Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Optimizer Smart device. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the Optimizer Smart device was 
approved by the Food and Drug Administration (FDA) in 2019; however, it remains the subject of multiple 
studies examining long-term efficacy, as well as randomized, controlled, double-blinded trials to quantify 
clinical efficacy. The services are not the standard of care or reasonable or medically necessary at this time. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Optimizer Smart device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you live alone and cannot go home. You 
say you need rehabilitation before you go home. The Plan denied your request. The Plan says admission to an 
LTACH is not medically necessary.  
 
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 that you are receiving all indicated treatments at the acute care hospital. There are no 
specific treatments you would receive at the LTACH that you are not currently receiving at approved acute 
hospital. 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 LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that a lower level of care will hinder progress and 
increase risk of re admission to the hospital. The Plan denied your request. The Plan says the coverage criteria 
has not been met. 
 
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 that you do not have complex nursing or rehabilitation needs. 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 you 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) and core buildups (D2950 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that these procedures are necessary to eat, and 
you cannot afford them on your own. The Plan denied your request. The Plan says these services are not 
covered under the Plan's dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
crown (D2740) and core buildups (D2950 x 2).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Confirm MDx testing (81551) provided on March 16, 
2023. 
 
You asked the Plan to pay for the Confirm MDx testing. You say that the test is 'standard of care' for the 
management of men at risk for undetected prostate cancer. The Plan denied your request. The Plan says criteria 
is not met for ConfirmMDx testing. 
 
The Plan follows Medicare rules. Medicare rules say that this testing is covered when the criteria in the 
Medicare rules section of this letter 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 Confirm MDx testing. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found that criteria is not met for 
ConfirmMDx as the patient was not being considered for a second biopsy due to persistent risk factors such as 
elevated/rising PSA and/or abnormal DRE by repeat testing. The review has determined that the enrollee did 
not meet the coverage criteria for the Confirm MDx testing (81551) provided on March 16, 2023. 
 
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 Confirm MDx testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the Confirm MDx testing (81551) provided on March 16, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Montegrity. 
 
You asked the Plan to pre-approve Montegrity. You say that the enrollee is dealing with persistent abdominal 
symptoms related to constipation. You say that the enrollee has tried and failed multiple medications for these 
symptoms including Linzess, Trulanece and Miralax. The Plan denied your request. The Plan says that self -
administered drugs do not fall under Medicare Part B coverage. 
 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 Montegrity.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Syfovre. 
 
You asked the Plan to pre-approve Syfovre. You say that the denial of coverage for Syfovre increases the 
likelihood that the enrollee will suffer from more rapid, irreversible vision loss. You also say this drug is 
currently the only available medication for her condition.  The Plan denied your request. The Plan says the drug 
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 Syfovre. Our reviewer says that this 
drug is not medically necessary for the enrollee. Our physician reviewer found that the enrollee does not have 
fundus autofluorescence imaging provided for review to document the size of the geographic atrophy to 
support treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Syfovre have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Syfovre.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty at L1 (22514). 
 
You asked the Plan to pre-approve kyphoplasty. 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 percutaneous vertebroplasty (PVP) and percutaneous 
vertebral augmentation (PVA) will be considered reasonable and necessary for osteoporotic conditions when 
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 kyphoplasty. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found detailed documentation is not evident 
regarding worsening pain. There is no indication of a progression of the body height loss. There is also a 
discrepancy regarding the location of the compression fracture. Moreover, there is magnetic resonance imaging 
(MRI) corroboration of plausible other causes of pain. Therefore, the enrollee does not meet the coverage 
criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty at L1 (22514).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 80305, 82077, G0482, and G0483 billed for 
date of service November 21, 2022.  
 
You asked the Plan to pay for procedure codes 80305, 82077, G0482, and G0483. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says payment for codes 80305, 82077, G0482, 
and G0483 is bundled into payment for other codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules also say that claims submitted 
where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. 
 
In this case, we have confirmed that code 80305 is a column II code to column I code 80306 with a modifier 
indicator of 0. We have confirmed that code 82077 is a column II code to column I code G0482 with a modifier 
indicator of 0. We have confirmed that code G0482 is a column II code to column I code 80306 with a modifier 
indicator of 0. The column II codes are therefore not payable. The MUE for CPT code G0483 is 1. The MAI 
value for this code is 2. You billed 4 units of this code, exceeding the MUE. 
 
Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes 80305, 82077, G0482, and G0483 billed for date of service 
November 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says admission to an IRF is not medically necessary.  
 
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 that 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 does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may a need for physical therapy 
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 an IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you live on the second floor and cannot go up and 
down steps. You are requesting admission to a SNF to build up your strength and be able to return home. The 
Plan denied your request. The Plan says criteria for approval of a SNF admission have not been met.  
 
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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
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 SNF care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lower spine 
(72148). 
 
You asked the Plan to pre-approve an MRI of the lower spine. 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 must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
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 an MRI of the lower spine. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found during the encounter 
of February 9, 2023, there were no red flag was noted. The enrollee has no reflex abnormality or weakness. 
There was no plain x-ray report. She has known diabetic neuropathy. There is no contraindication to a 6-week 
trial of physical therapy before going on to MRI. 
 
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 MRI of the lower spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lower spine (72148).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation. 
 
You asked the Plan to pre-approve additional mileage for routine transportation. You say that the enrollee 
needs transportation to medical appointments. The Plan denied your request. The Plan says the enrollee's 
benefit only allows 40 one-way trips with each one-way trip not exceeding 60 miles of driving distance. 
 
 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 routine transportation when the driving distance for a one-way trip is within 60 miles.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, the provider is 
located 93.2 miles away from the enrollee's residence. The Plan only covers distances up to 60 miles. 
Therefore, we decided that the Plan does not have to pre-approve additional mileage for routine transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for a transport chair (E1037) purchased on March 7, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to reimburse you for a transport chair. You say that you needed a wheelchair in an 
emergency and was not aware that the local medical supply store was out of network. The Plan denied your 
request. The Plan says enrollees must receive their medical services from an in-network provider with the 
exception being urgent or emergent services. Non-emergent services with non-contracted providers require 
prior authorization before services being rendered. 
 
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 reimburse you for care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to reimburse you for these 
items/services. Therefore, we decided that the Plan does not have to reimburse you for a transport chair 
(E1037) purchased on March 7, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (80307, 83789, G0480) provided on May 9, 
2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
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 codes 80307, 83789, & G0480 are not supported in the medical record. Specifically, the lab 
order does not specifically show what tests are being ordered. Code 83789 is for validity testing which is 
included in the base lab procedure and not separately payable. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for lab services (80307, 83789, G0480) provided on May 9, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says admission to an IRF is not supported based on the 
records received.  
 
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 that the enrollee does not require the intensity of services provided at an IRF.  
Specifically, the enrollee is not shown to require 15 hours per week of rehabilitative services and regular 
physician evaluation. The enrollees care needs can be met 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasties at T12 and L1 (22514, 22513). 
 
You asked the Plan to pre-approve kyphoplasties at T12 and L1. 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 percutaneous vertebroplasty (PVP) and percutaneous 
vertebral augmentation (PVA) will be considered reasonable and necessary for osteoporotic conditions when 
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 kyphoplasties at T12 and L1. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found detailed 
documentation is not evident regarding worsening pain. There is no indication of a progression of the body 
height loss, greater than 25% vertebral body height loss, kyphotic deformity, or a severe impact on daily 
activities. Moreover, the magnetic resonance imaging (MRI) does not corroborate the fractures are 
acute/subacute. There are multiple other plausible causes of the back pain demonstrated. Therefore, the enrollee 
does not meet the coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasties at T12 and L1 have not been met. Therefore, we decided that the 
Plan does not have to pre-approve kyphoplasties at T12 and L1 (22514, 22513).