Persius/hicric huggingface dataset:
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's records 
do no show the need for a doctor trained in rehabilitation, medically necessary care may be provided safely in 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 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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary for the enrollee as they 
live alone and have not made any progress with current treatment. The Plan denied your request. The Plan says 
while the enrollee will likely benefit from ongoing therapy to enhance their rehabilitation potential, there is no 
evidence that this cannot safely be done 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 the member is a 78-year-old female with a medical history including osteoarthritis of 
the hip with a hip replacement in March 2023 with subsequent dislocation that required a total hip arthroplasty 
revision. She was admitted to a skilled nursing facility from 3/23/23 to 04/07/23 for skilled rehab. She now 
resides in the nursing facility at a custodial level of care. The most recent therapy notes indicate that the 
member is able to ambulate household distances using a walker and without hands on assistance. 
 
In this case, the complexity of the members nursing, medical and rehabilitation needs do not require an acute 
rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The member does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, at an 
intensive rehabilitation therapy 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal surgery (22514). 
 
You asked the Plan to pre-approve the spinal surgery. You say that this procedure is medically necessary. The 
Plan denied your request. The Plan says coverage rules have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Percutaneous Vertebral Augmentation (PVA) is 
covered when there is an Acute or subacute osteoporotic Vertebral Compression Fracture (T1  L5) based on 
symptom onset, and documented by recent advanced imaging. 
 
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 spinal surgery. Our reviewer says 
that this procedure is not medically necessary. Our physician reviewer found the records show that the injury 
occurred in November 2022. This is no longer an acute fracture. Records do not fully document a trial of 
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 spinal surgery have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a spinal surgery (22514).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Volara System for oscillation and lung expansion 
(E1399). 
 
You asked the Plan to pre-approve a Volara System. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the Volara system is not a traditional high frequency chest wall oscillation 
device. The system is not shown to be safe and beneficial in the outpatient setting. 
 
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 Volara System. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee has chronic obstructive pulmonary disease with 
bronchiectasis. There is insufficient literature to support the safety and efficacy, as defined by Medicare rules, 
of the requested service. 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 a Volara System have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Volara System for oscillation and lung expansion (E1399).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp (J0881). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary for the 
enrollee's treatment for anemia due to chemotherapy. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred step therapy drugs Retacrit or Procrit. The Plan states there is no 
indication the preferred drug(s) would likely be: less effective, and/or cause adverse effects for the enrollee. 
 
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 the medication. Our physician reviewer 
found the Plan requires the enrollee must have had a poor response to Retacrit or Procrit therapy for at least 
two consecutive months even with appropriate dose adjustment, before they will approve the requested drug. In 
this case, the enrollee has not tried and failed the required drug(s). There is no documentation provided 
indicating that the Plans required drug(s) would likely be less effective and/or likely have adverse effects for 
the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Aranesp (J0881).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. You say that bi-level therapy has been considered and 
ruled to be ineffective in correcting the enrollee's ventilatory issues. You say that the enrollee requires 
nocturnal and daytime volume ventilation to decrease the risk of respiratory failure. You say that it is 
imperative that the enrollee is placed on the non-invasive ventilator to prevent future hospitalizations. The Plan 
denied your request. The Plan says the home mechanical ventilator is not covered because it would be set in 
average volume-assured pressure support (AVAPS) mode with Auto- expiratory positive airway pressure 
(EPAP) which could be delivered by bi-level positive airway pressure (BiPAP). 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a portable ventilator. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found a home ventilator is not 
medically necessary.  This enrollee has COPD of moderate severity.  There is no arterial blood gas (ABG) done 
while stable to document chronic carbon dioxide (CO2) retention.  If the enrollee does have chronic CO2 
retention, they may benefit from BiPAP with AVAPS during sleep as an outpatient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lightweight wheelchair (K0003). 
 
You asked the Plan to pre-approve a lightweight wheelchair. You say that the enrollee would benefit from the 
requested wheelchair. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
approval. 
 
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 lightweight wheelchair. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was noted to be able to ambulate but be unsteady. Clinical progress notes 
dated January 17, 2023, indicated that the enrollee was evaluated for edema. She was recently hospitalized with 
a hip fracture requiring arthroplasty. The enrollee was noted to have lower extremity edema. A face-to-face 
mobility evaluation performed on February 16, 2023, indicated the enrollee has difficulty walking and the 
treatment plan included a standard manual wheelchair. The enrollee has a history of stroke and weakness and 
recently suffered a hip fracture requiring hip arthroplasty. She cannot functionally ambulate with a cane or 
walker and is it risk for falling. She requires a manual wheelchair for mobility in performing daily activities. 
However, the mobility evaluation indicates that the enrollee can use a standard manual wheelchair for mobility 
and performing activities of daily living. Her home is accessible for a standard manual wheelchair. It is unclear 
why she requires a lightweight manual wheelchair. Therefore, the lightweight manual wheelchair is not 
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 a lightweight wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a lightweight wheelchair (K0003).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to request reconsideration 
of the denied authorization. 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 July 19, 2019. Therefore, 
we decided that the Plan does not have to pre-approve the dental services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a flex-walk system (L5981) and axial rotation unit 
(L5986) for a lower limb prosthesis.  
You asked the Plan to pre-approve lower limb prosthetic foot. You say that the best prosthetic foot for the 
enrollee is a level 3 prosthetic foot. The Plan denied your request. The Plan says the records do not show why 
level 3 components are needed. 
 
The Plan follows Medicare rules. Medicare rules state that coverage for lower limb prosthetic components is 
based on an assessment of the enrollees functional level. 
 
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 lower limb prosthetic foot. Our 
reviewer says that the enrollee does not meet criteria for the requested prosthetic components. Our physician 
reviewer found the enrollee has a below-knee amputation and a partial foot amputation of the contralateral side. 
There is no documentation supporting that the enrollee is able to ambulate at a K3 functional level. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lower limb prosthetic foot have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a flex-walk system (L5981) and axial rotation unit (L5986) for a lower limb 
prosthesis.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve two levels of MMB. We decided that the Plan does not have to 
pre-approve one level of MBB.  
 
You asked the Plan to pre-approve three levels of diagnostic medial branch blocks (MMB). You say that the 
service is medically necessary. The Plan says that the service is not medically necessary. 
 
We decided that the Plan has to pre-approve two levels of MMB.  
 
The Plan follows Medicare rules. Medicare rules say that diagnostic medial branch blocks are covered when 
the criteria listed in the Medicare Rules section 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 three levels of diagnostic medial branch 
blocks (MMB). Our reviewer says that the request exceeds utilization criteria in that only two levels bilaterally 
may be performed at one session.  Two levels are clearly 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 two levels of diagnostic medial branch blocks (MMB) have been met. 
Therefore, we decided that the Plan has to pre-approve two levels of MMB.  
 
We also decided that the Plan does not have to pre-approve one level of MBB. 
 
The Plan follows Medicare rules. Medicare 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 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of one level of MBB have not been met. Specifically, one to two levels, either 
unilateral or bilateral, are allowed per session per spine region.  Therefore, we decided that the Plan does not 
have to pre-approve one level of MBB. 
 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 portable oxygen concentrator. 
 
You asked the Plan to pre-approve these services. You say that the portable tank was suggested in case you 
need it while not at home. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a portable oxygen concentrator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 billed for date of service September 
15, 2022.  
You asked the Plan to pay for procedure code 99284. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 99284 is bundled into payment for code 99285. 
 
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, we have confirmed that code 99284 
is a column II code to column I code 99285. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99284 billed for date of service September 15, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (G0299, Q5001) provided on 
September 11, 2022 to October 10, 2022. 
 
You asked the Plan to pay for the home health services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes G0299, & Q5001 are not supported in the medical record. Specifically, the claim did 
not include a valid Federal Information Processing 
Standards (FIPS) State and County Code. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to 
pay for home health services (G0299, Q5001) provided on September 11, 2022 to October 10, 2022.
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 does not 
meet all the requirements, medically necessary care may be provided safely in 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 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. 
 
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 a power wheelchair and accessories (K0861, E0955, 
E0956, E0973, E0978, E1007, E1012, E1028, E2311, E2313, E2340, E2343, E2361, E2377, E2609, E2617, 
K0040). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the enrollee needs the 
requested wheelchair due to multiple sclerosis, paraplegia, diabetes mellitus, dysphagia, and recurrent 
pneumonia. The Plan denied your request. The Plan says Medicare only covers DME for use in the home. The 
request was denied as where the enrollee resides is not considered home. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a power wheelchair and accessories is being requested for use in a SNF or hospital. 
Therefore, we decided that the Plan does not have to pre-approve a power wheelchair and accessories (K0861, 
E0955, E0956, E0973, E0978, E1007, E1012, E1028, E2311, E2313, E2340, E2343, E2361, E2377, E2609, 
E2617, K0040).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87798, 87496, 87486, 87498) provided on 
September 2, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were billed for a single panel. Based on 
this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (87798, 87496, 87486, 87498) provided on 
September 2, 2022.