Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the VIA Disc procedure. 
 
You asked the Plan to pre-approve the VIA Disc procedure. You say that the enrollee's current diagnosis 
supports medical necessity. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the VIA Disc procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. 
 
 
 
 Our physician reviewer found there is little evidence in the medical literature to suggest that this is an 
appropriate procedure for the enrollees back pain. It is not an accepted standard of medical practice for the 
diagnosis or treatment of back pain. The requested injection of allograft, in this case VIA Disc NP, into the 
intervertebral disc for the treatment of degenerative disc disease is considered experimental and investigational.  
Therefore, VIA Disc is not medically reasonable or necessary for the treatment of degenerative disc disease. 
 
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 VIA Disc procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the VIA Disc procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint (SI) RFA (radiofrequency ablation) 
injection. 
 
You asked the Plan to pre-approve SI RFA injection. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says the requested service is considered as experimental 
or investigational. 
 
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 SI RFA injection. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is considered experimental therapy because of the large variability in efficacy 
reported in the peer reviewed literature. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SI RFA injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve sacroiliac joint (SI) RFA (radiofrequency ablation) injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 standard power wheelchair with single power 
option (K0836) and related accessories and features. 
 
You asked the Plan to pre-approve a Group 2 power wheelchair and related accessories and features. You say 
that the requested power wheelchair is a medical necessity for the enrollee. The Plan denied your request. The 
Plan says the requested power wheelchair 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 a Group 2 power wheelchair and related 
accessories and features. Our reviewer says that the requested items are not considered medically reasonable 
and necessary in this case. Our physician reviewer found that the enrollee does not have high risk for skin 
breakdown, does not use a catheter intermittently, does not have spasticity nor requires an alternative means of 
managing the power drive. 
 
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 Group 2 power wheelchair and related accessories and features. have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a Group 2 standard power wheelchair 
with single power option (K0836) and related accessories and features.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Keytruda and trastuzumab-qyyp. 
 
You asked the Plan to pre-approve Keytruda and trastuzumab-qyyp. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Keytruda and trastuzumab-qyyp. Our 
reviewer says that the enrollee does not meet criteria for these drugs. Our physician reviewer found the 
requested drug combination is not Food & Drug Administration (FDA) approved for the enrollee's condition. 
The requested combination is not supported by one of the major drug compendia or by clinical research appearing in a Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda and trastuzumab-qyyp have not been met. Therefore, we decided that 
the Plan does not have to pre-approve use of Keytruda and trastuzumab-qyyp.
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 it is imperative that you be placed somewhere to get 
stronger for your upcoming surgery. The Plan denied your request. The Plan says the service requested is not 
supported based on the limited records received. 
 
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. 
Daily skilled services are not shown to be required to establish a maintenance program or to prevent 
deterioration of your condition. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orgovyx (C9399). 
 
You asked the Plan to pre-approve the medication. 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 Orgovyx (C9399).   
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 medical records provided support the need for 
care in an IRF. The Plan denied your request. The Plan says that admission to an IRF is not medically 
necessary and does not meet the criteria for coverage.  
 
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 enrollee 
was admitted for sepsis, pneumonia, atrial fibrillation and myocardial infarction. 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: 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 you are requesting reconsideration for 
the denial of an LTACH admission. The Plan denied your request. The Plan says the enrollee does not meet the 
guidelines for LTACH services. 
 
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. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the Plan. Given there are offered alternatives, LTACH 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 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the cervical 
spine. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no clear documentation of a failed six-week long course of provider-directed 
conservative therapy with face-to-face follow-up within the past three months. 
 
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 the MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found that there are no red 
flags, such as weakness or absent reflex. The plain x-rays show degenerative changes. Medical necessity of 
MRI without a trial of physical therapy has not been established in the submitted records. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the cervical spine.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that without ventilator therapy, the enrollee is at high 
risk for hospital readmission and potentially life-threatening exacerbations. The Plan denied your request. The 
Plan says the requested therapy could be provided by a bilevel positive airway pressure (BiPAP) device. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not 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 ventilator. Our reviewer says that the 
enrollee does not meet criteria for a ventilator. Our physician reviewer found Medicare does not cover a home 
ventilator when used at settings that can be provided with a bilevel positive airway pressure (BiPAP) device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ventilator have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of a ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services (D5213 and D5214). 
 
You asked the Plan to pre-approve the dental services (D5213 and D5214). You say that you would like to 
request reconsideration of the denied dental services and that the services requested are medically necessary. 
The Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 02, 2023. 
Therefore, we decided that the Plan does not have to pre-approve the dental services (D5213 and D5214).
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code 43281. We decided that the 
Plan does not have to pay for the services described by procedure code 43644.  
 
You asked the Plan to pay for the surgery services provided on January 9, 2023. The Plan says that the billing 
criteria have not been met. 
 
We decided that the Plan has to pay for the services described by procedure code 43281.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan states that code 43281 is not appealable, however, that is not correct. The Plan has not 
provided valid rationale as to why this code cannot be appealed. As the Plan forfeited its opportunity to provide 
a sufficient denial rationale for these services, we find that the denial of payment is not supported.  Therefore, 
we decided that the Plan has to pay for the services described by procedure code 43281.  
 
We also decided that the Plan does not have to pay for the services described by procedure code 43644. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file, and Medicare rules. The claim shows that code 43644 was billed with secondary 
diagnosis code Z68.36, and tertiary diagnosis code I10. These codes are not among those covered for a 
secondary diagnosis from ICD-10 Code group 1 and a tertiary diagnosis from ICD-10 Code group 2. Based on 
this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pay for the services described by procedure code 43644. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve KEYTRUDA. 
 
You asked the Plan to pre-approve KEYTRUDA. You say that the enrollee needs for continued treatment. The 
Plan denied your request. The Plan says the criteria for medical necessity have not been met.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 KEYTRUDA. Our reviewer says that 
the drug is not medically necessary. Our physician reviewer found the use of this drug is not reasonable and 
necessary for the enrollee. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of KEYTRUDA have not been met. Therefore, we decided that the Plan does not 
have to pre-approve KEYTRUDA.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Viberzi. 
 
You asked the Plan to pre-approve the medication. You say that this medication is necessary for this enrollee. 
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 Viberzi.  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 was sent for therapy which was not 
enough treatment to resolve the injuries. The enrollee states she was not able to get the care she required after 
being sent home. An aggressive therapy in a rehabilitation was requested as it is needed so that the enrollee can 
return home and have some independence in standing, walking and dressing herself. The Plan denied your 
request. The Plan says that admission to an IRF is not medically necessary and does not meet the criteria for 
coverage.  
 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 
enrollee was admitted for surgical repair of a hip fracture after a fall. 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.