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

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation.. The Plan denied your request. The Plan 
says the request for additional transportation is not covered by the enrollees health plan. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation, nerves innervating the 
sacroiliac joint, with image guidance (64625 x2). 
 
You asked the Plan to pre-approve radiofrequency ablation, nerves innervating the sacroiliac joint, with image 
guidance. You say that this is medically necessary. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve radiofrequency ablation, nerves 
innervating the sacroiliac joint, with image guidance. 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 wide variation 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 radiofrequency ablation, nerves innervating the sacroiliac joint, with image 
guidance have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency 
ablation, nerves innervating the sacroiliac joint, with image guidance (64625 x2).
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 getting weaker and cannot go home. 
You say the enrollee does not have anybody to monitor them at home which can result in other issues such as 
falling. The Plan denied your request. The Plan says the enrollee does not meet Medicare guidelines for 
services in an IRF.  
 
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 do 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, at 
an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled therapy with 
ongoing safety concerns and a potential for functional improvement; however, the documentation doesnt 
support that they would meet criteria for admission to an acute inpatient rehabilitation facility. The enrollee can 
receive further services 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 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission is medically necessary. The Plan denied 
your request. The Plan says your records do not show that you have complex rehabilitation needs requiring 
evaluation by a rehabilitation physican at least three times a week for evaluation of functional and medical 
goals and progress. The Plan says services may be provided at 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 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Erbitux. 
 
You asked the Plan to pre-approve Erbitux. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the enrollee is in a clinical trial. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve Erbitux as part of a clinical trial. The Plan does not cover 
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-
approve Erbitux.
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 the enrollee meets the criteria for an 
LTACH admission. You also say there is no reason to think the enrollee will not require a 25-day length of stay 
at the LTACH, and the enrollee needs a critical illness hospital to allow for additional close physician 
monitoring to maximize recovery and allow for a stable discharge. The Plan denied your request. The Plan says 
the LTACH services requested do not meet the requirements for approval.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there are no services at LTACH that are not available in the enrollee's current setting and no therapeutic advantage to transfer is anticipated. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has very severe chronic 
obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA). There is no diagnosis of thoracic 
restrictive disease or neuromuscular disease. He has not tried and failed bi-level positive airway pressure 
(BiPAP) on average volume-assured pressure support (AVAPS) mode. The criteria for coverage are not met 
and the home ventilator 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
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 LTACH services. You say that the enrollee needs LTACH services. The 
Plan denied your request. The Plan says the enrollee is currently unstable for an LTACH admission. 
 
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 at the time of the request for LTACH services, the enrollee, who has not completed 
the acute hospital course and is medically unstable for transfer, requires no services available at the LTACH 
that are not available at the health care setting being offered by the Plan. There is no documentation provided,  
 indicating medical necessity for admission to an LTACH. The requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
array (63650, L8680). 
 
You asked the Plan to pre-approve percutaneous implantation of neurostimulator electrode array. You say that 
this is medically necessary. The Plan denied your request. The Plan says documentation does not show that all 
other treatment options have been tried and failed and this is the last resort to improving the enrollee's 
condition. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules say that implantation of stimulators can be covered under specific 
conditions. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve percutaneous implantation of 
neurostimulator electrode array. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the enrollee has not had a 
surgical consultation, chiropractic therapy or massage therapy. The enrollee has not had sacroiliac joint 
injections. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous implantation of neurostimulator electrode array have not been 
met. Therefore, we decided that the Plan does not have to pre-approve percutaneous implantation of 
neurostimulator electrode array (63650, L8680).
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 do not 
require an acute rehab 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, at an intensive rehabilitation therapy program. 
The enrollee continues to have a need for skilled therapy with ongoing safety concerns and a potential for 
functional improvement however, the documentation doesnt support that the enrollee would meet criteria for 
admission to an acute inpatient rehabilitation facility.  There is no indication that the enrollee would require 
skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a 
physician with at least 3 visits weekly to regain or maintain the enrollee's functional status.  The enrollee can 
receive further services 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 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission is medically necessary. The Plan denied 
your request. The Plan says your records do not show you need an intensive team for your care. The Plan says 
services may be provided at 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 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: 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 weaker from their hospitalization and 
has significant weight loss due to a medical emergency. You say the enrollee is presenting below prior level of 
function. The Plan denied your request. The Plan says the enrollee does not meet Medicare guidelines for 
services in an IRF.  
 
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 intensive rehabilitation. The enrollee does not require 
frequent physiatry oversight.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 27220 provided on April 18, 2023. 
 
You asked the Plan to pay for procedure code 27220. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the billed code is 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 27220 is restorative treatment to support closed treatment 
of acetabulum fracture. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 27220. Our reviewer says that the records do 
not support the code billed. Our reviewer found the provided documentation does not support that the 
procedure was performed.  
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 27220 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 27220 provided on April 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve varicose vein sclerotherapy and stab phlebectomy. 
 
You asked the Plan to pre-approve varicose vein sclerotherapy and stab phlebectomy. You say that varicose 
vein sclerotherapy and stab phlebectomy are medically necessary. The Plan denied your request. The Plan says 
varicose vein sclerotherapy and stab phlebectomy are not medically necessary.  
 
The Plan follows Medicare rules. 
 
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 varicose vein sclerotherapy and stab 
phlebectomy. Our reviewer says that the requested varicose vein sclerotherapy and stab phlebectomy are not considered medically reasonable and necessary in this case. Our physician reviewer found that for tributary 
treatment such as stab phlebectomy and sclerotherapy to be considered medically necessary per coverage 
criteria, there needs to be persistent significant symptoms following successful treatment of truncal (saphenous) 
reflux with these symptoms existing more than 6 weeks after the reflux was treated and despite conservative 
efforts.  Additionally, the veins to be treated need to be at least 4 mm in diameter (this condition is met).  As 
the patient has not yet undergone saphenous vein reflux treatment, the above criteria have not been met. The 
health Plan does not provide for simultaneous saphenous reflux treatment and tributary treatment.  A rationale 
for this is that many patients experience satisfactory relief with the truncal intervention alone. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of varicose vein sclerotherapy and stab phlebectomy have not been met. Therefore, 
we decided that the Plan does not have to pre-approve varicose vein sclerotherapy and stab phlebectomy.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Prolia. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee is at risk for repeat fractures based 
on their history. The Plan denied your request. The Plan says that the requested treatment order of Prolia 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 the medication. Our reviewer says that 
the request is medically necessary. Our physician reviewer found that the record indicates that the enrollee has 
a history of osteoporosis treated with Evista, Fosamax, Reclast and Prolia. Prolia is indicated by the Food and 
Drug Administration (FDA) for the treatment of postmenopausal women with osteoporosis at high risk for 
fracture. There is a documented response to Prolia therapy and Prolia is FDA approved for the enrollees 
diagnosis. 
 
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 medication have been met. Therefore, we decided that the Plan has to pre-
approve Prolia.  
 
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.