Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says the enrollee does not meet the requirements for approval.  
 
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. 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 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 this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the ambulance services (A0428 and A0425) provided on May 9, 2023. 
 
You asked the Plan to pay for the ambulance services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that they are not responsible for additional 
payment of these services. 
 
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. We find that to determine if the Plan is responsible for any payment towards the 
ambulance services, the claim from the primary payer should be provided to determine the allowed amount of 
the primary payer in addition to the amount actually paid by the primary payer. The file does not show there 
were any attempts to obtain this claim for review. Without this document, we are not able to determine if any 
of the formulas in the Medicare rules section have been met. Therefore, we decided that the Plan has to pay for 
the ambulance services (A0428 and A0425) provided on May 9, 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: 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 medical records provided support the need for 
the requested IRF admission. The Plan denied your request. The Plan says based on the available information, 
admission to the IRF is not reasonable and necessary, as the enrollee's condition does not meet the Medicare 
rules.  
 
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 lower extremity cellulitis. 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 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve InnovaMatrix AC, per sq cm (A2001 x320). 
 
You asked the Plan to pre-approve InnovaMatrix AC. 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 InnovaMatrix AC. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee requires documentation to show adequate blood flow (ankle-brachial 
indices), demostration of glycemic control (A1c), and adequate nutrition (albumin) to show that she meets 
criteria for coverage.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of InnovaMatrix AC have not been met. Therefore, we decided that the Plan does 
not have to pre-approve InnovaMatrix AC, per sq cm (A2001 x320).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections (64635, 64636). 
 
You asked the Plan to pre-approve facet joint injections. 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 follows Medicare rules. Medicare rules say that an initial thermal RFA of cervical, thoracic, or 
lumbar paravertebral facet joint (medial branch) nerves is considered medically reasonable and necessary for 
patients who have had at least two (2) medically reasonable and necessary diagnostic MBBs, with each one providing a consistent minimum of 80% sustained 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 facet joint injections facet joint injections. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the request exceeds 
utilization criteria as this would be the third and fourth sessions of RFA within a 12-month period. The 
utilization limit is 2 sessions within a rolling 12-month period. Therefore, the request is deemed not 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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections (64635, 64636).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an implant supported porcelain/ceramic crown (D6065) 
provided on April 12, 2023. 
 
You asked the Plan to pay for the implant supported crown. You say that this should have been covered under 
the original date of service in 2022. The Plan denied your request. The Plan says implants and related services, 
including implant removal related services are excluded from dental coverage. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
implant supported porcelain/ceramic crown (D6065) provided on April 12, 2023.
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 these services are medically necessary 
for the enrollee. The Plan denied your request. The Plan says the enrollee is receiving medically necessary 
acute and/or critical care. 
 
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. 
 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Briumvi (J2329). 
 You asked the Plan to pre-approve Briumvi. You say that this is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drug, 
Ocrevus. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Briumvi. Our reviewer says that the 
step therapy criteria for Briumvi have not been met. Our physician reviewer found there is no indication that 
the enrollee has tried and failed the Plan's required drug. The reviewer also found that there is no indication that 
the Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. 
Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Briumvi have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Briumvi (J2329).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that the enrollee has tried and failed artricularcortisone 
injections. You also say that the cortisone injections raise the enrollee's blood sugar. The Plan denied your 
request. The Plan says the enrollee has not recently completed physical therapy or home exercises. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Euflexxa. Our reviewer says that the 
requested drug, Euflexxa, is not medically necessary. Our physician reviewer found there was no 
documentation provided which supported that the patient had tried and failed non-pharmacological treatment. 
The reviewer found that the documentation does not support that the Euflexxa is medically reasonable and 
necessary for the patient. The reviewer also found that the documentation does not support that the Euflexxa is 
safe and effective for the patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Purewick urine collection system. 
 
You asked the Plan to pre-approve a Purewick urine collection system. You say that the item is necessary. The 
Plan denied your request. The Plan says the requested upgraded item is used for convenience and not primarily 
medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a Purewick urine collection system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that a portable oxygen concentrator 
is medically necessary for the enrollee due to their chronic respiratory failure and chronic obstructive 
pulmonary disease. The Plan denied your request. The Plan says a portable oxygen concentrator is not 
medically necessary.  
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 portable oxygen concentrator. Our 
reviewer says that a portable oxygen concentrator is not medically necessary. Our physician reviewer found 
that there is no provided evidence for home oxygen therapy. Therefore, the coverage criteria have not been met 
for a portable oxygen concentrator. 
 
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 portable oxygen concentrator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fylnetra (Q5130) 
 You asked the Plan to pre-approve Fylnetra. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, Neulasta or 
Udenyca. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Fylnetra. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided records do not support that 
the enrollee has tried and failed the preferred drugs. The reviewer also found that there is no indication that the 
Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 
Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Fylnetra have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Fylnetra (Q5130)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom ramp. 
 
You asked the Plan to pre-approve a custom ramp. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says a custom ramp is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a custom ramp.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a rhythm electrocardiogram (ECG), 1-3 leads; interpretation 
and report only (93042) provided on January 1, 2023. 
 
You asked the Plan to pay for the rhythm ECG. You say that the services were provided, and payment should 
be rendered. The Plan denied your request. The Plan says the documentation does not support the service 
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 93042 is a rhythm ECG, 1-3 leads; interpretation and 
report only. 
 
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 rhythm ECG. Our reviewer says that the services are not 
supported. Our reviewer found the documentation submitted was reviewed and does not meet 
criteria. Procedure report describes a 12 lead ECG was performed in emergency department. Per CMS - A 
rhythm ECG interpretation and report only (93042) is included in a 12-lead ECG interpretation and report 
(93000 or 93010). In this case, service was unbundled and was appropriately denied. 
 
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 rhythm ECG have not been met. Therefore, we decided that the Plan does 
not have to pay for a rhythm electrocardiogram (ECG), 1-3 leads; interpretation and report only (93042) 
provided on January 1, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code G2074 provided on June 28, 2023. 
 
You asked the Plan to pay for procedure code G2074. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
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. We find that the Plan has not provided enough evidence to support the denial of 
payment for procedure code G2074 based on Medicare criteria. Procedure code G2074 is eligible for payment 
when used for outpatient opioid treatment programs. Additionally, the file does not contain evidence that the 
Plan made any attempt to obtain additional information from the provider. Therefore, we decided that the Plan 
has to pay for procedure code G2074 provided on June 28, 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.