Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron 8MG tablet. 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says this medication is not used with chemotherapy drugs and does not 
meet Medicare rules for anti-nausea medications. 
 
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 pre-approve Ondansetron 8MG tablet.  
 
Benefits for the medication 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: 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. You say that you had a fall, and your doctor has requested you go 
to an inpatient rehab to resume your quality of life. The Plan denied your request. The Plan says the request is 
not medically necessary., The services you need can be provided safely in other settings, for example, a skilled 
nursing 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 your medical problems are stable and there are no complex nursing or rehabilitation 
needs. There is no documented need for intensive rehabilitation services and medically necessary care can be 
provided in a different 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: 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. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require, or to be able to tolerate, 15 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for an inpatient readmission starting on January 29, 2023. 
 
You asked the Plan to pay for an inpatient readmission. You say that the readmission is medically necessary. 
The Plan denied your request. The Plan says that this admission is related to a prior inpatient stay and occurred 
less than 15 days after the prior admission discharge. 
 
The Plan follows Medicare Rules. Medicare rules say that inpatient readmission is covered when medically 
necessary, and if the readmission did not result from a premature discharge from the same hospital. 
 
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 an inpatient readmission. Our reviewer says 
that the service is medically necessary. Our physician reviewer found that the review has determined that the 
readmission was medically necessary and was not the result from a premature discharge from the same 
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 an inpatient readmission have been met. Therefore, we decided that the Plan has 
to pay for an inpatient readmission starting on January 29, 2023.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency ambulance transportation (A0428). 
 
You asked the Plan to pre-approve non-emergency ambulance transportation. You say that the enrollee is 
unable to move on their own due to musculoskeletal and cardiovascular issues, and requires assistance. The 
Plan denied your request. The Plan says this request is not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same 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 non-emergency ambulance 
transportation. Our reviewer says that transportation by ambulance to and from hemodialysis is not medically 
necessary. Our physician reviewer found the enrollee is not shown to be bedbound. The enrollee is not shown 
to require the expertise of trained personnel or the equipment available only on an ambulance in order to 
effectuate a safe transport. Our reviewer also found that transportation can be provided by other means 
(stretcher van, wheelchair van, private car, taxi) without endangering the enrollees 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 non-emergency ambulance transportation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve non-emergency ambulance transportation (A0428).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
March 4, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service March 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a diagnostic facet block injection (64490). 
 
You asked the Plan to pre-approve a diagnostic facet block injection. 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 follows Medicare rules. Medicare rules say that Facet Joint Interventions are considered medically 
reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet specific criteria. 
 
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 diagnostic facet block injection. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found here, there are other 
probable pain generators that have not been addressed. Therefore, the request is deemed, at this time, medically 
unreasonable and not 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 a diagnostic facet block injection have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a diagnostic facet block injection (64490).
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. You say that you are medically ready for discharge but cannot 
return home until you receive physical rehabilitation. You say you live alone and need a physician to monitor 
you at least three times a week for evaluation of functional and medical progress. The Plan denied your request. 
The Plan says based on Medicare guidelines, 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 your nursing, medical and rehabilitation needs do not require 
an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You continue to 
have a need for skilled therapy with ongoing safety concerns and a potential for functional improvement 
however, the documentation doesnt support that you would meet criteria for admission to an acute inpatient 
rehabilitation facility. You can receive further services 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (CPT code 64628). 
 
You asked the Plan to pre-approve the intracept procedure. You say that the service is medically necessary. The 
Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered by 
Medicare due to insufficient evidence of efficacy. 
 
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. 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 
procedure (CPT code 64628).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a single photon emission computed tomography 
(SPECT) test (78452). 
 
You asked the Plan to pre-approve a SPECT test. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the requested service is 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 a SPECT test. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee had a negative stress test in 2018 and has had no cardiac symptoms. There is no 
documentation that the electrocardiogram shows an uninterpretable pattern or that the enrollee is unable to 
exercise. There is no evidence provided that would support the need for radionuclide stress testing at this time. 
 
   
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 SPECT test have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a single photon emission computed tomography (SPECT) test (78452).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device 
(E0601) and humidifier (E0562). 
 
You asked the Plan to pre-approve a CPAP device and humidifier. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the member already has these devices. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee has a CPAP device with humidifier. These items serve the same purpose as the 
requested. Therefore, we decided that the Plan does not have to pre-approve a continuous positive airway 
pressure (CPAP) device (E0601) and humidifier (E0562).
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. You say that the enrollee would benefit from inpatient 
rehabilitation services due to their medical complexity. The Plan denied your request. The Plan says the records 
do not show that the enrollee will be able to tolerate the intensity of services provided in the IRF setting. The 
services the enrollee needs can be provided safely in other settings, for example, a skilled nursing 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 there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has pneumonia, a feeding 
tube and cannot walk alone. The Plan denied your request. The Plan says the enrollee is receiving appropriate 
in-patient acute care and is currently unstable for transfer to a 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 in this case the documentation does not support that the enrollee has need for 
complex medical treatment in a LTACH. The enrollee does not require services at the LTACH that are not 
available at the acute care hospital or the skilled nursing facility. The enrollee has improved medically and can 
receive further care at the current acute care hospital or a lower level of care when deemed appropriate. 
 
 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 the LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment billed for date of service 
August 20, 2022. 
 
You asked the Plan to pay for the billed services. You say that the supplies are shipped before they are due. The 
Plan denied your request. The Plan says the date of service does not match the shipping date. The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
We looked at the file and the rules. The date of service on the claim submitted is inconsistent with the date of 
delivery documented. Based on this information, we decided that the Medicare rules for coverage have not 
been met. Therefore, we decided that the Plan does not have to pay for the durable medical equipment billed 
for date of service August 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a follow-up appointment and special testing with a 
tertiary ophthalmologist (92285, 68840, 68810, 99215). 
 You asked the Plan to pre-approve the physician service. You say that the enrollee's vision is getting worse. 
You also say that they have been seeing doctors at this facility for years. The Plan denied your request. The 
Plan says the services can be provided in network. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 physician service. Our reviewer 
says that services to be rendered by a tertiary provider is not medically necessary. Our physician reviewer 
found there are in-network providers available in a timely fashion. The reviewer found that the enrollee's 
condition does not require a tertiary provider. Therefore, the reviewer found that services at a tertiary facility 
are not 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 the physician service have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a follow-up appointment and special testing with a tertiary ophthalmologist 
(92285, 68840, 68810, 99215).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat medial branch block (MBB). 
 
You asked the Plan to pre-approve a repeat MBB. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says the requested service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that after the first diagnostic facet joint procedure, there 
must be a consistent positive response of at least 80% relief of primary (index) pain (with the duration of relief 
being consistent with the agent used). 
 
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 repeat MBB. Our reviewer says that a 
repeat MBB is not medically necessary. Our physician reviewer found the provided documentation does not 
support that 80% pain relief was achieved with the previous MBB. Therefore, the reviewer found that a repeat 
MBB is not 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 a repeat MBB have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat medial branch block (MBB).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the SNF admission is medically necessary, and you 
wish to use your benefits for therapy services. The Plan denied your request. The Plan says the SNF admission 
you are requesting is not medically necessary, reasonable and appropriate for your condition. 
 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. You do not require 
daily skilled nursing or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. You do 
not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 
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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.