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

 
We decided that the Plan does not have to pre-approve the injections (CPT code(s): 64636 and 64635). 
 
You asked the Plan to pre-approve the injections. You say that the services are necessary. The Plan denied your 
request. The Plan says the enrollee has had two medial branch blocks with apparently good results. The Plan 
states the enrollee's doctor wants to proceed with a radiofrequency ablation; however, the Plan cannot approve 
this request as the enrollee's doctor wants to treat three levels of your spine. The Plan states Medicare policy 
only allows two spinal segments to be treated at one time. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the injections have not been met. The request for more injections is 
not covered. The rules say that one to two levels, either unilateral or bilateral, are allowed per session per spine 
region. The need for a three or four-level procedure bilaterally may be considered under unique circumstances 
and with sufficient documentation of medical necessity on appeal. Therefore, we decided that the Plan does not 
have to pre-approve the injections (CPT code(s): 64636 and 64635).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
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 the enrollee has knee osteoarthritis. She 
has not tried and failed the Plan's required drugs, Orthovisc or Supartz FX. The records do not show that the 
required drugs would be contraindicated or less effective; therefore, Euflexxa is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Euflexxa.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that it is medically necessary due to 
the enrollee's unilateral primary osteoarthritis, right hip. The Plan denied your request. The Plan says the 
surgical procedure is approved. The surgery codes given has not been or is no longer on the Medicare Inpatient 
Only List. The documentation pre-operatively does not meet the threshold for an intensity of services or 
underlying enrollee hemodynamic instability that could only be managed in an acute inpatient setting. If the 
enrollee undergoes the procedure and intra or post-operatively requires care that meets an inpatient level of 
services, then the plan would approve inpatient care as an observation conversion. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient hospital care is met in this 
case. Our physician reviewer found inpatient care is necessary when the enrollees signs and symptoms and 
general medical condition can only be managed safely in an acute inpatient setting, when the enrollee requires 
diagnostic studies in an inpatient setting, or if it is medically necessary for the enrollee to remain in the acute 
inpatient setting. There must be a reasonable expectation that the enrollees care will need to span 2 or more 
midnights. Additionally, an enrollee would require inpatient admission if a surgery/procedure that is to be 
provided is on the Medicare inpatient only list or if the care includes new onset mechanical ventilation. In 
this case, the enrollee is planned for a surgical procedure that is elective and not on the "inpatient only" list. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the services (G0463) provided on October 20, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that this code is not 
payable. 
 
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. The Plan argues that this code has a status indicator "X" under the Physician 
Feed Schedule and is not payable. However, this is a payable code under OPPS, and therefore is payable in this 
case. The Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the services 
(G0463) provided on October 20, 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: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to waive the cost share for the eye exam. We decided that the Plan does not have 
to waive the cost share for the fundus photography.  
 
You asked the Plan to waive the cost share for the eye exam and the fundus photography provided on 
September 14, 2022.. You say that these services have been covered in previous years. The Plan says that this 
cost sharing was charged correctly. 
 
We decided that the Plan has to reduce the cost share for the eye exam.  
 
The record shows the claim was billed with current procedural terminology (CPT) code 92014 which is a 
medical eye exam. The Plan says that you must pay $59.56 for the ophthalmological service. Bases on the plan 
contract, however, you cannot be asked to pay more than a $35 copayment for the eye exam. Therefore, we 
decided that the Plan has to reduce the cost share for the eye exam.  
 
We also decided that the Plan does not have to waive the cost share for the fundus photography. 
 
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 50% 
coinsurance for the fundus photography. You have been asked to pay $17.44, which is 50% of the allowed 
amount for the fundus photography. The allowed amount is $34.87. ($34.87 x 50% = $17.44). Therefore, we 
decided that the Plan does not have to waive the cost share for the fundus photography. 
 
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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the services provided from July 20, 2022, to July 23, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that a timely decision 
was not made. 
 
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. The Plan has not provided a valid denial rationale. Without a valid rationale, the 
Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the services provided 
from July 20, 2022, to July 23, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a voice blood glucose kit with device from a non-
preferred provider. 
 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 services are available from the preferred providers. 
 
The Plan must follow Medicare rules. Medicare rules say that Plans may limit enrollees to preferred providers 
for durable medical equipment and supplies.  
 
We looked at the file and Medicare rules. The requested items are from a non-preferred provider. The services 
are available from one of the Plans preferred providers. 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 voice blood glucose kit with device from a non-preferred provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to reimburse you for the intralesional injection (11900), and triamcinolone 
acetonide (J3301) provided from April 13, 2022, to July 14, 2022. 
 
You asked the Plan to reimburse you for the injections. You say that you started going bald. You say that you 
were diagnosed with Alopecia. You say that you began receiving scalp injections to help with your hair loss. 
You also say that this was not cosmetic in nature. The Plan denied your request. The Plan says that the services 
in this case are not medically necessary. 
 
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 reimburse you for the injections. Our reviewer says 
that the injections were considered medically reasonable and necessary in this case. Our physician reviewer 
found the injections you received were considered the standard of care for your condition. Therefore, the 
reviewer found that the injections were 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 injections have been met. Therefore, we decided that the Plan has to 
reimburse you for the intralesional injection (11900), and triamcinolone acetonide (J3301) provided from April 
13, 2022, to July 14, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study. 
 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 services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a sleep study is covered when specific criteria are 
met. 
 
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 the enrollee has an established 
diagnosis of obstructive sleep apnea (OSA) and has been reportedly using a continuous positive airway 
pressure (CPAP) device for years. He reports awakenings and daytime sleepiness, but the Epworth sleepiness 
score is normal.  There is no device download to assess compliance and effectiveness of the CPAP.  There is no 
substantial weight change, or other illnesses that would require an attended sleep study. The diagnosis is not in 
question, and there are no suspicions for parasomnias or other sleep disorders. The sleep study is not reasonable 
or medically necessary based on the submitted records. 
 
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 sleep study.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hallux rigidus correction with cheilectomy, debridement 
and capsular release of the first metatarsophalangeal (MTP) joint; with implant as evidenced by partial or total 
replacement of the first MTP joint using synthetic cartilage. 
 
You asked the Plan to pre-approve the requested surgery. You say that the requested hallux rigidus correction 
with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint; with implant as 
evidenced by partial or total replacement of the first MTP joint using synthetic cartilage is medically necessary. 
The Plan denied your request. The Plan says the requested hallux rigidus correction with cheilectomy, 
debridement and capsular release of the first metatarsophalangeal joint; with implant as evidenced by partial or 
total replacement of the first MTP joint using synthetic cartilage 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 surgery. Our reviewer says that the 
requested hallux rigidus correction with cheilectomy, debridement and capsular release of the first 
metatarsophalangeal joint; with implant as evidenced by partial or total replacement of the first MTP joint using synthetic cartilage is not medically necessary. Our physician reviewer found this procedure is 
experimental at this time. More research is needed to show safety and efficacy of synthetic cartilage partial 
joint replacement of the MTP joint. 
 
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 surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve hallux rigidus correction with cheilectomy, debridement and capsular release of 
the first metatarsophalangeal (MTP) joint; with implant as evidenced by partial or total replacement of the first 
MTP joint using synthetic cartilage.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
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 the enrollee received oral medications and had stable vital signs. There are no 
identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee 
does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of 
illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
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 enrollee was admitted for pneumonia and respiratory failure. Medical problems 
are stable. There are no complex nursing or rehabilitation needs. The enrollee does 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. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: 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 failed home trials with bilevel positive 
airway pressure (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 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: 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 enrollee needs to continue with aggressive IRF 
care. The Plan denied your request. The Plan says the enrollee's medical and therapy needs can be met at a less 
intensive 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 that the complexity of the enrollees nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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.