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 the enrollee requires an interdisciplinary therapy care 
team made-up of occupational and physical therapy. You also say that the enrollee has a serious, life-
threatening constellation of acute medical problems that have left her at a functional status below her baseline. 
The Plan denied your request. The Plan says based on the available information, admission to 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 patient was 
admitted for a chronic obstructive pulmonary disease (COPD) exacerbation. 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that this is medically necessary. The Plan denied 
your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the record indicates that the enrollee has 
recent onset memory loss. The record provided does not establish that impairment has been present for six 
months, that the enrollee meets the diagnostic criteria of both Alzheimer's disease and frontotemporal dementia 
or that the examination is being requested in the context of a clinical trial. The elements of the coverage criteria 
are not satisfied. 
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
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 hospital isn't able to accommodate 
the enrollee and provide the level of care needed. The Plan denied your request. The Plan says the LTACH 
services requested do not meet the requirements for approval. 
 
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 has not finished the acute care component of their hospitalization and is 
not safe for transfer. 
 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 pre-approve a pneumatic compression device (PCD) (E0652). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the enrollee's existing pain 
levels preclude use of static pressure applied by a basic pump. You also say that the enrollee's open 
wounds/ulcers/skin breakdown preclude the use of static pressures applied by the basic pump. The Plan denied 
your request. The Plan says the records do not show that the enrollee has tried and failed a basic leg pump for 
four weeks. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee has 
lymphedema extending onto the chest, trunk and/or abdomen.  Therefore, we decided that the Plan does not 
have to pre-approve a pneumatic compression device (PCD) (E0652).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo. 
 You asked the Plan to pre-approve Vabysmo. 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. 
 
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 Vabysmo. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the provided records do not indicate that 
the enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that the 
enrollee has a contraindication to, or would have an adverse effect from the plan's preferred step one 
alternative. The elements of the coverage criteria are not satisfied. The requested service cannot be 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vabysmo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vabysmo.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infrared therapy devices provided on August 10, 2022. 
 
You asked the Plan to pay for infrared therapy devices. You say that it is medically necessary. The Plan denied 
your request. The Plan says it is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that infrared therapy devices are used to treat an area of 
the skin and adjacent subcutaneous tissues of a patient with infrared therapy energy, using an array of 
juxtaposed infrared diodes affixed to a flexible pad to retain skin contact. The devices can also produce local 
warming, though this may be a secondary effect. The use of infrared therapy devices has been proposed for a 
variety of disorders; including treatment of diabetic neuropathy, other peripheral neuropathy, skin ulcers and 
wounds, and similar related conditions, including conditions such as pain arising from these conditions. A wide 
variety of devices are currently available. 
 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 infrared therapy devices. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the documentation does not reveal 
that the enrollee has diabetic neuropathy, other peripheral neuropathy, skin ulcers and wounds, and similar 
related conditions, including conditions such as pain arising from these conditions. The criteria for the 
application modality 1 or more areas infrared have not been met per NCD Infrared Therapy Devices (270.6). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of infrared therapy devices have not been met. Therefore, we decided that the Plan 
does not have to pay for infrared therapy devices provided on August 10, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need transportation 
for your medical appointments. The Plan denied your request. The Plan says this request will exceed the 
maximum number of transportation trips allowed per year. 
 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 a maximum of 48 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that this request exceeds the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips (A0120).
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 an LTACH is the most appropriate 
setting for the enrollee to continue to receive their ongoing care. The Plan denied your request. The Plan says 
the LTACH services requested do not meet the requirements for approval. 
 
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 required medical services identified 
that are available at the LTACH that are not available at the current health care setting being offered by the 
Plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate 
for the diagnosis and condition of the enrollee at this time. Additionally, the documentation does not support 
that an additional 25 days of hospitalization are reasonably expected for the enrollee in this case. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the periodontal scaling and root planing (D4342) for the 
upper right and lower right quadrant. 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee has more than 3 teeth in each 
quadrant. The Plan denied your request. The Plan says the downgraded dental code is correct, because the x-ray 
cannot confirm if the enrollee has 4 or more teeth in the requested area. 
 
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. The Plan covers the dental 
services when the services are medically necessary and reasonable.  
 
  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 dental services. Our reviewer says 
that the downgrade of dental code D4342 to D4241 in these quadrants is upheld. Our physician reviewer found 
that the documentation indicates that the record of periodontal charting does not show periodontal pockets 
greater than 4mm in more than 3 teeth in the maxillary right and mandibular right quadrants. Also due to the 
poor quality of the radiographs provided, a determination of bone loss or subgingival calculus could not be 
made. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the periodontal scaling and root planing (D4342) for the upper right and lower right 
quadrant.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93224, 93229 and 93228 billed for dates of 
service July 24, 2023, to August 7, 2023. 
 
You asked the Plan to pay for procedure codes 93224, 93229 and 93228. You say that these services were 
necessary and are supported in the medical record. The Plan denied your request. The Plan says these codes are 
not supported in the medical record. 
 
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 93224 is external electrocardiographic recording up to 48 
hours by continuous rhythm recording and storage; includes recording, scanning analysis with report, review 
and interpretation by a physician or other qualified health care professional. The CPT code manual definition of 
code 93229 is external mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible electrocardiogram (ECG) data 
storage (retrievable with query) with ECG triggered and patient selected events transmitted to a remote 
attended surveillance center for up to 30 days; technical support for connection and patient instructions for use, 
attended surveillance, analysis and transmission of daily and emergent data reports as prescribed by a physician 
or other qualified health care professional. The CPT code manual definition of code 93228 is external mobile 
cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis 
and greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG triggered and 
patient selected events transmitted to a remote attended surveillance center for up to 30 days; review and 
interpretation with report by a physician or other qualified health care professional. 
 
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 procedure codes 93224, 93229 and 93228. Our reviewer says 
that these codes are not supported in the medical record. Our reviewer found that the medical records do not 
include sufficient documentation to support the criteria for these procedure codes. In addition, a physician order 
for these services was not included in the documentation. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 93224, 93229 and 93228 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 93224, 93229 and 93228 billed for dates of 
service July 24, 2023, to August 7, 2023.
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 proton beam therapy is the only modality 
that can accurately and safely treat the enrollee's disease without exceeding dose thresholds to the heart, lung, 
and breast. The Plan denied your request. The Plan says this 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 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 no actual planning records were provided. Routine use of proton therapy for breast 
cancer is not an accepted standard of care. Intensity-modulated radiation therapy (IMRT) that is photon based 
is designed to facilitate normal tissue sparing and could very readily be considered in this enrollee if a 3-dimensional plan is not acceptable. While proton therapy can be used, the case file does not provide a plausible 
rationale for the need of proton therapy over conventional radiation and/or IMRT in this 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 proton beam therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam therapy.
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 is ready to admit pending 
fast appeal overturn for an LTACH admission. The Plan denied your request. The Plan says the LTACH 
services requested do not meet the requirements for approval. 
 
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 treatment of the enrollee's cancer has been complicated by acute respiratory 
failure secondary to diffuse immunotherapy induced pneumonitis. The enrollee was making progress but was 
recently readmitted to the intensive care unit and requires 12 liters of supplemental oxygen during the day and 
bilevel positive airway pressure (BiPAP) at night. In addition, an infectious etiology is suspected as an 
infectious disease consultation has been requested. Transfer to the LTACH is not safe at this time given the 
enrollee's high oxygen requirements. 
 
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 Tolvaptan. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tolvaptan.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac injection (27096). 
 
You asked the Plan to pre-approve a sacroiliac injection. 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 sacroiliac joint injections (SIJI) will be considered 
medically reasonable and necessary when certain requirements are met.  
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 sacroiliac injection. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found there is no exam or imaging 
evidence of SI joint problem. There is no instability fracture or lesion of the SI joint. 
 
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 sacroiliac injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a sacroiliac injection (27096).