Persius/hicric huggingface dataset:
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 meets IRF criteria and is reasonably 
expected to participate in and benefit from 15 hours of therapy a week. You say the enrollee requires daily 
physician oversight to actively manage medical conditions and comorbidities to optimize recovery and avoid 
rehospitalization during intensive rehab. 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 the complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee continues to have a need for skilled therapy with ongoing safety concerns and a potential for functional 
improvement however, the documentation doesnt support that they meet criteria for admission to an acute 
inpatient rehabilitation facility. The enrollee 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intradialytic parenteral nutrition. 
 You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the etiology for the malnourishment is not due to a clinical malabsorptive state. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the documentation does not support that the enrollee has a permanent impairment with 
absorption of nutrients in the alimentary tract. The requested parental nutrition is not considered 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve intradialytic parenteral nutrition.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cala Trio. 
 
You asked the Plan to pre-approve Cala Trio. 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 where electric nerve stimulation is employed to treat 
motor function disorders, no reimbursement may be made for the stimulator or for the services related to its 
implantation since this treatment cannot be considered reasonable and 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 Cala Trio. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the medical records provided 
there is no documentation that the enrollee meets the coverage criteria detailed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Cala Trio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Cala Trio.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Opdivo. 
 
You asked the Plan to pre-approve Opdivo. You say that this drug is for the enrollee's condition. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
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 Opdivo. Our reviewer says that the 
enrollee does not meet criteria for Opdivo. Our physician reviewer found Opdivo is not Food & Drug 
Administration (FDA) approved for the enrollee's diagnosis. This drug is not supported by one of the major 
drug compendia or by clinical research appearing in a Medicare-approved medical journal. Whether there is a 
benefit for checkpoint inhibitor immunotherapy in patients undergoing perioperative chemotherapy alone is 
uncertain and under investigation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to 
pre-approve use of Opdivo.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crutch substitute (E0118). 
 
You asked the Plan to pre-approve a crutch substitute. You say that you need this walker so you can get 
around. The Plan denied your request. The Plan says a crutch substitute does not meet the program's 
requirements for Medicare Part B coverage. 
 
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 crutch substitute. Our reviewer says 
that a crutch substitute is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested device has not been shown to be superior to other standard treatments for the 
medical condition. Our reviewer also found that the studies do not indicate the requested device improves an 
individuals function or general health. 
 
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 crutch substitute have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a crutch substitute (E0118).
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 will need an LTACH setting 
to assist with wound care, continued antibiotics, pain medication, physical therapy, and occupational therapy. 
You say you have tried 12 skilled nursing facilities that all report they are unable to meet the enrollee's needs. 
The Plan denied your request. The Plan says the request for admission to an LTACH is being denied as 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 care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The 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 LTACH services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 95886 and 95887 billed for date of service April 6, 
2022. 
 
You asked the Plan to pay for procedure codes 95886 and 95887. You say that procedure codes 95886 and 
95887 carry no bundling conflicts or additional coding requirements. You say that these codes are recognized 
as separate distinct services and need to be processed for separate reimbursement. The Plan denied your 
request. The Plan says that procedure codes 95886 and 95887 were not billed with an acceptable primary 
procedure code. 
 
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 looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure codes 95886 and 95887 have been met. Specifically, the claim was billed with 
procedure code 95909. In this case, we have confirmed that procedure code 95909 is an appropriate primary 
procedure code for 95886 and 95887. The Plan has not provided supporting documentation that procedure code 
95909 was not eligible for payment. Therefore, we decided that the Plan has to pay for procedure codes 95886 
and 95887 billed for date of service April 6, 2022.  
 
  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: 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 is stable for transfer from 
the short-term acute care hospital and is in need of specialized recovery services. You say that neither skilled 
nursing nor an extended stay is a sustainable solution for this enrollee. The Plan denied your request. The Plan 
says criteria for admission to the LTACH 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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The 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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) 
joint with image guidance (64625). 
 
You asked the Plan to pre-approve the RFA. You say that this service is medically necessary to treat the 
enrollee's medical condition. 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 the RFA. Our reviewer says that the 
requested RFA is not considered medically reasonable and necessary in this case. Our physician reviewer 
found RFA of the SI joint innervation has not been found to have consistent efficacy. Therefore, the reviewer 
found that the requested RFA is not medically reasonable and 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 RFA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint with image guidance (64625).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
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 step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Aranesp.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that the enrollee did not tolerate BiPAP therapy. The 
Plan denied your request. The Plan says a ventilator is not covered by Medicare for this purpose. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide continuous or 
bilevel positive airway pressure (CPAP or BiPAP) therapy, regardless of the underlying medical condition, 
shall not be covered.  
 
We looked at the file and Medicare rules. A ventilator is not covered by Medicare for this purpose. Based on 
this information, we decided that Medicare rules for coverage of ventilator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve use of a ventilator.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve an inpatient level of care for lumbar surgery. 
 
You asked the Plan to pre-approve inpatient services. The Plan denied your request. The Plan says that the 
enrollee does not have complicated medical conditions. 
 
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that 
CMS designates to be inpatient-only services. These services have an OPPS status indicator of C in the 
OPPS Addendum B and are listed together in Addendum E of each years OPPS/ASC final rule.  
 
The file shows that an elective lumbar laminectomy was approved by the Plan. The service at issue in this 
appeal includes current procedural terminology (CPT) code 22850. This code is listed with a status indicator of 
C on Addendum B of the 2023 OPPS/ASC final rule. This means the service has been designated as 
inpatient only, and therefore must be part of an inpatient admission. Therefore, we decided that the Plan has 
to pre-approve an inpatient level of care for lumbar surgery.  
 
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: 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 LTACH can render services that will 
improve the enrollee's condition and avoid unnecessary hospital readmissions. The Plan denied your request. 
The Plan says based on Medicare guidelines, the LTACH services requested do not meet the requirements for 
approval. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. 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 Plan. The requested 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 
the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stab phlebectomies (37765, 37766). 
 
You asked the Plan to pre-approve the stab phlebectomies. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that treatments for symptomatic varicose tributaries are 
either compressive sclerotherapy or microphlebectomy. The treatments of the tributary veins will be considered 
medically necessary if saphenous reflux is not present or already successfully eliminated, the veins are greater 
than 4 mm in diameter and if the patient remains symptomatic after a six-week trial of conservative therapy. 
 
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 stab phlebectomies. Our reviewer 
says that these procedures are not medically necessary. Our physician reviewer found the last office visit 
records describe the patients symptoms as some heaviness and soreness but nothing severe. For stab 
phlebectomy to be considered medically necessary, there needs to be persistent significant symptoms despite 
conservative treatment. 
 
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 stab phlebectomies have not been met. Therefore, we decided that the Plan 
does not have to pre-approve stab phlebectomies (37765, 37766).
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
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 complexity of the enrollee's 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. The enrollee has routine post-acute needs and does not require 
frequent physiatry oversight. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF admission is 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 your functional status is at an outpatient level for rehabilitation. The IRF is 
excluded from functioning as a medical step-down unit per Medicare guidelines. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.