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

 
We decided that the Plan does not have to pre-approve radiofrequency ablation of the sacroiliac joint. 
 
You asked the Plan to pre-approve the requested services. You say that the procedure takes the pain away. The 
Plan denied your request. The Plan says the request is not supported by research. 
 
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 requested services. Our physician 
reviewer found that you have a history of sacroiliitis and sacrococcygeal disorder. Studies show that this 
procedure does not improve outcomes compared to standard treatment of sacroiliac joint pain. Radiofrequency 
ablation for denervation, whether performed using traditional, cooled, or pulsed radiofrequency, is considered 
investigational and therefore, not medically necessary. The review has determined that the requested SI joint 
RFA 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation of the sacroiliac joint.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging, tomographic (SPECT) 
(including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated 
technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or 
pharmacologic) and/or redistribution and/or rest reinjection (CPT code 78452).  
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says there is no indication that exercise cannot be performed. 
 
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 service. Our physician reviewer 
found there is no evidence provided that would support the need for radionuclide stress testing. In summary, 
there is insufficient documentation to support the medical necessity for the requested cardiac stress testing in 
this enrollees 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 the service the myocardial perfusion imaging, tomographic (SPECT) (including 
attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, 
additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) 
and/or redistribution and/or rest reinjection (CPT code 78452) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical ventricular restoration procedure, includes 
prosthetic patch, when performed (CPT code 33548). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says Medicare does not consider this procedure to be 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 service. 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 whether placement of a ventricular restorative procedure with prosthetic patch in this 
enrollee is medically necessary. An exhaustive review of the current medical literature pertaining to such 
procedures confirms multiple observational studies suggesting clinical benefit. However, there remain no randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such statistically rigorous 
studies are completed, this procedure remains investigational, and it is premature to presume clinical outcomes 
and benefit. At the current time, our physician reviewer would not consider the ventricular restorative 
procedure with prosthetic patch to be medically necessary in this enrollee. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve surgical ventricular restoration procedure, includes prosthetic patch, when performed (CPT 
code 33548).
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 were independent before and want to return to being 
independent. The Plan denied your request. The Plan says based on Medicare guidelines, the Inpatient 
Rehabilitation Facility (IRF) services requested 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 enrollee does not require the intensity of services provided at an IRF. Our 
physician reviewer also found that the enrollee is not shown to require 15 hours per week of rehabilitative 
services and regular physician evaluation. Our physician reviewer also found that the enrollee's 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 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 the IRF care is medically necessary. The Plan denied 
your request. The Plan says authorization denied because the IRF care is not medically necessary, and the 
enrollee's needs can be met at a lower level of care such as a skilled nursing facility (SNF). 
 
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's medical status does not require intensive physician and nursing oversight in an IRF. The enrollee's medical condition continues to require management on the acute care floor 
prior to transfer to a 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DPYD (dihydropyrimidine dehydrogenase) testing (81232) 
provided on December 30, 2021. 
 
You asked the Plan to pay for DPYD testing. You say that this service was reasonable and necessary. The Plan 
denied your request. The Plan says this service is unlikely to impact therapeutic decision-making in the clinical 
management of a patient and is denied as not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that certain codes are automatically denied as not 
medically necessary as they are unlikely to impact therapeutic decision making in the clinical management of a 
patient.  
 
We looked at the file and Medicare rules. Code 81232 is listed under the Group 3 Paragraph of Article A56199. 
This means that this service is considered automatically denied as not medically necessary. Therefore, we 
decided that the Plan does not have to pay for DPYD (dihydropyrimidine dehydrogenase) testing (81232) 
provided on December 30, 2021.
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 appealing, on behalf of the enrollee, the pre-
service denial of inpatient rehabilitation facility admission. The Plan denied your request. The Plan says 
admission to inpatient rehabilitation was denied as not meeting criteria, is not medically necessary, and a lower 
level of care might be appropriate. 
 
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 has a medical history of hypertension, coronary artery disease, atrial 
fibrillation, chronic kidney disease requiring hemodialysis, and prostate cancer requiring chemotherapy The 
enrollee was admitted to the hospital on September 6, 2022 for back pain and was attending physical therapy 
for a clavicular fracture. A computed tomography of the lumbar spine did not demonstrate a fracture. It did 
show degenerative changes with spinal stenosis. Prior to hospitalization, the enrollee was independent with 
daily activities and mobility. Physical therapy documentation dated September 15, 2022 indicated that the 
enrollee requires contact guard assistance to supervision when ambulating with a walker and performing 
transfers. The enrollee also requires supervision for grooming and dressing. 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the shoulder. 
 
You asked the Plan to pre-approve an MRI of the shoulder. You say that the services are necessary. The Plan 
denied your request. The Plan says that based on the documentation provided, coverage criteria has not been 
met. 
 
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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Medical records were requested and never received from the health plan. 
Without this information, the plan's denial is not able to be substantiated. Therefore, we decided that the Plan 
has to pre-approve a magnetic resonance imaging (MRI) of the shoulder.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of SNF care from August 29, 2022, 
forward. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee is making progress and has gained 
strength. The Plan denied your request. The Plan says the stay is not medically necessary based on SNF 
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 this enrollee does not meet severity of illness or intensity of service criteria for an 
inpatient basis in a SNF 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 continuation of SNF care from August 29, 2022, forward.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre 14-day sensor. You say that the services are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan must follow Medicare rules. 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. Based on this information, we decided that Medicare rules for coverage of a 
Freestyle Libre 14-day sensor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre 14-day sensor.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (88305) provided on December 28, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that payment for CPT code 88305 is not supported in the medical record. Specifically, code 88305 was 
billed with place of service code 22, and is assigned a PC/TC indicator of 1. As such, this code was not billed 
with an appropriate modifier for payment consideration. Based on this information, we decided that Medicare 
rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay 
for the services (88305) provided on December 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit and be safest 
at a long-term acute care hospital due to the medical complexity. The Plan denied your request. The Plan says 
rules for LTACH care have not been met. 
 
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 the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve a portable ventilator. You say that the requested ventilator is to be used for 
the treatment of COPD. The Plan denied your request. The Plan says the request for a home mechanical 
ventilator set in AVAPS mode with Auto-EPAP (AE) that could be delivered by 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 a portable ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found you have OSA, atrial fibrillation, 
previous CVA, and recent hospitalizations for pneumonia. Pulmonary function testing shows moderate to 
severe restrictive lung disease, without obstruction or bronchodilator response.  Imaging during hospitalizations 
show evidence of pulmonary vascular congestion and pleural effusions, consistent with HFpEF. There is no 
documentation of chronic CO2 retention on ABG as an outpatient while stable.  There is no documentation of 
COPD, thoracic restrictive disease, or neuromuscular disease. You do not have a diagnosis for which Medicare 
covers a home ventilator. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
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 requested LTACH admission is 
medically necessary. The Plan denied your request. The Plan says the requested LTACH admission is not 
medically necessary. 
 
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 admission is not medically necessary. Our physician reviewer found the enrollee 
appears to be still somewhat unstable and requires additional short-term acute care services that can safely be 
administered at the current facility until more stable for transfer to a lower level of care. The enrollee does not 
require services at the LTACH that are not already available at the current facility. There are no services at the 
LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to 
the LTACH is not medically necessary as the enrollee is not stable for transfer. Completion of treatment at the 
current facility is 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 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is medically necessary. 
 
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 at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. 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 LTACH services.