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 the enrollee exceeds the criteria for an 
appropriate long term acute care hospital admission. The Plan denied your request. The Plan says the enrollee 
does not meet all the requirements. Care can be provided in the current inpatient hospital. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by a tertiary level of care 
neurosurgeon. 
 
You asked the Plan to pre-approve an office visit to be provided by a tertiary level of care neurosurgeon. 
You say that the requested office with a tertiary level of care neurosurgeon is medically necessary. The Plan 
denied your request. The Plan says you do not meet tertiary care level guidelines. Instead, the consult is 
approved with community level neurosurgeon. 
 
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 an office visit to be provided by a 
tertiary level of care neurosurgeon. Our reviewer says that the requested office visit with a tertiary level of care 
neurosurgeon is not considered medically reasonable and necessary in this case. Our physician reviewer found that you report some ongoing pain a year after a lumbar fusion procedure. The 
records show that your orthopedic surgeon indicated that you had done well post-operatively and was on their 
expected course. There were otherwise no unique factors in this case that would necessitate evaluation at the 
tertiary level of care at this time. Community resources have not been trialed/exhausted to date. The services 
you are seeking are commonly offered and rendered within the non-tertiary level of care. The request for a 
tertiary consult would therefore exceed your clinical needs at this time. It would also be seen as mostly being 
for convenience. This would not meet the Medicare definition of medical necessity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an office visit to be provided by a tertiary level of care neurosurgeon have not 
been met. Therefore, we decided that the Plan does not have to pre-approve an office visit to be provided by a 
tertiary level of care neurosurgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy duty walker (E0149) with a seat attachment 
(E0156). 
 
You asked the Plan to pre-approve a heavy duty walker with a seat attachment. You say that the items are 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the weight 
requirements for a heavy duty walker. 
 
The Plan must follow Medicare rules. Medicare rules say that a heavy duty walker (E0148, E0149) is covered 
for beneficiaries who meet coverage criteria for a standard walker and who weigh more than 300 pounds. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a heavy duty walker with a seat attachment have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a heavy duty walker (E0149) with a seat attachment (E0156).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 1, 2022, to July 
30, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from July 1, 2022, to July 30, 
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 you require inpatient rehabilitation level of care. The 
Plan denied your request. The Plan says your medical conditions are stable and do not require daily physician 
oversight. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the records do not show any results from an overnight sleep oximetry test. 
 
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 ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found that the enrollee was recently hospitalized with an acute exacerbation of heart failure with preserved ejection fraction 
(HFpEF), with pulmonary edema. An arterial blood gas study (ABG) was consistent. with acute on chronic 
hypercarbic respiratory failure. The enrollee is also obese.  Bedside spirometry was quoted as showing an 
FEV1 of 0.19 L, which is incompatible with life, suggesting a poor-quality test. No other information on lung 
function is available. There is no diagnosis of thoracic restrictive disease or neuromuscular disease. There is no 
ABG done while stable to document chronic CO2 retention. If that is present, the patient may benefit from 
bilevel positive airway pressure (BiPAP) with average volume-assured pressure support (AVAPS) during 
sleep.  Medicare does not cover a home ventilator when used at settings that can be provided with BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires long term acute care 
level of care. The Plan denied your request. The Plan says the enrollee can remain in the current acute care 
location until such time no further acute level care is needed. A discharge to a lower level of care would not be 
appropriate with ongoing acute care needs. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Prolia (J0897). 
 You asked the Plan to pre-approve Prolia. You say that Prolia is a medical necessity for the enrollee. The Plan 
denied your request. The Plan says step-therapy rules for coverage of Prolia have not been met. 
 
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 Prolia. Our reviewer says that Prolia is 
not medically reasonable and necessary in this case. Our physician reviewer found that the Plan requires 
a history of an osteoporotic fracture or a trial of drug zoledronic acid before they will approve the requested 
drug. The enrollee does not have history of osteoporotic fracture nor has the enrollee tried and failed the 
required drug. There is no documentation provided indicating that the Plans required drug would likely be less 
effective and/or likely have adverse effects 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Prolia (J0897).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says the 
coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. We looked at the file and Medicare rules. The documentation does not indicate that the enrollee uses insulin 
with at least three daily injections or requires frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of the requested 
device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Visco-3 (J7321). 
 You asked the Plan to pre-approve Visco-3. You say that Visco-3 is a medical necessity for the enrollee. The 
Plan denied your request. The Plan says step-therapy rules for coverage of Visco-3 have not been met. 
 
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 Visco-3. Our reviewer says that Visco-
3 is not medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has not 
trialed viscosupplemental treatments such as Monovisc, Orthovisc and Synvisc or Synvisc-One. Step therapy, 
as outlined by the Plan, requires that at least 3 of these preferred products be trialed first. The documentation 
does not outline contraindications or reasons why these medications were not considered, nor that the Plans 
required drugs would likely be less effective and/or likely have adverse effects 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 Visco-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Visco-3 (J7321).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint (SIJ) injection. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary and will be beneficial. 
The Plan denied your request. The Plan says the exam does not show the pain is coming from the sacroiliac 
joint.  
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 injection. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, there is no documentation on physical examination of three (3) or more positive tests 
results. The clinical value and effectiveness of an SIJ injection in the absence of tenderness and negative 
provocative testing results have not been demonstrated in the peer-reviewed literature. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sacroiliac joint (SIJ) injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0656, 
E0667). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show lymphedema extending to the trunk that has been unresponsive 
to other therapies. 
 
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 as the records do not document any objective evidence of lymphedema of the chest, trunk or 
abdomen on examination, then it cannot be said that the enrollee has unique characteristics that would indicate 
a segmented pump over a standard pump. 
 
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 pneumatic compression device (E0652, E0656, E0667).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
January 2, 2023. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service January 2, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a suction assisted lipectomy procedure. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
request 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 requested services. Our physician 
reviewer found that there is no documentation that suction assisted lipectomy at issue in this case meets all 
Medicare criteria for being medically reasonable and necessary. The provided records in this case do not 
document that the suction assisted lipectomy is not cosmetic in nature.  
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a suction assisted lipectomy procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a four-wheeled rollator walker. 
 
You asked the Plan to pre-approve a walker. You say that you want this walker due to your arthritis and 
disequilibrium. The Plan denied your request. The Plan says you do not meet the criteria for the requested item. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a wheelchair. Your current wheelchair serves the same purpose as the requested 
walker. The medical records provided do not show that a walker is needed as part of your treatment plans. 
Therefore, we decided that the Plan does not have to pre-approve a four-wheeled rollator walker.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that other modalities have been ruled out. The Plan 
denied your request. The Plan says the ventilator is not covered for the requested use. 
 
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 a ventilator. Our physician reviewer 
found that the enrollee has chronic respiratory failure consequent to chronic obstructive pulmonary disease.  The home ventilator is being requested for use in intelligent volume assured pressure support (IVAPS) mode 
with auto-EPAP (AE) which could be provided by a BiPAP device with average volume assured pressure 
support (AVAPS) and a back-up rate. The records do not document a trial and failure of a BiPAP device with 
AVAPS and a back-up rate. Ventilators used to provide bi-level therapy for the enrollees condition is not 
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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.