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

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the nerves innervating 
the sacroiliac (SI) joint. 
 
You asked the Plan to pre-approve RFA of the nerves innervating the SI joint. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve RFA of the nerves innervating the SI 
joint. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is insufficient literature demonstrating the safety and 
efficacy of the requested service for the enrollee's clinical condition. 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. The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of RFA of the nerves innervating the SI joint have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the nerves innervating the 
sacroiliac (SI) joint.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CNBP (CCHC-type zinc finger nucleic acid binding 
protein) (eg, myotonic dystrophy type 2) gene analysis, evaluation to detect abnormal (eg, expanded) alleles. 
 
You asked the Plan to pre-approve CNBP (CCHC-type zinc finger nucleic acid binding protein) (eg, myotonic 
dystrophy type 2) gene analysis, evaluation to detect abnormal (eg, expanded) alleles. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the requested services are not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that specific gene analyses are covered. Any gene 
analysis not listed is not covered.  
 
We looked at the file and Medicare rules. The requested CNBP gene analysis is not listed as a covered test. 
Based on this information, we decided that Medicare rules for coverage of CNBP (CCHC-type zinc finger 
nucleic acid binding protein) (eg, myotonic dystrophy type 2) gene analysis, evaluation to detect abnormal (eg, expanded) alleles have not been met. Therefore, we decided that the Plan does not have to pre-approve CNBP 
(CCHC-type zinc finger nucleic acid binding protein) (eg, myotonic dystrophy type 2) gene analysis, 
evaluation to detect abnormal (eg, expanded) alleles.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. 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 Botox is covered for certain conditions. 
 
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 Botox. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee does not have any FDA-
approved indication or off-label use listed in the coverage rules to support Botox use. Overactive bladder has 
insufficient high-quality evidence to support general use of Botox for this condition and it is not FDA approved 
for this indication. Therefore, the coverage criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the intermittent urinary catheter coded A4351 provided on April 18, 
2022, to July 18, 2022. 
 
You asked the Plan to pay for the intermittent urinary catheter. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says that This charge is incidental to another service. The member does 
not owe this amount. 
 
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. Review of the file shows that the Plan is denying these items because this charge 
is incidental to another service. The documentation submitted did not include explanation of what service it is 
incidental to and why it is not separately payable. No Medicare rules were provided to support this denial. 
Therefore, we decided that the Plan has to pay for the intermittent urinary catheter coded A4351 provided on 
April 18, 2022, to July 18, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve unlisted procedure, neck or thorax identified with code 
21899 to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the unlisted neck or thorax procedure. You say that you are having heart 
problems due to your thyroid 
not functioning properly and it needs to be removed as soon as possible. The Plan denied your request. The 
Plan says the requested services can be provided by a 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 
unlisted procedure, neck or thorax identified with code 21899 to be provided by an out-of-network (OON) 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an immediate upper denture (D5130), and an immediate 
lower denture (D5140). 
 
You asked the Plan to pre-approve the dental services. You say that you need replacement dentures because the 
ones you have do not fit properly. The Plan denied your request. The Plan says your benefit for the requested 
item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 13, 2022. 
Therefore, we decided that the Plan does not have to pre-approve an immediate upper denture (D5130), and an 
immediate lower denture (D5140).
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 LTACH is medically necessary. The 
Plan denied your request. The Plan says the LTACH is not medically necessary, and the enrollee's needs can be 
met at a lower level of care such as a skilled nursing facility. 
 
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 was admitted with aortic valve endocarditis. The record indicates that the 
enrollee is improving but still requires acute care services before transitioning to a lower level of care. The 
enrollee continues to receive acute care services, and these have not been denied.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an irrigation tray with bulb or piston syringe (A4320). 
 
You asked the Plan to pre-approve an irrigation tray. You say that you would like coverage for the supplies to 
be considered to see if emergency room visits can be prevented. The Plan denied your request. The Plan says 
this request is clearly for routine intermittent irrigation. 
 
The Plan must follow Medicare rules. Medicare rules say that when syringes, trays, sterile saline, or water are 
used for routine irrigation, they will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Specifically, the record shows that this request is for coverage of 
catheter irrigation supplies that are used on a routine basis of three times per week. Based on this information, 
we decided that Medicare rules for coverage of an irrigation tray have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an irrigation tray with bulb or piston syringe (A4320).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation. 
 
You asked the Plan to pre-approve additional mileage for routine transportation. You say that you need to get 
to your appointment. The Plan denied your request. The Plan says your benefit only allows 32 one-way trips 
with each one-way trip not exceeding 75 miles of driving distance. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when the driving distance for a one-way trip is within 75 miles.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, the provider is 
located 83.9 miles away from your residence. The Plan only covers distances up to 75 miles. Therefore, we 
decided that the Plan does not have to pre-approve additional mileage for routine transportation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve revision of Gastric Sleeve to Roux-en-Y Gastric 
Bypass. 
 You asked the Plan to pre-approve revision of Gastric Sleeve to Roux-en-Y Gastric Bypass. 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 repeat bariatric surgery is generally not 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 revision of Gastric Sleeve to Roux-en-
Y Gastric Bypass. Our reviewer says that the services are not medically necessary. Our physician reviewer 
found the record indicates that you have previously had bariatric surgery but has been unsuccessful in 
achieving weight loss. The record provided indicates dietary indiscretion and lack of exercise. The record 
provided is insufficient to establish that the clinical circumstances demonstrate reasonability and necessity for 
the requested procedure. The elements of the coverage criteria are not satisfied. The requested service is not 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of revision of Gastric Sleeve to Roux-en-Y Gastric Bypass have not been met. 
Therefore, we decided that the Plan does not have to pre-approve revision of Gastric Sleeve to Roux-en-Y 
Gastric Bypass.
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 you are unable to move around independently 
without assistance. The Plan denied your request. The Plan says the IRF care is not medically necessary, and 
your needs can be met at a lower level of care such as 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 the enrollee was admitted for ataxia and dysarthria. Your medical problems are stable, and there are no complex nursing or rehabilitation needs. You do not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the medical record supports a need for physical and/or occupational therapy, there is no 
documented need for intensive rehabilitation services. 
 
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 pre-approve a sacroiliac (SI) joint injection. 
 
You asked the Plan to pre-approve a sacroiliac joint injection. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a sacroiliac joint injection. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has a history of traumatic sacroiliitis. The enrollee had a 
minimally invasive right sacroiliac joint fusion performed one year ago with good result. The enrollee was 
evaluated on February 7, 2023, with one month history of left-sided sacroiliitis, described as throbbing and 
worse with lifting. The physical examination indicated pain with provocative maneuvers of the left sacroiliac 
joint. Diagnostic imaging indicated a stable fusion of the right sacroiliac joint and the titanium implants. The 
enrollee has been treated with medications, physical therapy, home exercises, ice/heat, and activity 
modification. The enrollee underwent a right sacroiliac joint injection on February 22, 2023. There is no 
documentation on physical examination of tenderness of the SI joint and no mention of SI provocative testing being completed with positive findings. The clinical value and effectiveness of an SI joint injection in the 
absence of tenderness and negative provocative testing results have not been demonstrated in the peer-reviewed 
literature. In addition, the submitted documentation indicates that there is suspicion for left sided sacroiliitis 
and a right sacroiliac joint injection has been requested. Therefore, the enrollee does not meet criteria for the 
requested services. 
 
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 sacroiliac joint injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a sacroiliac (SI) joint injection.
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 
September 30, 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 September 30, 2022.
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 admission to an IRF is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for 
admission to an IRF. The enrollee's needs can be met at a lower level of care. 
 
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 acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you can get the proper care from an IRF. You say 
that you need to go to rehab to build your endurance because you are weak and live alone with no assistance. 
The Plan denied your request. The Plan says an IRF admission is not medically necessary, and you can get the 
services you need in other settings. 
 
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 you cannot tolerate intensive rehabilitation and do not require frequent physician 
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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair lift. 
 
You asked the Plan to pre-approve a stair lift. You say that the enrollee is a fall risk. You also say that this is 
medically necessary. The Plan denied your request. The Plan says the requested stair lift is not covered by 
Medicare or the Plan. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair lift.
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 enrollee requires care at a SNF for daily physical 
and occupational therapy. You say that the enrollee requires pain management. The Plan denied your request. 
The Plan says a SNF admission is not medically necessary, and the enrollee's needs can be met in other 
settings. 
 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 that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on 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 SNF care.