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

 
We decided that the Plan does not have to pre-approve diagnostic or therapeutic injections (62323) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve diagnostic or therapeutic injections. You say that the enrollee needs these 
injections as part of her conservative treatment. The Plan denied your request. The Plan says the enrollee must 
receive care from a network provider. There are in-network providers than can render this service. 
 
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 
diagnostic or therapeutic injections (62323) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint 
nerves (64633, 64634). 
 
You asked the Plan to pre-approve destruction by neurolytic agent. You say that the enrollee is in pain. You say 
the enrollee has had medial branch blocks and they have not helped. 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 destruction by neurolytic agent. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that it has been more than two years since the last radiofrequency ablation 
procedure, and the enrollee has not had any new diagnostic procedures. The review has determined that the 
requested procedure 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 destruction by neurolytic agent have not been met. Therefore, we decided that 
the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint nerves (64633, 
64634).
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 you are a fall risk and do not feel that physical 
therapy 3 times a week will be enough. The Plan denied your request. The Plan says you can safely receive the 
services you need 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 your nursing, medical, and rehabilitation can be provided in a 
lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. You require treatment by multiple therapies, including physical therapy and occupational 
therapy, but this can be provided in a lower level of care. There is documentation that there is a reasonable 
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF, but the services required can be provided at a lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting reconsideration for 
the denial of an LTACH admission. The Plan denied your request. The Plan says the enrollee does not meet the 
guidelines for care in an LTACH. 
 
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 enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. There are no services available at the LTACH that the 
enrollee requires that are not available at the health care setting being offered by the 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: 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 you disagree with the IRF admission denial. The 
Plan denied your request. The Plan says an IRF admission 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 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 or occupational therapy, there is no documented need for intensive rehabilitation services. 
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. Medically necessary care can be provided in a different 
level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve 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 MILD procedure. 
 
You asked the Plan to pre-approve a MILD procedure. You say that you are requesting reconsideration of the 
denied authorization. The Plan denied your request. The Plan says this procedure is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that an image-guided lumbar decompression procedure 
will be covered by Medicare when provided in a clinical study. 
 
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 MILD procedure. Our reviewer says 
that the coverage criteria has not been met. Our physician reviewer found that the detailed documentation is not 
evident regarding the enrollee being enrolled in a clinical study. Therefore, the enrollee does not meet the 
criteria for a MILD procedure. 
 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 MILD procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a MILD procedure.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqvio. 
 
You asked the Plan to pre-approve the drug. The Plan denied your request. The Plan says Leqvio is not 
medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 drug. Our reviewer says that Leqvio 
is not medically necessary. Our physician reviewer found that the requested 1136 units of Leqvio is FDA-
approved. However, Leqvio is not supported by one of the major drug compendia or by clinical research. Also, 
1136 units of Leqvio is not safe and effective and otherwise reasonable and necessary for the 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 the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Leqvio.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arterial catheter placement. 
 
You asked the Plan to pre-approve the outpatient procedure. You say that medical records have been provided 
to support medical necessity. The Plan denied your request. The Plan says this is considered experimental for 
the enrollee's condition. 
 
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 procedure. Our reviewer 
says that the requested arterial catheter placement is not considered medically reasonable and necessary in this 
case. Our physician reviewer found here is insufficient literature to support the safety and efficacy, as defined 
by Medicare rules, of the requested service. The record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service. Therefore, the reviewer found that the requested arterial catheter placement 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 outpatient procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve arterial catheter placement.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional SafeRide mileage (A0140, A0110). 
 
You asked the Plan to pre-approve additional mileage. You say that you are having surgery and you need 
transportation for future appointments. The Plan denied your request. The Plan says you are requesting an 
additional 2.8 miles for a total of 32.8 miles and your benefit only allows 30 miles. The Plan also says you have 
exceeded your benefit limit. 
 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 up to 6 one-way trips and each one-way trip must not exceed 30 miles of driving 
distance.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, trips over 30 miles 
are not covered. Therefore, we decided that the Plan does not have to pre-approve additional SafeRide mileage 
(A0140, A0110).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies (A6222, A6223) provided on April 7, 
2023. 
 
You asked the Plan to pay for the wound care supplies. You say that these items were medically necessary. The 
Plan denied your request. The Plan says these items are not separately payable when the enrollee is an 
inpatient. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the wound care supplies was used in a SNF or hospital. Therefore, we decided that the Plan 
does not have to pay for wound care supplies (A6222, A6223) provided on April 7, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Syfovre. 
 
You asked the Plan to pre-approve the drug. The Plan denied your request. The Plan says Syfovre is not 
medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 drug. Our reviewer says that 
Syfovre is not medically necessary. Our physician reviewer found that the requested use of Syfovre is FDA-
approved. However, Syfovre is not safe and effective and otherwise reasonable and necessary for the 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 the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Syfovre.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy. 
 
You asked the Plan to pre-approve proton beam therapy. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve proton beam therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found proton beam therapy is not medically reasonable and necessary in this case. There is 
insufficient prospective, long-term clinical data available to determine whether or not proton beam radiation 
therapy for prostate cancer is superior, inferior, or equivalent to external beam radiation therapy, intensity-modulated radiation therapy (IMRT), or brachytherapy with regards to safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam therapy.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance service, advanced life support and ground mileage provided 
on March 1, 2023. 
 
 
You asked the Plan to pay for the ambulance service and ground mileage. You say that the enrollee was not 
inpatient until March 2, 2023, the day after our date of service. The Plan denied your request. The Plan says 
that the enrollee was inpatient on dates of service February 25, 2023, to March 3, 2023. 
 
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  has not provided the medical records for the enrollee's inpatient stay. 
Without the records we are unable to determine whether the enrollee was inpatient on the requested date of 
service. Therefore, the Plan has not shown that it's decision to deny the ambulance transport services has been 
substantiated. Therefore, we decided that the Plan has to pay for ambulance service, advanced life support and 
ground mileage provided on March 1, 2023. 
  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical supplies provided on April 3, 2023. 
 
You asked the Plan to pay for medical supplies. You say that this denial will prevent the enrollee from 
receiving necessary medical supplies. The Plan denied your request. The Plan says for an enrollee in a covered 
inpatient stay, Medicare does not make separate payment for medical supplies when the enrollee is in the 
institution. 
 
The Plan must follow Medicare rules. Medicare rules say that separate payment is not made for medical 
supplies furnished to an enrollee who is in a covered Part A inpatient stay.  
 
We looked at the file and Medicare rules. This enrollee was in a covered inpatient stay on this date of service. 
Based on this information, we decided that Medicare rules for coverage of medical supplies have not been met. 
Therefore, we decided that the Plan does not have to pay for medical supplies provided on April 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services (procedure code 99223) 
rendered on December 26, 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 the records do not support the services 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, the CPT Code Manual definition of code 99223 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit." 
 
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 the documentation supports a 
comprehensive exam, but not a comprehensive history or medical decision making of high complexity 
 
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 evaluation and management services (procedure code 99223) rendered on December 26, 2022.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a single lumbar sympathetic nerve block. We decided that the 
Plan does not have to pre-approve a series of lumbar sympathetic nerve blocks.  
 
You asked the Plan to pre-approve lumbar sympathetic nerve blocks. You say that the enrollee's associated 
symptoms meet coverage criteria. The Plan says that the criteria for coverage have not been met. 
 
We decided that the Plan has to pre-approve a single lumbar sympathetic nerve block.  
 
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 lumbar sympathetic nerve blocks. Our 
reviewer says that the request is medically necessary. Our physician reviewer found that there is no literature to 
support for a series of sympathetic blocks. A single block may confirm the diagnosis. A single Lumbar 
sympathetic block is medically reasonable and 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 lumbar sympathetic nerve block. have been met. Therefore, we decided that the 
Plan has to pre-approve a single lumbar sympathetic nerve block.  
 
  We also decided that the Plan does not have to pre-approve a series of lumbar sympathetic nerve blocks. 
 
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 lumbar sympathetic nerve blocks. Our 
reviewer says that the request is not medically necessary. Our physician reviewer found that there is no 
literature to support for a series of sympathetic blocks.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lumbar sympathetic nerve blocks. have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a series of lumbar sympathetic nerve blocks. 
 
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.