Persius/hicric huggingface dataset:
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 long term acute care level of care is most 
appropriate for the enrollee to achieve the best outcome due to his complex medical needs. The Plan denied 
your request. The Plan says the enrollee's records do not show that you need continued treatments that can only 
be given in a hospital setting, when ready to leave the hospital, you can safely receive this care in another 
setting, at a a Skilled Nursing Facility or at home with home health services or outpatient setting if appropriate. 
 
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 available at the LTACH that the enrollee requires that are not available at the current health care setting being offered by the health 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A4310 and A4338 rendered on March 15, 
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 when available, a comprehensive code should be selected. 
 
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 the denied codes is: 
 
Healthcare Common Procedure Coding System (HCPCS) A4310: 
 
Insertion tray without drainage bag and without catheter (accessories only) 
 HCPCS A4338: 
 
Indwelling catheter; foley type, two-way latex with coating (teflon, silicone, silicone elastomer, or hydrophilic, 
etc.), each 
 
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 there is a more appropriate code 
to report when A4310 and A4338 are both provided. A4311 contains all components of the other 2 codes and is 
the best comprehensive code in this scenario. 
 
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 procedure codes A4310 and A4338 rendered on March 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for posterior tibial nerve stimulation provided on  
November 11, 2022. 
 
You asked the Plan to pay for posterior tibial nerve stimulation. You say that  The Plan denied your request. 
The Plan says the requested posterior tibial nerve stimulation does not meet the Medicare Local Coverage 
Article criteria and is not medically necessary. 
 
The Plan follows Medicare rules. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for posterior tibial nerve stimulation. Our 
reviewer says that posterior tibial nerve stimulation is not considered medically necessary in this case. Our 
physician reviewer found PTNS is indicated in patients with overactive bladder/urge incontinence that have 
failed standard anticholinergic drug therapy or have demonstrated intolerance to anticholinergic drug therapy 
despite best attempts at management of the most common side effects of such therapy, such as dry mouth and 
constipation.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of posterior tibial nerve stimulation have not been met. Therefore, we decided that 
the Plan does not have to pay for posterior tibial nerve stimulation provided on November 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation-problem focused (D0140) 
provided on December 6, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says your benefit for the service provided has 
already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the service provided was exhausted on date of service April 28, 2022.  Specifically, the Plan provides coverage for a limited oral evaluation once every year. You previously received 
this service on April 28, 2022, which was paid for by the Plan. Therefore, you have exhausted the allowable 
benefit for this service. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation-
problem focused (D0140) provided on December 6, 2022.
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 enrollee is getting worse and will be harder to 
return to prior level of function. The Plan denied your request. The Plan says the enrollee's records do not show 
that you need an intensive team for your care, services needs can be provided safely in other settings, skilled 
nursing facility, home with home health services or home with outpatient therapy. 
 
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. 
 
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: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from October 3, 2022, to 
October 5, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee required a 3 day length of 
stay for which medical treatment was received and you request payment for the services rendered The Plan 
denied your request. The Plan says that these services was not authorized. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the review indicates that the enrollee, with a history of atrial fibrillation/flutter, hypertension, 
heart failure with preserved ejection fraction (HFpEF), cerebral vascular accident (CVA), and status post 
pacemaker insertion. The enrollee was admitted October 3, 2022, for Tikosyn therapy. The enrollee required 
telemetry monitoring with measuring of the corrected for heat rate (QTc) interval and tolerated the medication 
and was discharged home on October 6, 2022. The review has determined that the record showed that at the 
time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital 
care (including earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from October 3, 2022, to October 5, 2022.  
 
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 hyperbaric oxygen therapy (HBO therapy). 
 
You asked the Plan to pre-approve HBO therapy. You say that the enrollee needs to complete treatment. The 
Plan denied your request. The Plan says the records do not show that wound healing has occurred. 
 
The Plan follows Medicare rules. Medicare rules state that HBO therapy is only covered for certain indications. 
 
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 HBO therapy. Our reviewer says that 
the enrollee does not meet the criteria for HBO therapy. Our physician reviewer found the records do not show 
that wound healing has occurred. Additionally, standard wound care with exposed bone with osteomyelitis 
includes resection with creation of a soft tissue envelope overlying the site of infection. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HBO therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve hyperbaric oxygen therapy (HBO therapy).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Renflexis. 
 You asked the Plan to pre-approve Renflexis. You say that Renflexis is medically necessary. The Plan denied 
your request. The Plan says a trial of Avsola, Remicade, or Infliximab is required before alternatives can be 
considered. 
 
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 Renflexis. Our reviewer says that 
Renflexis is not medically necessary. Our physician reviewer found the records do not show a trial of the plan 
preferred drugs, or any reason they would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Renflexis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Renflexis.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Tempus xF testing provided on November 26, 2022. 
 
You asked the Plan to pay for Tempus xF testing. You say that this test is medically necessary. The Plan denied 
your request. The Plan says this test is not covered because it is not FDA approved. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, when the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF test is not FDA approved. Based 
on this information, we decided that Medicare rules for coverage of Tempus xF testing have not been met. 
Therefore, we decided that the Plan does not have to pay for Tempus xF testing provided on November 26, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block. 
 
You asked the Plan to pre-approve a genicular nerve block. You say that a genicular nerve block is medically 
necessary. The Plan denied your request. The Plan says the requested genicular nerve block 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 genicular nerve block. Our reviewer 
says that the requested genicular nerve block is not considered medically reasonable and necessary. Our 
physician reviewer found that genicular nerve blocks and genicular nerve radiofrequency ablation are 
considered investigational and not medically necessary for the treatment of chronic knee pain, including, but 
not limited to any of the following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not 
candidates for knee replacement surgery. The review has determined that the requested genicular nerve block 
of the right knee 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 a genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continued stay at the inpatient behavioral health level 
of care. 
 
You asked the Plan to pre-approve a continued stay at the inpatient behavioral health level of care. The Plan 
denied your request. The Plan says this request does not meet Medicare guidelines. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 continued stay at the inpatient 
behavioral health level of care. Our reviewer says that the enrollee does not meet the Medicare criteria for 
continued inpatient psychiatric care. Our physician reviewer found it was not expected this enrollee would 
improve in a reasonable period of time beyond the dates in question as they were not showing any 
dangerousness to self or others, auditory or visual hallucinations and without aggressive behaviors while not 
showing any acute threats of safety. Our reviewer also found that it does not appear medically necessary and 
reasonable to have psychiatric care provided at the acute inpatient level of care rather than 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 a continued stay at the inpatient behavioral health level of care have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a continued stay at the inpatient 
behavioral health level of care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for orthopedic footwear purchased from March 30, 
2022, through November 11, 2022. 
 
You asked the Plan to reimburse you for orthopedic footwear. You say that you want the Plan to reimburse you 
for these purchases. The Plan denied your request. The Plan says you do not have diabetes, the shoe is not an 
integral part of a leg brace, and the L3215 code is a Medicare statutorily non-covered code. 
 
The Plan must follow Medicare rules. Medicare rules say that shoes, inserts, and modifications are covered in 
limited circumstances. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of orthopedic footwear have not been met. Therefore, we decided that the Plan does not have to 
reimburse you for orthopedic footwear purchased from March 30, 2022, through November 11, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zarxio (Q5101). 
 
You asked the Plan to pre-approve Zarxio. The Plan denied your request. The Plan says this drug is not covered 
per Medicare rules. 
 
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 Zarxio. Our reviewer says that Zarxio is 
not medically reasonable and necessary for the enrollee. Our physician reviewer found the requested use of 
Zarxio (Q5101) is not FDA-approved for the enrollees diagnosis. The use is not supported by one of the major 
drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services (CMS) 
approved medical journal. Our reviewer found that data states granulocyte colony stimulating factor (G-CSF) 
should not be given based on the severity of the neutropenia, but rather based on the presence of recurrent 
infections. Our physician reviewer also found that the use is not listed as not indicated, not supported, or not 
recommended in any of the compendia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zarxio have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Zarxio (Q5101).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a right total hip arthroplasty. 
 
 
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 has not been a full course of conservative treatment. 
 
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 that there are limited large-scale, long-term references showing the safety and efficacy of the requested 
surgery in this clinical setting. There are limited large-scale, long-term references showing the safety and 
efficacy of the requested surgery in this clinical setting. Long term, large volume studies are not evident reflecting improved ultimate outcomes of pain and functioning (with or without computer-assisted type 
devices, as requested herein.) No compelling rationale is presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested right total hip 
arthroplasty, in this case, 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 right total hip arthroplasty.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mandibular partial denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 25, 2019. 
Therefore, we decided that the Plan does not have to pre-approve mandibular partial denture (D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99232) provided on November 3, 2022 to 
November 6, 2022. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as 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. 
 
We find that CPT code 99232 is not supported in the medical record. Specifically, the same evaluation and 
management service was billed already by the same provider group on the same date of service for this 
enrollee. Based on this information, we decided that Medicare rules for coverage of the physician services have 
not been met. Therefore, we decided that the Plan does not have to pay for physician services (99232) provided 
on November 3, 2022 to November 6, 2022.