Persius/hicric huggingface dataset:
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 in order to rehabilitate your 
lower limbs and left arm as well as needing consistent monitoring for your cardiac condition. 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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), of diagnostic or therapeutic substance(s) 
(e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including 
needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging 
guidance (62321). 
 
You asked the Plan to pre-approve injections. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the medical records show that the enrollee had this procedure done on March 16, 2023. 
To qualify for the same procedure again, the enrollee must have had at least 50% improvement or more for at 
least three (3) months after the first procedure. It has been less than a month since the first procedure. 
Therefore, the injection is considered 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 injections. 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 neck and bilateral shoulder pain and has the diagnosis of cervical 
radiculopathy. A cervical MRI on March 1, 2023, revealed C2-3 right facet arthropathy, C3- C4 mild left 
foraminal narrowing, C4-5, C6-7, and C7-T1 mild to moderate bilateral foraminal narrowing, and C5-6 mild 
bilateral foraminal narrowing. Her physical examination was unremarkable. Her pain medication includes 
oxycodone. She had physical therapy in the past. A C7-T1 epidural steroid injection (ESI) performed on March 
16, 2023, was reported as providing 90% relief on the left but no relief on the right. The treating physician has 
requested a repeat C7-T1 ESI. The LCD requires at least 50% pain relief for 3 months.  This was not achieved 
and therefore, the request is deemed 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 injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve injection(s), of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, 
steroid, other solution), not including neurolytic substances, including needle or catheter placement, 
interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (62321).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne Heme (F1Heme) test provided January 
11, 2023. 
 
You asked the Plan to pay for the F1Heme test. You say that this test was medically necessary and covered by 
Medicare. The Plan denied your request. The Plan says this testing is not covered because the documentation 
does not show that the enrollee meets criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, when the test is FDA approved. 
 
We looked at the file and Medicare rules. In this case we do not find that the requested test has FDA approval or clearance as a companion in vitro diagnostic. Based on this information, we decided that Medicare rules for 
coverage of the F1Heme test have not been met. Therefore, we decided that the Plan does not have to pay for 
the FoundationOne Heme (F1Heme) test provided January 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99310 billed for November 1, 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 with the correct place of service (POS) code. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the correct place of service 
(POS) code. 
 
We looked at the file and Medicare rules. The file shows that the claim was incorrectly billed with POS code 
13 for an assisted living facility. 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 procedure code 
99310 billed for November 1, 2022.
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 the enrollee's current medical condition 
requires an LTACH admission. The Plan denied your request. The Plan says the enrollee does not meet the 
requirements 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 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 health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. All medically 
necessary care is being provided in the current acute care setting.  The health plan has approved ongoing care 
in the current acute care 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 77003 and 64483 billed for date of service 
December 14, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the rules for 
payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
In this case, we have confirmed that code 77003 is a column II code to column I code 64483. Code 77003 has 
not been billed with an appropriate modifier to bypass the edit. The MUE for CPT code 64483 is 1. The MAI 
value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on the claim submitted, 
Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 77003 and 64483 billed for date of service December 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(Intracept procedure) (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the requested procedure is necessary 
to treat the enrollee's back pain. The Plan denied your request. The Plan says the requested procedure 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 Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the provided documentation does not clearly show the cause of the enrollee's 
back pain. Therefore, the reviewer found that the requested procedure 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 the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve thermal destruction of intraosseous basivertebral nerve (Intracept procedure) 
(64628).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient hospital care. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that an inpatient hospital stay is medically 
necessary. The Plan denied your request. The Plan says a lower level of care is more appropriate. 
 
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 the medical record does show that as of June 1, 2023, the enrollee was medically 
stable enough for 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for acute inpatient hospital care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve coverage for Denosumab (Xgeva). 
 You asked the Plan to pre-approve step therapy medication. You say that the medication is medically necessary 
for the enrollee. The Plan denied your request. The Plan says the requested medicine is not the preferred 
product for the enrollee's condition. The enrollee does not meet the Part B Step Therapy requirements for 
Denosumab. 
 
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 step therapy medication. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the enrollee has a history of 
osteoporosis. The provider has requested coverage of Denosumab (Xgeva). The enrollee does not have a 
history of failure, contraindication, or intolerance to the formulary alternatives, injectable bisphosphonate 
zoledronic acid (Zometa). This is not a continuation of therapy in the past 365 days. Medicare allows health 
plans to use step therapy for some Part B medicines. The medicine you requested is not the preferred product 
for the enrollees condition. The member does not meet the Part B Step Therapy requirements for Denosumab 
(Xgeva). The review has determined that the documentation does not support that Denosumab is medically 
reasonable and necessary for the enrollee. The documentation does not support that Denosumab is safe and 
effective 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 step therapy medication have not been met. Therefore, we decided that the Plan 
does not have to pre-approve coverage for Denosumab (Xgeva).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (20650, 64708) provided on October 20, 
2022. 
 
You asked the Plan to pay for the surgical services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the codes billed are 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 CPT code. 
 
We find that CPT code 20650 and 64708 is not supported in the medical record. Specifically, the billed codes 
are inclusive to code 25447 that was also billed. Based on this information, we decided that Medicare rules for 
coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to pay 
for surgical services (20650, 64708) provided on October 20, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqvio. 
 
You asked the Plan to pre-approve Leqvio. You say that the requested Leqvio is medically necessary. The Plan 
denied your request. The Plan says the enrollee must try and fail one high-intensity statin along with ezetimibe 
(as a single-entity or as a combination product) for greater than or equal to 8 continuous weeks.  
 
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 Leqvio. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee has not been on 
Ezetimibe with high dose statin therapy for 8 weeks. In this case, the enrollee has not tried and failed the 
required drug for 8 weeks. There is no documentation provided indicating 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 Leqvio have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Leqvio.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88313 billed for date of service October 27, 
2022.  
 
You asked the Plan to pay for procedure code 88313. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88313 is 8. The MAI value for this code is 3. You billed 11 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88313 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88313 billed for date of service October 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a freestyle libre 14 continuous glucose monitor (CGM). 
 
You asked the Plan to pay for the CGM. You say that the items should be covered as the enrollee disagrees 
with the denial. The Plan denied your request. The Plan says the items denied correctly as the enrollee does not 
meet the clinical requirements to be approved. 
 
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 have diabetes, 
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 pay for a freestyle libre 14 continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism, electric, any type (E0627). 
 
You asked the Plan to pre-approve a seat lift mechanism. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for approval. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section 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 a seat lift mechanism. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the enrollee has osteoarthritis of 
her back and knees with a history of falls. She has a stable gait with a walker. There is no evidence presented of 
weakness or inability to rise from a chair. Per LCD 33801, there is no evidence the enrollee is unable to stand 
up from a regular armchair or any chair in the home. 
 
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 seat lift mechanism have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a seat lift mechanism, electric, any type (E0627).
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 demonstrates potential for making 
measurable improvement in functional capacity and can participate in the required intensive therapy. 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 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 or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left atrial appendage closure (LAAC) procedure.  
 
You asked the Plan to pre-approve the requested LAAC procedure. You say that it is felt that the enrollee 
medically requires this procedure.  The Plan denied your request. The Plan says the NCD criteria are not met in 
this case.  
 
The Plan follows Medicare rules. Medicare rules say that LAAC procedures may be covered for enrollees with 
a CHA2DS2-VASc score of 3 or higher who have had a formal decision-making visit using an evidence-based 
too on oral anticoagulation. 
 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 requested LAAC procedure. Our 
reviewer says that the criteria for medical necessity are not met in this case.  Our physician reviewer found the 
records document that the enrollee's CHA2DS2-VASc score is only 2 at this time. In addition, while there is 
reference to consideration of the LAAC, there is no documentation of performance of an evidence-based shared 
decision-making interaction on anticoagulation. As such, guidelines would not support implantation of a LAAC 
in this setting. In summary, LAAC placement would not be considered reasonable or medically 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 the requested LAAC procedure have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a left atrial appendage closure (LAAC) procedure.