Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a positron emission tomography (PET) with concurrently acquired 
computed tomography (CT) (78815). 
 
You asked the Plan to pre-approve a PET/CT scan. You say that this PET/CT scan is a medically necessity at 
this point. The Plan denied your request. The Plan says that the enrollee has had four PET Scans following their 
initial diagnosis of metastatic squamous cell carcinoma. The Plan also says that this requested service does not 
meet Medicare coverage guidelines. 
 
The Plan follows Medicare rules. Medicare rules say that coverage of more than three FDG PET scans is 
allowed to guide subsequent management of anti-tumor treatment strategy after completion of initial anti-
cancer therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a PET/CT scan. Our physician reviewer 
found this enrollee has an area of disease that is distinguishable only by PET scan. Our reviewer found that it is 
contiguous with other nonmalignant changes from prior radiation and the FDG avidity is evaluated to 
determine response. No other test would offer this distinction. Our physician reviewer also found that the 
requested service is reasonable and 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 PET/CT scan have been met. Therefore, we decided that the Plan has to pre-
approve a positron emission tomography (PET) with concurrently acquired computed tomography (CT) 
(78815).  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional miles for routine transportation beyond the 
Plan's 75-mile trip limit. 
 
You asked the Plan to pre-approve additional miles for routine transportation. You say that you need 
transportation to this oral surgeon. The Plan denied your request. The Plan says the requested trip exceeds the 
maximum number of miles covered under your transportation benefit. 
 
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 up to 75 miles of driving distance per one-way trip.   
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. Therefore, we decided that the 
Plan does not have to pre-approve additional miles for routine transportation beyond the Plan's 75-mile trip 
limit.
Appeal type: Practitioner Services
Decision: Favorable

You asked the Plan to pre-approve ESI. You say that the enrollee has already undergone lumbar surgery in the remote past. You say that the enrollee is not currently an appropriate candidate for further surgery. You also say that correspondence is sent to the enrollee's primary care provider routinely to update them on the enrollee's continued steroid injections. The Plan denied your request. The Plan says that the requested injection is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that that epidural steroid injection (ESI) will be considered medically reasonable and necessary when the three requirements 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 ESI. Our reviewer says that the requested ESI is medically necessary. Our physician reviewer found the provided documentation indicates that the enrollee has lumbar radiculopathy. The reviewer found that the enrollee has trialed NSAIDs. The reviewer found that the enrollee has had previous nerve blocks at L5. The reviewer also found that provided imaging indicates a prior fusion and a herniated disc. Therefore, the reviewer found that the requested ESI is 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 ESI have been met. Therefore, we decided that the Plan has to pre-approve epidural steroid injection (ESI) (64483).

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 inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that your family feels the rehab hospital will give 3 hours 
of therapy daily and acceleration of therapy would be better to help you become more independent. The Plan 
denied your request. The Plan says you do not meet the Medicare criteria for admission to an IRF. 
 
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 in this case, the complexity of your nursing, medical and rehabilitation needs do not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You 
do not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an 
intensive rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient 
rehabilitation facility. You continue to have a need for skilled therapy with ongoing safety concerns and a 
potential for functional improvement however, the documentation doesnt support that you would meet criteria 
for admission to an acute inpatient rehabilitation facility. There is no indication that you would require skilled 
rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a physician 
with at least 3 visits weekly to regain or maintain your functional status. You can receive further services at a 
lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is at risk for not regaining maximum 
function. The Plan denied your request. The Plan says the request is not medically necessary. 
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 80503 billed for date of service June 22, 
2022. 
 
You asked the Plan to pay for procedure code 80503. The Plan denied your request. The Plan says payment for 
code 80503 is bundled into payment for code 84165.  
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 80503 
is a column II code to column I code 84165. 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 80503 billed for date of service June 22, 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 that you would like to be more independent and need more one on one time. You say that you need more aggressive therapy to get stronger. The Plan denied your request. The Plan says an IRF admission is not medically necessary, and your needs can be met at an alternate 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 you do not require rehabilitation nursing or treatment by multiple therapies. Although you've had a functional decline from your baseline level of function and would benefit from occupational and physical therapy, you do not require the intensity of therapies provided in acute inpatient rehabilitation.

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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex device. 
 
You asked the Plan to pre-approve a Vertiflex device. 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 a Vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the vertilfex device is experimental. More research is needed. 
 
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 Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Vertiflex device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from inpatient 
rehabilitation services due to their medical complexity. The Plan denied your request. The Plan says IRF is not 
medically necessary, and the enrollee's needs can be met at a lower level of care such as skilled nursing facility 
(SNF), home health or outpatient therapy. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the cervical 
spine (72141). 
 
You asked the Plan to pre-approve an MRI of the cervical spine. The Plan denied your request. The Plan says 
the records do not include a detailed neurological examination nor any reports or references for an x-ray or 
prior imaging of the neck to support an MRI is needed. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 an MRI of the cervical spine. Our 
reviewer says that an MRI of the cervical spine is not reasonable and necessary for the enrollee. Our physician 
reviewer found the enrollee has a history of neck pain and left arm weakness which had resolved as of their last 
encounter on August 15, 2022. No cervical spine x-ray report is in the records.  Our reviewer found that the 
enrollee had a short course of steroids, but it seems that was tapered and no longer taken. The enrollee's 
neurological exam was cursory, and reflexes were not assessed. Our physician reviewer also found that no red 
flags were documented to provide an indication for an immediate MRI without first attempting a 6-week trial 
of conservative management including physical therapy. 
 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the cervical spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the cervical spine (72141).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not have clinical conditions that cannot 
be appropriately treated in the current hospital, and there are no issues for which LTACH may offer a 
therapeutic advantage. 
 
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 transfer to the LTACH is not medically necessary as the enrollee is not yet stable and 
as it would not be clinically advantageous. Completion of treatment at the current facility is 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the radiofrequency ablation, nerves innervating the 
sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography) (64625). 
 
You asked the Plan to pre-approve the radiofrequency procedure. You say that the medical records provided 
support the necessity of the services in dispute. The Plan denied your request. The Plan says this procedure is 
considered experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The clinical value and effectiveness of radiofrequency ablation to the 
SI joint in the setting of sacrococcygeal disorder have not been demonstrated in the peer reviewed literature. 
Sacral lateral nerve branch blocks and/or ablations to treat pain in the joint that connects the pelvis to the 
tailbone (sacroiliac joint) are not supported by research and not covered. Based on this information, we decided 
that Medicare rules for coverage of the radiofrequency procedure have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the radiofrequency ablation, nerves innervating the sacroiliac joint, 
with image guidance (ie, fluoroscopy or computed tomography) (64625).
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 rehab is needed for your recovery. The Plan denied 
your request. The Plan says criteria for admission to the IRF have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found your medical problems are stable and there are no complex nursing or rehabilitation 
needs. While you may benefit from physical and occupational therapy, your rehabilitation needs can be safely 
met in an alternate and low intensity 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 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 home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested home ventilator is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for a home 
ventilator. 
 
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 home ventilator. Our reviewer says 
that the enrollee does not meet criteria for a home ventilator. Our physician reviewer found the record indicates 
that the enrollee has chronic respiratory failure from chronic obstructive pulmonary disease. The record 
indicates that the enrollee was successfully treated with BiPAP and AVAPS. The provided primary source 
documentation does not contain sufficient detailed information in the medical record to justify the treatment selected. The enrollee could be treated with a BiPAP machine with AVAPS capability. The plan has indicated 
coverage for such a device is available upon request. The elements of the coverage criteria are not satisfied. 
The requested service cannot be 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Sanexas device and vitamin injections (97032, 96372, 
97112, 97016, J3411, J3415, J3420, and J1955). 
 
You asked the Plan to pre-approve a Sanexas device and vitamin injections. You say that there is no in-network 
provider for electrical stimulation treatment. The Plan denied your request. The Plan says the absence of a 
documented vitamin deficiency, there is no medically proven reason for the enrollee to receive these injections 
as part of pain management. 
 
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 Sanexas device and vitamin 
injections. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the documentation does not reveal evidence of a vitamin 
deficiency. The documentation does not reveal clear physical exam evidence of peripheral polyneuropathy on 
an objective exam. Our reviewer found that the documentation does not reveal objective electrodiagnostic 
studies revealing peripheral polyneuropathy or radiculopathy or entrapment/compression neuropathy causing 
the enrollee's symptoms. Our physician reviewer also found that the requested treatment is not the standard of 
care for the enrollee's condition.  
 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 Sanexas device and vitamin injections have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Sanexas device and vitamin injections (97032, 96372, 
97112, 97016, J3411, J3415, J3420, and J1955).