the setting of lung cancer. The record does not indicate the presence 
of bronchiectasis. The enrollee does not have an enumerated condition for which coverage is available under 
the rules. The elements of the coverage criteria are not satisfied. The requested service is not 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 a HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).