Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the deep brain stimulation (DBS). 
 
You asked the Plan to pre-approve the deep brain stimulation. You say that the enrollee meets the criteria for 
dystonia that is FDA approved. The Plan denied your request. The Plan says the deep brain stimulation is not 
medically necessary. The Plan says the medical effectiveness of the electric nerve stimulation has not been 
verified by scientifically controlled studies.  
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 deep brain stimulation. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has a dystonic tremor, and the use of DBS is not covered by 
the applicable LCD/NCD. Therefore, this service would not be considered 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 deep brain stimulation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the deep brain stimulation (DBS).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the heart with 
quantitative evaluation of coronary calcium. 
 
You asked the Plan to pre-approve the CT scan of the heart. You say that the services are medically necessary. 
The Plan denied your request. The Plan says the services are considered not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 the CT scan of the heart. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found there is insufficient support in 
the peer-reviewed literature demonstrating a significant benefit of CT imaging of the heart with quantitative 
evaluation of coronary calcium in guiding optimal management of this enrollee. The CT imaging of the heart 
without contrast material with quantitative evaluation of coronary calcium is considered 
experimental/investigational for the evaluation and management of this enrollee's medical 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 the CT scan of the heart have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a computed tomography (CT) scan of the heart with quantitative evaluation of 
coronary calcium.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve these services. You say that the services are not medically necessary. The 
Plan denied your request. The Plan says you disagree with the denial. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the documented clinical symptoms 
show buttock pain in addition to back pain. The cause of the enrollee's pain is not clear. The Intracept 
procedure is not reasonable or medically necessary based on the submitted records. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Intracept procedure.
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 medical records support the need for IRF 
admission. The Plan denied your request. The Plan says the notes we received do not show the enrollee has a 
medical need for this service. Your medical and therapy needs could be met in a skilled nursing unit. 
 
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 hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
has a history of diabetes, coronary artery disease, end stage renal disease on peritoneal dialysis, below the knee 
amputation in 2022 and is living at home with weakness. Medical problems are stable. There are no complex 
nursing or rehabilitation needs. While the medical records support 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee had a stroke and will now be needing 
physical therapy prior to returning to home. The Plan denied your request. The Plan says the enrollee does not 
meet criteria for a SNF admission. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the documentation does not support that the enrollee requires skilled nursing services 
with the specialized skill, knowledge, and judgment of a skilled professional nurse to safely and effectively be 
provided only in a SNF. The enrollee's needs do not require the necessary services on an inpatient basis in a 
SNF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergent transportation trips (A0425, A0428) to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve non-emergent transportation trips. You say that the enrollee needs 
transportation for his dialysis treatments. The Plan denied your request. The Plan says the enrollee must use 
network providers for most services. The service requested is available in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested ambulance provider in this case is not a network provider with the Plan. The Plan has network 
ambulance providers available who can provide the items/services at issue in this appeal. We found no 
exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan 
does not have to pre-approve non-emergent transportation trips (A0425, A0428) to be provided by an out-of-
network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has 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 medically necessary for 
the enrollee's complex medical needs. The Plan denied your request. The Plan says that the records do not show 
that the enrollee needs continued treatments and care that can only be given in a hospital 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 considered medically reasonable and necessary in this case. Our physician 
reviewer found due to the enrollee's complex medical history they had a major stroke resulting in a significant 
functional impairment impacting multiple organ systems. The enrollee requires daily medical monitoring and 
skilled services from nursing and therapists for complications related to the stroke as well as their chronic 
medical problems. The enrollee is stable to discharge to long term care facility but requires the highest level of 
care at this time due to their increased risk for decompensation. 
 
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 been met. Therefore, we decided that the Plan has to 
pre-approve long term acute care hospital (LTACH) services.  
 
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 pre-approve a CT scan. 
 
You asked the Plan to pre-approve a CT scan. You say that a CT scan of the thorax is necessary. The Plan 
denied your request. The Plan says a CT scan is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a CT scan. Our reviewer says that the 
requested CT scan is not medically necessary. Our physician reviewer found the medical necessity for the 
requested CT of the thorax has not been established in the submitted records. 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a CT scan.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the outpatient ablation and kyphoplasty to T12 and L5 
with vertebroplasty to sacrum. 
 
You asked the Plan to pre-approve the outpatient ablation and kyphoplasty to T12 and L5 with vertebroplasty 
to sacrum. You say that  the procedures will help reduce the enrollee's pain and improve her quality of life. The 
Plan denied your request. The Plan says  the outpatient ablation and kyphoplasty to T12 and L5 with 
vertebroplasty to sacrum 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 the outpatient ablation and kyphoplasty 
to T12 and L5 with vertebroplasty to sacrum. Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found there is no trial of fracture bracing, and there is no physical exam evidence of facet joint pain. This means the services are 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 outpatient ablation and kyphoplasty to T12 and L5 with vertebroplasty to 
sacrum have not been met. Therefore, we decided that the Plan does not have to pre-approve the outpatient 
ablation and kyphoplasty to T12 and L5 with vertebroplasty to sacrum.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (95908, 95937) provided on January 23, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes are 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. 
 
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 use of codes 95908 
and 95937 is not supported by the records provided. Our reviewer found that for code 95908, the record does 
not contain evidence that a diagnostic nerve conduction study of 3-4 nerves was performed. The services 
performed were part of intraoperative neuromonitoring. There is a more appropriate way to report this. For 
code 95937, the record states that train of four testing was performed. This is included in the intraoperative 
monitoring and cannot be reported separately as neuromuscular junction testing.  
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 the services (95908, 95937) provided on January 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve the portable ventilator. You say that this item is medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 the portable ventilator. Our reviewer 
says that the requested equipment is not medically necessary. Our physician reviewer found  the record indicates that the enrollee has chronic respiratory failure from obstructive sleep apnea with non-paralyzed 
elevated diaphragm. The enrollee's condition can be treated with a BiPAP machine. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular bone graft (21215). 
 
You asked the Plan to pre-approve a mandibular bone graft. You say that a mandibular bone graft is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says a mandibular bone graft 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 a mandibular bone graft. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that a review of the documentation and studies comparing the healing of the surgical sites of 
third molar removal indicates there was no statistical difference in the healing or rates of surgical 
complications. The placement of bone graft material is not a normal procedure in third molar removal. 
 
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 mandibular bone graft have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a mandibular bone graft (21215).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you cannot perform your activities of daily living 
and are improving with help from physical therapy. The Plan denied your request. The Plan says the SNF 
services requested do not meet the requirements for approval.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine (72148) 
and a magnetic resonance imaging (MRI) of the thoracic spine (72146). 
 
You asked the Plan to pre-approve the MRIs. The Plan denied your request. The Plan says that the enrollee has 
not completed six weeks of provider directed treatment, and the provider directed treatment did not occur 
within the last 3 months. 
 
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 the MRIs. Our reviewer says that this 
request is medically reasonable and necessary. Our physician reviewer found the enrollee has symptoms which 
may relate to lumbar or thoracic spine disease. The enrollee's neurological exam is normal. Our reviewer found 
that the enrollee has done a complete physical therapy program beginning April 12, 2023, and ending July 12, 
2023. The enrollee is still symptomatic. Our physician reviewer also found that this request for MRIs of the 
thoracic and lumbar spine should be approved. 
 
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 MRIs have been met. Therefore, we decided that the Plan has to pre-
approve a magnetic resonance imaging (MRI) of the lumbar spine (72148) and a magnetic resonance imaging 
(MRI) of the thoracic spine (72146).  
 
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 pre-approve office visit and services (99205, 93000) to be provided 
by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve office visit and services to be provided by an OON provider. You say that 
the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are 
able to provide these services. Therefore, coverage criteria have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
office visit and services (99205, 93000) to be provided by an out-of-network (OON) provider.