Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
array, epidural (63650), fluoroscopic guidance and localization of needle or catheter tip for spine or 
paraspinous diagnostic or therapeutic injection procedures (77003) and an implantable neurostimulator 
electrode (L8680). 
 
You asked the Plan to pre-approve 2 additional lumbar spinal cord stimulator wire placements. You say that it 
is medically necessary for the enrollee's lower back pain. The Plan denied your request. The Plan says the 
enrollee is allowed two spinal cord stimulator wires for each area of his body. 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 looked at the file and Medicare rules. The records show that the enrollee has two spinal cord stimulators 
already in place. Medicare rules say two temporary spinal cord stimulator trials are approved per anatomic 
spinal region. Based on this information, we decided that Medicare rules for coverage of 2 additional lumbar 
spinal cord stimulator wire placements have not been met. Therefore, we decided that the Plan does not have to 
pre-approve percutaneous implantation of neurostimulator electrode array, epidural (63650), fluoroscopic 
guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection 
procedures (77003) and an implantable neurostimulator electrode (L8680).
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 an LTACH level of care can prevent 
multiple re-admissions and help manage THE enrollee's ongoing medical complications. You say that the 
enrollee continues to suffer from ongoing medical complications and needs close physician monitoring which 
cannot be managed at a lower level of care. The Plan denied your request. The Plan says an LTACH admission 
is not medically necessary, the enrollee's needs can be met in their current setting. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. The health plan has approved ongoing care in the 
current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee was independent before their hospital 
course. You say the enrollee meets full medical and functional criteria to qualify for an IRF stay, and this level 
of care would ensure maximal gains following discharge from the short-term acute care hospital. The Plan 
denied your request. The Plan says the enrollee does 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 the complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While 
the enrollee may benefit from physical and occupational therapy, the enrollee's rehab needs can be provided in 
a lower intensity and alternate 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an insertion or replacement of permanent cardiac 
contractility modulation system, including contractility evaluation when performed, and programming of 
sensing and therapeutic parameters; pulse generator with transvenous electrodes (0408T). 
 
You asked the Plan to pre-approve an Optimizer Smart device. You say that the enrollee's medical condition 
may benefit from this procedure. The Plan denied your request. The Plan says the requested procedure 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 an Optimizer Smart device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found an exhaustive review of the current medical literature pertaining to the 
CCM system confirms multiple observational studies suggesting clinical benefit from CCM. Several 
randomized clinical trials of CCM versus control have also been reported, along with meta-analysis pooling the 
data from multiple studies, with CCM providing meaningful improvement in quality-of-life scores and 
objective functional capacity. While the clinical studies led to FDA approval in 2019, CCM remains the subject 
of multiple studies examining long-term efficacy, as well as randomized, controlled, double-blinded trials to 
quantify clinical efficacy. Until such statistically rigorous studies are completed, it is premature to presume 
clinical outcomes and benefit. At the current time, the CCM system is not medically necessary for this 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 an Optimizer Smart device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an insertion or replacement of permanent cardiac contractility modulation 
system, including contractility evaluation when performed, and programming of sensing and therapeutic 
parameters; pulse generator with transvenous electrodes (0408T).
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 you were admitted for knee arthroplasty. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex interspinous stabilization device. 
 
You asked the Plan to pre-approve the requested services. You say that the Vertiflex offers a new method of 
pain relief. The Plan denied your request. The Plan says unproven procedures are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that the Vertiflex device is experimental. More research is needed to show its safety and 
efficacy. Therefore, the request 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Vertiflex interspinous stabilization device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electroencephalograms (EEG) (95720) provided from 
June 19, 2022, to June 23, 2022. 
 
You asked the Plan to pay for the services. You say that this was ordered due to seizures. The Plan denied your 
request. The Plan says charges for or in connection with services or supplies that are determined by the Plan to 
be considered experimental or investigational are excluded from 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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee had sepsis and mental status changes. A standard EEG was not performed. The review 
has determined that the services at issue in this case were not medically reasonable or 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the electroencephalograms (EEG) (95720) provided from June 19, 2022, to June 23, 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 IRF care is medically necessary. The Plan denied 
your request. The Plan says that the 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 that that the enrollee does not have complex nursing or rehabilitation needs. 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 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia Inj 60mg/ml. 
 
You asked the Plan to pre-approve a prescription drug. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the request of Prolia for age-related osteoporosis without current 
pathological fracture falls under part D, and is not covered under part B. This Plan does not manage the 
pharmacy benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Prolia Inj 60mg/ml.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy evaluation provided on July 29, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the physical therapy evaluation. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says prior authorization was not 
obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the physical therapy evaluation provided on July 
29, 2021, by an out-of-network (OON) provider.
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 the LTACH admission is medically 
necessary. The Plan denied your request. The Plan says criteria for admission to the LTACH have not been 
met. 
 
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 that the enrollee appears to be improving on current treatment and should only 
require short-term additional acute care services that can safely be administered at the current facility. Transfer 
to the LTACH would not be clinically advantageous at this time, and 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve ablation of malignant prostate tissue (55880). 
 
You asked the Plan to pre-approve the services. You say that the enrollee is too old for salvage radical 
prostatectomy and would be best treated with salvage high intensity-focused ultrasound (HIFU). The Plan 
denied your request. The Plan says that there is no clinical evidence to support the medical necessity of this the 
device or that the enrollee meets Medicare criteria. 
 
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 the services. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found that the National Comprehensive Cancer Network (NCCN) Guidelines Version 1.2023 Prostate 
Cancer for radiation therapy recurrence lists high intensity focused ultrasound (HIFU) as one of the 
recommended treatment regimens for recurrent cancer, biopsy positive, and studies negative for distant 
metastases, as the enrollee in this case has. Numerous clinical studies have demonstrated treatment efficacy that 
is comparable to surgery or radiation, but with a much lower risk of side effects such as impotence, 
incontinence, and bowel injury.  
 
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 been met. Therefore, we decided that the Plan has to pre-
approve ablation of malignant prostate tissue (55880).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the train of four testing provided on May 24, 2022. 
 
You asked the Plan to pay for the train of four testing. The Plan denied your request. The Plan says this testing 
is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that all services integral to accomplishing a procedure 
are considered bundled into that procedure and, therefore, are considered a component part of the 
comprehensive code.  
 
We looked at the file and Medicare rules. The requested train of four testing is considered integral to the 
procedure and intraoperative neuromonitoring and is not separately payable. Based on this information, we 
decided that Medicare rules for coverage of the train of four testing have not been met. Therefore, we decided 
that the Plan does not have to pay for the train of four testing provided on May 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (36558, 77001, 99152, 76937) provided 
on July 13, 2022. 
 
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the codes billed are not separately payable. 
 
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 code 36558, 77001, 99152, & 76937 is not supported in the medical record. Specifically, the 
codes billed are inclusive to the primary procedure. Based on this information, we decided that Medicare rules 
for coverage of the radiology services have not been met. Therefore, we decided that the Plan does not have to 
pay for radiology services (36558, 77001, 99152, 76937) provided on July 13, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve intensity-modulated radiation therapy (IMRT). 
 
You asked the Plan to pre-approve IMRT. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says that this is 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 pre-approve IMRT. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found as the American Society for Radiation Oncology (ASTRO) consensus statement does not 
explicitly state that accelerated partial breast radiation (APBI) is unsuitable, or unacceptable, and while whole 
breast radiation was offered and discussed it would seem that the treatment does fall within accepted standards 
of medical practice, even if not the optimal treatment, though it is the treatment the enrollee agreed to. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IMRT have been met. Therefore, we decided that the Plan has to pre-approve 
intensity-modulated radiation therapy (IMRT).  
 
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.