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 it is medically necessary. 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 enrollees 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 congestive heart failure and lower extremity wounds. 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injection procedure for sacroiliac joint, anesthetic/ 
steroid, with image guidance (27096). 
 
You asked the Plan to pre-approve Injection procedure for sacroiliac joint, anesthetic/steroid, with image 
guidance. You say that without injection the enrollee is unable to walk or stand. The Plan denied your request. 
The Plan says the enrollee's records show imaging demonstrating another cause of lumbosacral pain. 
Additionally, physical examination 
did not include multiple provocative maneuvers to assess if the sacroiliac joint is the source of your pain, the 
request is not medically necessary. 
 
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 Injection procedure for sacroiliac joint, 
anesthetic/ steroid, with image guidance. Our reviewer says that the service is not medically necessary. Our 
physician reviewer found the review has determined that the requested sacroiliac joint injection 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 Injection procedure for sacroiliac joint, anesthetic/ steroid, with image guidance 
have not been met. Therefore, we decided that the Plan does not have to pre-approve Injection procedure for 
sacroiliac joint, anesthetic/ steroid, with image guidance (27096).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76377 billed for date of service September 
13, 2022. 
 
You asked the Plan to pay for procedure code 76377. You say that this service was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this claim is missing a necessary 
secondary diagnosis code from a select list. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that there are specific secondary diagnosis codes which must be reported with CPT codes 76376 and 
76377 to support medical necessity. Claims missing one of the specified secondary diagnosis codes will be 
denied automatically. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 76377 have not been met. Specifically, this claim was submitted with primary 
diagnosis code C79.51 and secondary diagnosis code C50.919. Neither of these codes are among the specified 
necessary secondary diagnosis codes for this service. Therefore, we decided that the Plan does not have to pay 
for procedure code 76377 billed for date of service September 13, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you are requesting an expedited reconsideration for 
the denial of a SNF admission. You say the provider didn't have the opportunity to do a peer to peer, and the 
enrollee is ready to transition to a sub-acute rehabilitation center. The Plan denied your request. The Plan says 
the SNF services requested do not meet the requirements for approval.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. The enrollees care needs can be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Step-Therapy
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 requested drug is necessary for the enrollee's 
treatment. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, 
Orthovisc or Supartz FX. 
 
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 Euflexxa. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found that the enrollee has not tried and failed 
the preferred drugs, Orthovisc or Supartz FX. There is no documentation provided indicating that the Plans 
preferred 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 Euflexxa have not been met. Additionally, we have confirmed that the 
requested medication will be dispensed by a pharmacy and will be brought to the office for administration. 
Since the medication does not represent an expense to the physician and will not be included in the physician's 
bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve 
Euflexxa.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuous intraoperative neurophysiology monitoring 
rendered on October 27, 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 Current Procedural Terminology (CPT) code 95940 remains not supported. 
 
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 95940 is Continuous intraoperative neurophysiology 
monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes (List 
separately in addition to code for primary procedure). 
 
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.  Our reviewer found that CPT code 95940 is not supported. The record states that 
the provider was monitoring the patient via an internet connection. The provider did not perform monitoring 
with personal attendance in the operating room. There is a more specific code for remote intraoperative 
neuromonitoring. 
 
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 continuous intraoperative neurophysiology monitoring rendered on October 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic coronavirus detection testing provided on January 
24, 2023.  
 
You asked the Plan to pay for the genetic testing . You say that this was medically necessary.  The Plan denied 
your request. The Plan says the claim for this molecular pathology testing did not include the required unique 
identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the genetic testing  
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic coronavirus 
detection testing provided on January 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (POV K0801). 
 
You asked the Plan to pre-approve power operated vehicle. You say that you need a scooter to get around the 
home. The Plan denied your request. The Plan says you do not meet criteria for this power operated vehicle. 
 
The Plan follows Medicare rules. Medicare rules state that power operated vehicles are only covered if certain 
criteria 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 power operated vehicle. Our reviewer 
says that you do not meet criteria for a power operated vehicle. Our physician reviewer found you have a 
manual wheelchair and are able to do mobility-related activities of daily living in your home. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of power operated vehicle have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a power operated vehicle (POV K0801).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vacuum assisted socket system (VASS) (L5781). 
 
You asked the Plan to pre-approve a VASS. You say that the enrollee needs this item. The Plan denied your 
request. The Plan says this is not proven to be effective. 
 
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 VASS. Our reviewer says that the 
requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found 
there is not evidence the VASS improves function. 
 
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 VASS have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a vacuum assisted socket system (VASS) (L5781).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tertiary-care provider office visit to be provided by an 
out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a tertiary-care provider office visit. You say that the requested service is a 
medical necessity for you. The Plan denied your request. The Plan says that you had a non-small cell lung 
cancer treated in 2019 and a papillary thyroid cancer resected in 2020. You are on surveillance. You do not 
require tertiary care for surveillance and in-network care has been shown to be available. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The provider at issue in this case is not a network provider with the Plan. 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 tertiary-care provider office visit. Our reviewer says that tertiary care is 
not medically reasonable and necessary in this case. Our physician reviewer found that you had a non-small 
cell lung cancer treated in 2019 and a papillary thyroid cancer resected in 2020. You are on surveillance. You 
do not require tertiary care for surveillance and in-network care has been shown to be available. 
 
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 tertiary-care provider office visit have not been met.  
 
The Plan has network providers available who can provide the items/services at issue in this appeal. We found 
no exception that would require the Plan to pre-approve a tertiary-care provider office visit. Therefore, we 
decided that the Plan does not have to pre-approve a tertiary-care provider office visit to be provided by an out-
of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for would care supplies provided on February 6, 2023. 
 
You asked the Plan to pay for would care supplies. You say that this should be covered. The Plan denied your 
request. The Plan says this was not authorized. 
 The Plan must follow Medicare rules. Medicare rules say that Health Maintenance Organizations (HMOs) may 
offer a Point of Service (POS) option as a mandatory or optional supplemental benefit and may either require 
or waive prior authorization rules for obtaining POS services. The Plan contract says that some services, 
including durable medical equipment and surgical supplies, such as dressings, require prior authorization. 
 
We looked at the file and Medicare rules. The supplies at issue were not authorized. Based on this information, 
we decided that Medicare rules for coverage of would care supplies have not been met. Therefore, we decided 
that the Plan does not have to pay for would care supplies provided on February 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the spinal electrical osteogenesis stimulator (E0748) 
provided on December 8, 2022. 
 
You asked the Plan to pay for the spinal electrical osteogenesis stimulator. You say that the service was 
medically necessary. The Plan denied your request. The Plan says there is no evidence of a failed spinal fusion 
where a minimum of nine months has elapsed since the last surgery. 
 
The Plan follows Medicare rules. Medicare rules say that a spinal electrical osteogenesis stimulator will be 
denied as not medically necessary if none of the criteria above 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 pay for the spinal electrical osteogenesis stimulator . 
Our reviewer says that the spinal electrical osteogenesis stimulator is not medically necessary. Our physician 
reviewer found the provided documentation does not indicate a failed spinal fusion where a minimum of nine 
months has elapsed since surgery. The reviewer found that the enrollee did not have a multi-level spinal fusion 
surgery. The reviewer also found that the enrollee does not have a history of previous spinal surgery. 
Therefore, the reviewer found that the spinal electrical osteogenesis stimulator is not medically 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 spinal electrical osteogenesis stimulator have not been met. Therefore, we 
decided that the Plan does not have to pay for the spinal electrical osteogenesis stimulator (E0748) provided on 
December 8, 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. The Plan denied your request. The Plan says there 
is not enough medical evidence that shows the procedure is helpful and safe for knee pain. 
 
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 items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found genicular nerve blocks and genicular nerve radiofrequency ablation are considered 
investigational for the treatment of chronic knee pain. 
  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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cala Trio device and supplies. 
 
You asked the Plan to pre-approve a Cala Trio device. You say that the requested device is necessary for 
treatment of the enrollee's condition. You also say that the enrollee does not have any contraindications to 
transcutaneous afferent patterned stimulation (TAPS) therapy. 
 The Plan denied your request. The Plan says the requested device is experimental and investigational and 
therefore is not covered. 
 
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 Cala Trio device. Our reviewer says 
that the requested Cala Trio device is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested device is considered experimental and investigational. Therefore, the reviewer found that the requested device 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 Cala Trio device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Cala Trio device and supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a continuous glucose monitor (CGM). You say that you would like to 
request reconsideration of the denied authorization. The Plan denied your request. The Plan says the service is 
not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a non-adjunctive continuous glucose monitor 
(CGM) must be billed with code E2103. The rules also say that only devices reviewed by the PDAC and 
assigned code E2103 may be billed using this code.   
We looked at the file and Medicare rules. The request at issue is for the Freestyle Libre 3 non-adjunctive CGM. 
However, this device has not been reviewed by the PDAC and has not been assigned code E2103. As such, this 
non-adjunctive CGM device is not eligible for coverage at this time. Therefore, we decided that the Plan does 
not have to pre-approve a continuous glucose monitor (CGM).