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. 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 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 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. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. 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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the removal of tissue from wounds
(97597) rendered from May 7, 2021, to May 14, 2021.
You asked the Plan to waive the copayments for the removal of tissue from wounds. You say that there was no
disclosure of an additional copayment of the facility. You also say that you feel the services were billed
incorrectly. The Plan denied your request. The Plan says you were charged the correct copayment amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50
copayment per visit for in-network, outpatient surgery.
You have been asked to pay a $50 copayment per visit, for the removal of tissue from wounds (97597), for a
total of $100 ($50 copayment x 2 surgical visits = $100). This means that you have been asked to pay the
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments
for the removal of tissue from wounds (97597) rendered from May 7, 2021, to May 14, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve paravertebral facet joint injections for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is a lack of documentation to allow coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found per the coverage criteria, a facet joint procedure is not considered reasonable and necessary after anterior 
cervical fusion. As this enrollee has undergone an anterior cervical fusion, performing a medial branch block is 
not reasonable or necessary. Additionally, there is no documentation provided indicating that the facet joint is 
the main source of pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve paravertebral facet joint injections for the enrollee.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the laboratory work by an out-of-network provider on May 19, 2021.
You asked the Plan to pay for the laboratory work. You say that you do not have access to the enrollee's information until the services are rendered. You say the enrollee was seen by an in-network physician with no control over the laboratory used and should not be penalized. The Plan denied your request. The Plan says that no prior authorization was obtained.
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 did not show if the referring physician was an out-of-network provider. This means we cannot determine if the Plan's denial of non-emergent service is supported. Therefore, we decided that the Plan has to pay for the laboratory work by an out-of-network provider on May 19, 2021.
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 pay for the ultrasound services represented by code 76705 provided 
on June 13, 2021. 
 
You asked the Plan to pay for code 76705. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered 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. In this case, we have confirmed that code 76705 
is a column II code to column I code 93976. 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 the ultrasound services represented by code 76705 provided on 
June 13, 2021.
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 admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.
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 there is no documentation provided necessitating admission to a LTACH. You are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available at the present setting where you are currently receiving care. There are no services available at the LTACH that you require that are not available at the health care setting being offered by the health plan.
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 wheelchair repairs (K0739) and replacement parts 
(E2370). 
 
You asked the Plan to pre-approve wheelchair repairs and replacement parts. You say that this is necessary for 
the enrollee's wheelchair to work. The Plan denied your request. The Plan says this is not supported by the 
records. 
 
The Plan must follow Medicare rules. Medicare rules say that repairs to equipment which a beneficiary owns 
are covered when necessary to make the equipment serviceable. The rules also say for Medicare to consider 
coverage and payment for any item or service, the information submitted by the supplier or provider must 
corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage 
criteria have been met.  
 
We looked at the file and Medicare rules. No documentation has been submitted to show the current condition 
of the enrollee's wheelchair. Based on this information, we decided that Medicare rules for coverage of 
wheelchair repairs and replacement parts have not been met. Therefore, we decided that the Plan does not have 
to pre-approve wheelchair repairs (K0739) and replacement parts (E2370).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cervical epidural steroid injection (62320). 
 
You asked the Plan to pre-approve a cervical epidural steroid injection. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the service is experimental. 
 
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 cervical epidural steroid injection. 
Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. 
Our physician reviewer found according to the coverage criteria, cervical epidural steroid injections without 
imaging guidance is considered experimental/ investigational, or unproven. 
 
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 cervical epidural steroid injection have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a cervical epidural steroid injection (62320).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additions to the prosthetic leg identified with codes 
L5828, L5845, L5848, L5856, L5981, L5850, L5925, and L5986. 
 
You asked the Plan to pre-approve additions to the prosthetic leg. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested items are not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that additions for prostheses are only covered for certain 
indications. 
 
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 additions to the prosthetic leg. Our 
reviewer says that the documentation does not support that the requested items are medically reasonable or 
necessary. Our physician reviewer found the documentation shows that you are a K3 ambulator. You have a 
demonstrated need for long distance ambulation at variable speeds and over uneven terrain. The Prosthetist 
notes identify that you use a cane when you have low back pain and a walker when your prosthesis is off. The 
documentation shows that the requested items appear to exceed your medical need. You are noted to use a cane 
at times and are noted as disabled which is not consistent with a K3 level of ambulation. Additionally, the 
physician documentation does not indicate that you require a microprocessor knee over a mechanical knee. The 
physician notes do not support that you require an advanced foot and ankle. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additions to the prosthetic leg have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additions to the prosthetic leg identified with codes L5828, L5845, L5848, 
L5856, L5981, L5850, L5925, and L5986.
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 IRF care is medically necessary and supported by the clinical documentation provided. The Plan denied your request. The Plan says the enrollee does not need to be seen by a rehabilitation doctor at least 3 times a week. The Plan says that the enrollee does not need an intensive team for her care. The Plan says that the enrollee can safely receive the services needed in another setting.
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. The enrollee has a history of dementia and depression and has recent vertigo, dizziness and falling spells. The enrollee's 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 documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. 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 non-sterile gloves (A4927).
You asked the Plan to pre-approve non-sterile gloves. You say that the requested item is a medical necessity for you. The Plan denied your request. The Plan says rules for coverage have not been met because the requested item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that DME is equipment which can withstand repeated use. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of non-sterile gloves have not been met. Specifically, the request is for an item that cannot withstand repeated use and therefore cannot be defined as DME. Therefore, we decided that the Plan does not have to pre-approve non-sterile gloves (A4927).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics (L3000, L2820). 
 
You asked the Plan to pre-approve foot orthotics. You say that the requested items are a medical necessity for 
you because you are in a lot of pain and cannot walk. The Plan denied your request. The Plan says these items 
are not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3000, L2820).
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 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 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. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. 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. 
 
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 Percutaneous Electrical Nerve Stimulation (PENS).
You asked the Plan to pre-approve PENS. You say that you feel the requested services are necessary. 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 PENS is non-covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PENS have not been met. Therefore, we decided that the Plan does not have to pre-approve Percutaneous Electrical Nerve Stimulation (PENS).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a ganglion impar block procedure.
You asked the Plan to pre-approve ganglion impar block. You say that nothing else is working for you. The Plan denied your request. The Plan says that the denial of authorization for this procedure is correct, because this is considered investigational and there is insufficient evidence in peer-reviewed literature that ganglion impar block for treatment of coccyx pain results in proven beneficial outcomes.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve ganglion impar block. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found a ganglion impar block is the standard of care for coccyxodynia.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ganglion impar block have been met. Therefore, we decided that the Plan has to pre-approve a ganglion impar block procedure.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orthovisc. 
 
You asked the Plan to pre-approve Orthovisc. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 Orthovisc. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found you have osteoarthritis 
of the right hip. You have been treated with medical therapy and physical therapy. The literature states that 
intra-articular injections of sodium hyaluronate are unproven and not medically necessary for treating any other 
indication due to insufficient evidence of efficacy including but not limited to the following:  Hip osteoarthritis, 
temporomandibular joint osteoarthritis, and temporomandibular joint disc displacement. The documentation 
does not support that the Orthovisc is safe and effective for you. Therefore, you do not meet criteria for the 
requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Orthovisc.