Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve two (2) bilateral facet joint blocks. We decided that the Plan 
does not have to pre-approve one (1) facet joint block.  
 
You asked the Plan to pre-approve a lumbar/sacral facet joint block (64493).. You say that the injections are 
needed.  The Plan says that no unique circumstances are documented that would sufficiently explain the need 
for a three-level procedure.  
 
We decided that the Plan has to pre-approve two (2) bilateral facet joint blocks.  
 
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 
LCD limits the number of levels treated to two (2) bilaterally. Only 2 levels are medically 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 the services have been met. Therefore, we decided that the Plan has to pre-
approve two (2) bilateral facet joint blocks.  
 
We also decided that the Plan does not have to pre-approve one (1) facet joint block. 
 
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 one (1) facet joint block. Our reviewer 
says that the third level does not meet the criteria and is not medically 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 one (1) facet joint block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve one (1) facet joint block. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 23, 2023. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says several attempts 
were made to obtain the medical records documenting the surgical procedure.  
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the office visit have been met. The 
required medical records documenting the surgical procedure have not been provided. Therefore, we decided 
that the Plan does not have to pay for an office visit provided on January 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vyzulta. 
 
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 Vyzulta.   
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care for the total knee 
arthroplasty (27447). 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient hospital care is medically 
necessary. The Plan denied your request. The Plan says the knee replacement does meet Medicare coverage 
criteria; however, the request was made on an inpatient basis which is not covered due to you not meeting 
requirements for prolonged postoperative monitoring. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case.Our 
physician reviewer found you are medically stable and have been provided medical clearance for the procedure. 
There is no specific clinical rationale for inpatient level of care services. Though the total knee replacement 
meets Medicare coverage criteria, the request for this surgery to be done on an inpatient basis does not. The 
review indicates that the record did not show that the admitting physician reasonably expects that you 
necessary hospital care will span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care for the total knee arthroplasty (27447).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided from January 20, 2023, to 
February 22, 2023. 
 
You asked the Plan to pay for the physical therapy. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and 
available and requires authorization for certain services. No medical necessity for an out-of-network provider 
such as an urgent or an emergent situation that has been documented.   
 
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 pay 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 did not pre-approve the 
service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physical therapy provided from January 20, 2023, to 
February 22, 2023.
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 need therapy, and only have one leg, he is a fall 
risk right now. The Plan denied your request. The Plan says your records do not show you have complex 
rehabilitation needs that require frequent evaluation by a rehabilitation doctor. 
 
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 your 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repatha. 
 
You asked the Plan to pre-approve the medication. You say that you disagree with the denial. 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 Repatha.   
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is still very weak, and it would benefit 
getting skilled inpatient therapy for a few days up to one week to help regain in-dependency. The Plan denied 
your request. The Plan says the enrollee's skilled therapy needs can be actively supported by home based 
skilled therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from January 18, 2022, to 
October 13, 2022. 
 
You asked the Plan to pay for the psychotherapy. You say that this psychiatrist has been the same provider 
since the beginning your treatment and she has been treating your depression for more than ten years and 
knows how to control it. The Plan denied your request. The Plan says non-emergent, non-urgent services with 
out-of-network providers require prior authorization. 
 
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 pay 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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for psychotherapy provided from January 18, 2022, to  
October 13, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from October 7, 2022, to 
November 2, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that where required by law or regulation, report the Federal 
Information Processing Standards (FIPS) State and County Code of the place of residence where the home 
health service is delivered with code 85. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the valid FIPS code. 
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 pay for the home health services rendered from October 7, 
2022, to November 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image guided proton beam therapy (77399).  
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says there is no current research showing that the enrollee's type of cancer 
responds better to the requested type of treatment than the type that can be approved by the Plan, Intensity-
Modulated Radiation Therapy (IMRT).  
 
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 items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found proton therapy is not experimental, but rather is simply another means if delivering radiation, 
and has been in use for the treatment of oncology patients for decades. There are dosimetric advantages to using proton therapy over intensity-modulated radiation therapy (IMRT) in select situations, in which proton 
therapy offers a clinically meaningful benefit.  For this enrollee, there is no plausible reason for why IMRT 
would be unacceptable or that proton therapy would offer a plausible clinically meaningful benefit over 
standard of care IMRT. 
 
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 image guided proton beam therapy (77399).
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 still have an infection in your amputated area, 
staples have never been removed. The Plan denied your request. The Plan says your request does not meet 
Medicare guidelines because you no longer require skilled services on a daily inpatient basis. 
 
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 skilled nursing facility (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 skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuous glucose monitor (CGM) device. 
 You asked the Plan to pre-approve the CGM. You say that the enrollee requires a CGM to check their blood 
glucose levels. The Plan denied your request. The Plan says the requested CGM is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia, had an in-person visit with their treating physician to evaluate 
their diabetes control and to determine whether the criteria for coverage have been met.  Based on this 
information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the continuous glucose monitor (CGM) device.
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 would benefit from rehab for their 
complex medical needs. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
acute inpatient rehabilitation.  
 
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 enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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 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 an ultra-lightweight manual wheelchair (K0005). 
 
You asked the Plan to pre-approve the wheelchair. You say that the manual wheelchair you have is old and is 
too heavy for you to move in and out of your car. The Plan denied your request. The Plan says there is no 
indication that the current power scooter is not meeting the enrollee's needs within the home. 
 
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 Group 1 power operated vehicle (K0800) which was provided April 18, 2022. 
The Group 1 power operated vehicle (K0800) serves the same purpose as the wheelchair. Therefore, we 
decided that the Plan does not have to pre-approve an ultra-lightweight manual wheelchair (K0005).
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 need to regain strength and you are afraid if 
discharged to home you will fall and end up back in the hospital. The Plan denied your request. The Plan says 
your records do not show that you have complex rehabilitation needs that require frequent evaluation by a 
rehabilitation doctor. Services needed may be provided safely in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mental health clinic services billed with code 96373 for date 
of service September 27, 2022. 
 
You asked the Plan to pay for the mental health clinic services. You did not provide a specific argument for 
coverage of this service with your appeal request. The Plan denied your request. The Plan says this service was 
not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that for mental health services provided by a 
Federally Qualified Health Center (FQHC), the provider must bill either G0463 or G0470 for these services.  
Other codes are not appropriate for services provided by a FQHC. 
 
In this case, the mental health services in question were provided by a FQHC.  However, this FQHC billed an 
inappropriate code for the services provided.  Until the provider bills this service correctly, the Plan cannot be 
obligated to pay for it.  You have the right to request that the provider correct its billing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the mental health clinic services have not been met. Therefore, we decided that the Plan does not 
have to pay for mental health clinic services billed with code 96373 for date of service September 27, 2022.