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

 
We decided that the Plan does not have to pre-approve a repeat facet joint injection/medial branch block 
(MBB). 
 
You asked the Plan to pre-approve the repeat MBB. You say that the enrollee was helped by the first injection. 
A second MBB should be allowed. The Plan denied your request. The Plan says the first MBB did not produce 
sufficient relief. 
 
The Plan follows Medicare rules. Medicare rules say that a second confirmatory diagnostic facet joint 
procedure is considered medically reasonable and necessary in patients who achieved at least 80% relief of 
primary (index) pain (with the duration of relief being consistent with the agent used). 
 
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 repeat MBB. Our reviewer says that 
the requested injection is not medically necessary. Our physician reviewer found This patient has chronic neck 
pain for years. The pain has not improved with conservative treatments such as medications (hydrocodone, 
Celebrex, and gabapentin), steroid injection, and chiropractic care. There is no non-facet pathology to explain 
the pain, and clinical assessment indicates that of pain is the facet joint. You had a cervical medial branch block 
on March 29, 2022, that resulted in seventy (70%) relief.  
 
The LCD requires 80% pain relief to be considered positive. This was not achieved. Therefore, the request is 
considered 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 repeat MBB have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a repeat facet joint injection/medial branch block (MBB).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 test you received in Mexico on January 19, 
2022. 
 
You asked the Plan to pay for the COVID-19 test. You say that you were required to get a COVID-19 test in 
order to return to the United States. The Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not cover services outside of the 
United States.  Your contract does offer worldwide coverage, but only for emergency and urgently needed care.  
A COVID-19 test needed for return travel does not meet this emergent or urgent restriction, despite the 
requirement that you have the test done prior to returning.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the COVID-19 test have not been met. Therefore, we decided that the Plan does not have to pay for 
the COVID-19 test you received in Mexico on January 19, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultrasound services provided to the enrollee on January 13, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 76641 RT (1 unit) remains not supported. 
 
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, the CPT Code Manual definition of code 76641-RT and 7664-LT is "Ultrasound, breast, unilateral, 
real time with image documentation, including axilla when performed; complete." 
 
We asked our coder 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 services at issue in 
this case were not supported by the medical records. Our reviewer found a review of the records showed a 
unilateral breast ultrasound was listed at the procedure heading on 1/13/22 but the report describes full breast 
ultrasound of both the right and left breasts. Thus, the heading of the procedure supports unilateral exam but 
the technique and findings as well as the conclusion portions of the report shows a bilateral exam was done.  
We looked at this coder'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 ultrasound services provided to the enrollee on January 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spine surgery. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says there must be a recent magnetic resonance imaging (MRI) or computed tomography 
(CT) submitted with these records. 
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there are no recent imaging studies of the spine to include an MRI or CT scan within the past 6 months. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve spine surgery.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve warfarin 1mg tablets. 
 
You asked the Plan to pre-approve the warfarin tablets. You say that the enrollee requires this to prevent blood 
clots. The Plan denied your request. The Plan says this is an oral drug and is not covered by Medicare Part B. 
 
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 warfarin 1mg tablets.  
 
Benefits for the warfarin tablets may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve IgE RAST allergen testing provided to the enrollee on May 10, 
2021. 
 
You asked the Plan to pre-approve the services. You say that this should be paid for. The Plan denied your 
request. The Plan says that the denial of this allergen testing was appropriate given the clinical scenario. 
 
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 services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the patient was instructed to remove potentially aggravating topical care products, begin antihistamine as 
needed. RAST allergy testing was performed and requested. Clinically this testing was supported by the 
provided documentation as it would help in the treatment and prevention of potential triggers of her dermatitis. 
Therefore, the enrollee meets the criteria. 
 
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 IgE RAST allergen testing provided to the enrollee on May 10, 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: 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 services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has 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 there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Transfer to LTACH is not medically necessary as it would not be 
clinically advantageous at this time. Completion of care 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 long term acute care hospital (LTACH) 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 records provided support the need for care in an 
IRF. The Plan denied your request. The Plan says IRF care is not medically necessary, and the enrollee's needs 
can be met 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 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 past medical history of end stage renal disease and had been in skilled nursing for 2 months. She was 
discharged home on May 27, 2022, and has ongoing weakness 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 enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for 
an intensive rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a routine transportation trip to a destination more than 
75 miles away. 
 
You asked the Plan to pre-approve the requested trip. You say that this transportation is necessary. The Plan 
denied your request. The Plan says the requested trip exceeds the maximum distance allowed by this 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 when each one-way trip is not more than 75 miles.   
 We looked at your request, the records in the case file, and the rules. You are requesting a trip that exceeds the 
maximum covered distance. 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 a routine 
transportation trip to a destination more than 75 miles away.
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 LTACH would be the best option for the 
enrollee's recovery. The Plan denied your request. The Plan says this 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 the patient is a 59-year-old female who was admitted to the acute care hospital with 
rhabdomyolysis post fall, acute kidney injury, and cutaneous abscess of the abdominal wall, treated with 
surgery, wound care including wound VAC, and antibiotics. Recent notes describe the patient as tolerating 
current treatment but requiring ongoing antibiotics and uncomplicated wound care.  
 
The patient appears to be stable and requires only short-term additional acute care services that can be safely 
completed at the current facility until more appropriate for a lower level of care. The patient does not require 
services at the LTACH that are not already available at the current facility. Transfer to LTACH is not medically necessary as it would not be clinically advantageous.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator trial. 
 
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 no documentation of other conservative care trials such as acupuncture, 
massage, or chiropractic care, nor psychological. 
 
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 the enrollee has not trialed several conservative therapies to manage the pain. There is no surgical 
consultation.  The request does not meet the LCD or NCD criteria.  The request is 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 pre-approve a spinal cord stimulator trial.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraspinal chiropractic manipulative treatment (code 
98943) and the electrical stimulation (code G0283) provided by a chiropractor on December 21, 2021. 
 
You asked the Plan to pay for the chiropractic services.. You say that these services were medically necessary. 
The Plan denied your request. The Plan says these are not Medicare-covered chiropractic services.  While the 
member does have a supplemental chiropractic benefit for non-Medicare covered chiropractic services, the 
member has exhausted that benefit for 2021. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. The Plan does have a 
supplemental chiropractic benefit that will cover chiropractic services beyond manual manipulation of the spine.  This benefit is limited to 30 visits each calendar year.  Records show that the member exhausted this 30-
visit maximum on December 3, 2021, so no additional non-Medicare covered chiropractic services are eligible 
for coverage after that date. Therefore, we decided that the Plan does not have to pay for the extraspinal 
chiropractic manipulative treatment (code 98943) and the electrical stimulation (code G0283) provided by a 
chiropractor on December 21, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve laboratory services provided to the enrollee on November 10, 
2021. 
 
You asked the Plan to pre-approve the services. You say that this should be paid for. The Plan denied your 
request. The Plan says that this testing is unlikely to impact therapeutic decision-making in the clinical 
management of the patient. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if 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 the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the review indicates that the enrollee met the criteria for this testing. There is a dominant abnormal clone 
with SF3B1 mutation. The TET2 and GNAS mutations are detected in subclones. These abnormalities are 
consistent with myelodysplastic syndrome (MDS), refractory anemia with ring sideroblasts. Patients with ring 
sideroblasts/SF3B1 mutation may respond to the recently approved drug, luspatercept (Reblozyl). 
 
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 laboratory services provided to the enrollee on November 10, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for angiography services provided to the enrollee on April 21, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the code cannot be verified. 
 
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, the CPT Code Manual definition of code 75726 is "Angiography, visceral, selective or 
supraselective (with or without flush aortogram), radiological supervision and interpretation." 
 
We asked our coder 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 services at issue in 
this case were not supported by the medical records. Our reviewer found that although this procedure is 
documented in the operative report, the procedure is inclusive to CPT 37244, per CPT code descriptor 
"inclusive of all radiological supervision and interpretation."  The documentation does not support this service 
as a separate procedure.   
We looked at this coder'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 angiography services provided to the enrollee on April 21, 2021.
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 records provided support the need for IRF care. 
The Plan denied your request. The Plan says IRF care is not medically necessary as the enrollee's medical 
issues are stable. 
 
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 
was admitted for surgical repair of a hip fracture after a fall. 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 enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for 
an intensive rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.