Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4239 billed for date of service March 2, 
2023. 
 
You asked the Plan to pay for procedure code A4239. The Plan denied your request. The Plan says procedure 
code A4239 is considered bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code A4239 has a status indicator of P on the Physician Fee Schedule. This means that procedure code A4239 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code A4239 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A4239 billed for date of service March 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care services provided on September 23, 2022, to 
September 30, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the wound care services. You say that you would like retroactive authorization 
for the services in dispute based on medical necessity.  The Plan denied your request. The Plan says the 
enrollee was seen at home for evaluation of multiple chronic vascular ulcers. The Plan says that these services 
were available in-network.  
 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 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 pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for wound care services provided on September 23, 
2022, to September 30, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4239 billed for date of service March 2, 
2023. 
 
You asked the Plan to pay for procedure code A4239. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code A4239 is considered bundled or excluded. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code A4239 has a status indicator of P on the Physician Fee Schedule. This means that procedure code A4239 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code A4239 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A4239 billed for date of service March 2, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 You asked the Plan to pre-approve Evenity. 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. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Evenity. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found Based on the medical records provided 
there is no indication that the enrollee has tried and failed the required drugs. There is no indication that the 
plan's required drugs would likely be less effective and/or likely have adverse effects 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 Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
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 is stable and no longer needs 
to remain in a short-term acute hospital. You also say the enrollee's needs can be met at an LTACH level of 
care. The Plan denied your request. The Plan says admission to the 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 all medically necessary care is being provided in the current acute care setting.  
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. The Plan has approved ongoing care in the current acute care setting.  The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 miscellaneous durable medical equipment (DME) 
supply or accessory (A9999). 
 
You asked the Plan to pre-approve a miscellaneous DME. You say that you feel the oxygen system is necessary 
for your health. The Plan denied your request. The Plan says the documentation requirements have not been 
met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
 
 
 The record does not contain a valid physician order, a face-to-face encounter with your pulmonary doctor, or 
relevant medical records which support medical necessity for the supplies requested in this case. The record 
shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, 
we decided that the Plan does not have to pre-approve a miscellaneous durable medical equipment (DME) 
supply or accessory (A9999).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a flag (K0108), power seat elevation system (E2300), 
electronic connection (E2311), harness (E2313), and expandable controller (E2377). 
 
You asked the Plan to pre-approve a flag, power seat elevation system, electronic connection, harness, and 
expandable controller. You say that the provided medical documentation supports the need of the custom 
medical equipment being requested for the enrollee. The Plan denied your request. The Plan says the seat 
elevator does not serve a primary medical purpose and is statutorily non-covered. The Plan says that a flag does 
not serve a medical purpose and cannot be covered. The Plan also says that the electronic connection, harness, 
and expandable controller cannot be covered as it is not medically necessary to control the three approved 
power options through the joystick. 
 
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 power seat elevation system, 
electronic connection, harness, and expandable controller. 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 adequate strength in upper extremity to manage standard power drive controls. Our reviewer also found 
that the power seat elevation is not medically necessary per Medicare rules. 
 
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 flag, power seat elevation system, electronic connection, harness, and 
expandable controller have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
flag (K0108), power seat elevation system (E2300), electronic connection (E2311), harness (E2313), and 
expandable controller (E2377).
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 the enrollee is stable and suitable for transfer 
to the LTACH, and their needs cannot be adequately cared for in their current condition at a skilled nursing 
facility or any other lower level of care. The Plan denied your request. The Plan says admission to the 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 the record indicates that the enrollee has ongoing acute medical issues and still 
requires acute care services before transitioning to a lower level of care. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires 
services that they are not currently receiving but that would be available at the LTACH facility. The elements 
of the coverage rules are not satisfied.   
 
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 an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets IRF admission criteria, and you 
would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the 
IRF services requested do 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 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 enrollee may have 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve carpal tunnel release. 
 
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 that you are being treated for carpal 
tunnel syndrome. There is no detailed documentation regarding a trial and failure of recent, reasonable, 
comprehensive, less invasive conservative care measures. The most recent examination did not support the 
presence of left-sided carpal tunnel syndrome. Moreover, there are no electrodiagnostic studies provided or 
noted to corroborate carpal tunnel syndrome. There are limited large-scale, long-term references showing the safety and efficacy of the requested surgery in this clinical setting. No compelling rationale is presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
requested carpal tunnel release, in this case, is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve carpal tunnel release.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR). 
 
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 an ILR is covered when specific 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has no history of atrial 
fibrillation or any significant cardiac arrhythmias noted on electrocardiogram (ECG) monitoring. A recent 
randomized clinical trial found that continuous monitoring for atrial fibrillation with an ILR was not superior to 
usual care in reducing stroke or systemic embolism among patients at high risk of stroke but without a known 
prior history of atrial fibrillation (1). At this time, insertion of an ILR would not be considered medically 
appropriate and necessary in this enrollee's clinical management. 
 
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 implantable loop recorder (ILR).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient admission for a reverse shoulder arthroplasty. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the surgery is needed, and that 
inpatient admission should be allowed. The Plan denied your request. The Plan says this can be done as an 
outpatient procedure 
 
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 there is no documentation provided to support the expectation that this surgery will 
require greater than a 2 midnight stay. This procedure is not listed on the inpatient only list, and the enrollee is 
medically stable. 
 
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 inpatient admission for a reverse shoulder arthroplasty.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heart procedure called percutaneous transluminal 
coronary lithotripsy. 
 
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 records show that you underwent 
cardiac catheterization on June 1, 2023 followed by a successful stenting procedure. The use of the requested 
lithotripsy is not 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 a heart procedure called percutaneous transluminal coronary lithotripsy.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
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 medical records do not contain 
magnetic resonance imaging (MRI) showing only modic changes without facet degenerative joint disease or 
foraminal stenosis. The Intracept procedure is therefore not reasonable or 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 an Intracept procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a revision of total shoulder arthroplasty (23473). 
 
You asked the Plan to pre-approve a revision of total shoulder arthroplasty. You say that the requested service 
is a medical necessity for you. The Plan denied your request. The Plan says the requested service 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 revision of total shoulder arthroplasty. 
Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. 
Our physician reviewer found that there is no documentation of a 6- to 12-week trial of conservative measures 
for shoulder pain. Additional conservative measures are needed to demonstrate the medical necessity of the 
requested procedure.  
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 revision of total shoulder arthroplasty have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a revision of total shoulder arthroplasty (23473).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient surgery, knee replacement (27447) to be 
provided by an out-of-area (OOA) provider.  
 
You asked the Plan to pre-approve outpatient surgery. You say that the enrollee should be covered for knee 
surgery in Florida. The Plan denied your request. The Plan says surgery was requested in Florida by a doctor 
who is not in the enrollee's health plans network. The records do not show that the enrollee needs emergency 
care. The enrollee must use in-network providers in the enrollee's area for all medical services. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 We looked at the file and Medicare rules. The requested provider in this case is not a network provider with the 
Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We 
found no exception that would require the Plan to pre-approve these items/services. Based on this information, 
we decided that Medicare rules for coverage of outpatient surgery have not been met. Therefore, we decided 
that the Plan does not have to pre-approve outpatient surgery, knee replacement (27447) to be provided by an 
out-of-area (OOA) provider.