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

 
We decided that the Plan does not have to pre-approve genicular radiofrequency ablation services. 
 
You asked the Plan to pre-approve genicular radiofrequency ablation services. You say that this procedure is 
medically necessary. The Plan denied your request. The Plan says the requested procedure is considered 
experimental and/or unproven. 
 
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 genicular radiofrequency ablation 
services. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee is a 70 year old man with chronic 
inflammatory demyelinating polyneuropathy with resultant pain in his legs and feet. This is an 
experimental/investigational procedure for leg and foot pain. The procedure 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 genicular radiofrequency ablation services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve genicular radiofrequency ablation services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
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 admission is not medically necessary. 
 
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 these services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital 
with a urinary tract infection and cirrhosis. She received oral medications and insulin and had stable vital signs. 
She received physical and occupational therapy in the hospital and needs varied assistance with activities of 
daily living. She has no skilled nursing needs. She has skilled therapy needs but does not require skilled 
therapy on a daily basis. As a practical matter, the enrollee does not require the necessary services on an 
inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic manipulative treatment. 
 
You asked the Plan to pre-approve chiropractic manipulative treatment. The Plan denied your request. The Plan 
says the enrollee has made little improvement and does not meet the coverage criteria. 
 
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 chiropractic manipulative treatment. 
Our reviewer says that the requested chiropractic manipulative treatment is not considered medically 
reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has 
subluxations. The record indicates that four additional treatments are requested but no record of previous 
treatments are provided. The record indicates that the enrollee's symptoms have not improved since the last 
visit. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare 
rules, of the requested service. The elements of the coverage criteria are not satisfied.  
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of chiropractic manipulative treatment have not been met. Therefore, we decided 
that the Plan does not have to pre-approve chiropractic manipulative treatment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (any type) used with a non-invasive 
interface (e.x mask/chest shell) (E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the item is not medically necessary. 
 
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 reviewer says 
that the service is not medically necessary. Our physician reviewer found there is no prior diagnosis of COPD 
and the patient improved on 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 (any type) used with a non-invasive interface (e.x mask/chest 
shell) (E0466).
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. The Plan denied your request. The Plan says the enrollee is unable 
to take part in 3 hours of therapy a day. 
 
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 physician reviewer found 
that the enrollee was admitted to the acute care hospital for a bladder injury, pelvic fracture, and fracture of 
thumb after a motor vehicle accident. Her medical problems are stable.  There is not a reasonable expectation that she will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. While she has a need for physical and 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Skilled Nursing Facility (SNF) care 
provided from January 1, 2022, to January 15, 2022. 
 
You asked the Plan to waive the copayment for SNF care. You say that the services should be covered as you 
disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly based 
on the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $188 
copayment for days 21-100 of Skilled nursing facility (SNF) care.  
 
 You have been asked to pay a $1,840 copayment for 10 days of SNF care, which is less than the standard 
$1,880 ($188 x 10 = $1,880). This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for Skilled Nursing Facility 
(SNF) care provided from January 1, 2022, to January 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vision care services (99214, 92004, 92250) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve OON vision care. You say that you trust this provider and need to be seen 
soon for your yearly check-up. The Plan denied your request. The Plan says out-of-network services are only 
covered in certain limited circumstances. The requested care is not urgent or emergent, and the services you 
need can be safely received from an in-network provider. 
 
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 
vision care services (99214, 92004, 92250) to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery 
(Current Procedural Terminology (CPT) code 22869). 
 
You asked the Plan to pre-approve the surgery. You say that the service is medically necessary. The Plan 
denied your request. The Plan says this service is considered experimental and investigational as it is not 
identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer-
reviewed medical literature published in the English language. 
 
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 surgery. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex superion device placement surgery (Current Procedural Terminology (CPT) 
code 22869).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve laser treatment of psoriasis (CPT code 96920). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says that your medical records do not indicate that you have failed to adequately respond to a 
minimum of three (3) continuous months of at least one topical preparation from three (3) different drug 
categories of aggressive topical therapies. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found excimer laser is standard of care for psoriasis. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve laser treatment of psoriasis (CPT code 96920).  
 
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 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 you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical 
and/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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 6, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on May 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis 5 mg tablet. 
 
You asked the Plan to pre-approve Eliquis. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical 
benefit. 
 
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 Eliquis 5 mg tablet.  
 Benefits for Eliquis 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Movantik. 
 
You asked the Plan to pre-approve Movantik. You say that the enrollee has been using this medication with 
great results. The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B 
benefit. 
 
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 Movantik.  
 
 Benefits for Movantik 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 appears to be unstable and requires additional acute care services that can 
safely be administered at the current facility until the patient is more stable for transfer. There are no services at 
the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer 
to LTACH will be considered not medically necessary based on recent notes as the patient is too unstable and 
as it would not be clinically advantageous. 
 
 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on April 7, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says only one code from this date range may be reported per date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 80307 is "Drug test(s), presumptive, any number of drug 
classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay 
[eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry 
either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service." 
 
We find that CPT code 80307 is not supported in the medical record. Specifically, this code was billed twice 
for this date of service, which is inappropriate billing. 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 drug testing services provided to the enrollee on April 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (CPT code(s): 64628 and 
64629). 
 
You asked the Plan to pre-approve the intracept procedure. You say that the only remaining option is an 
invasive surgical procedure, which would be less than ideal to try and solve your problem. You state you would 
like to avoid this invasive type of surgery. 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 there is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception to guidelines. Therefore, the requested intracept 
intraosseous nerve ablation at L3, L4, L5, and S1, 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 the intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the intracept procedure (CPT code(s): 64628 and 64629).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oral surgical splint (21085). 
 
You asked the Plan to pre-approve an oral surgical splint. You say that this device is medically necessary for 
treating the enrollee's condition. The Plan denied your request. The Plan says this device is not covered by 
Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that oral appliances generally are classified as dental 
devices and are not classified as durable medical equipment (DME). The following items (not all-inclusive) are 
considered to be dental devices and will be denied as non-covered, not DME: Oral occlusal appliances used to 
treat temporomandibular joint (TMJ) disorders. Based on this information, we decided that Medicare rules for 
coverage of an oral surgical splint have not been met. Therefore, we decided that the Plan does not have to pre-
approve an oral surgical splint (21085).