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 admission to an IRF is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for 
admission to 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 Based on documentation, the enrollee requires an intensive rehabilitation program of 
3 hours of therapy a day for a minimum of 5 days per week. The enrollee will require multiple specialists, 
including physical therapy (PT), occupational therapy (OT)  and speech. The enrollee will require coordination 
of multiple disciplines under direction of rehab physician to attain maximal level of progression prior to 
discharge. There is a reasonable expectation that this enrollee will be able to fully participate and benefit from 
an intensive rehabilitation therapy program.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve one month rental of a power wheelchair (K0823). 
 
You asked the Plan to pre-approve one month rental of a power wheelchair. You say that the item is medically 
necessary. The Plan denied your request. The Plan says they have already covered four months of the 
wheelchair rental leaving only 9 months remaining of the 13-month rental period. 
 
The Plan must follow Medicare rules. The rules say that as of January 1, 2011, standard power wheelchairs are 
only available as capped rental items.  
 
In this case, the Plan has approved coverage for rental of a power wheelchair for an additional nine months. 
This will bring you to the 13-month cap rental period. Therefore, we decided that the Plan does not have to pre-
approve one month rental of a power wheelchair (K0823).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing this denial. The Plan denied your 
request. The Plan says the denial of IRF care is correct. 
 
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 does not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
While the enrollee may need physical and/or occupational therapy, the documentation does not support that the 
enrollee would meet criteria for admission to an IRF. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the New Leaf Flex-A-Bed HiLo Queen adjustable 
bed (E1399) purchased May 19, 2022. 
 
You asked the Plan to reimburse you for the adjustable bed. You say that you were told that the company you 
purchased the bed from was not in network, but you could still use them, and you would just need to file 
reimbursement. The Plan denied your request. The Plan says this bed does not meet the definition of DME and 
is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to reimburse you for the New Leaf Flex-A-Bed HiLo Queen adjustable bed 
(E1399) purchased May 19, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit. 
 
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 Medicare may pay for unlabeled uses for FDA-
approved 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has anemia of chronic 
disease related to systemic lupus erythematosus. The use of Retacrit is not approved by the Food and Drug 
Administration (FDA) for this diagnosis. The use is not supported by the drug compendia and current medical 
literature. The Retacrit 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 Retacrit.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the VIA Disc NP procedure (0627T). 
 
You asked the Plan to pre-approve the procedure. You say that this recommendation is medically necessary. 
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 procedure. Our reviewer says that 
the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found this is considered an experimental procedure 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 the procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the VIA Disc NP procedure (0627T).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 22 or more drug 
classes (G0483) provided on March 28, 2023. 
 
You asked the Plan to pay for the definitive UDT for 22 or more drug classes. You say that the number of 
definitive urine drug classes requested are not medically necessary. The Plan denied your request. The Plan 
says this testing was medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that definitive drug testing is covered when the criteria in
the rules section of this letter 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 pay for the definitive UDT  for 22 or more drug 
classes. Our reviewer says that the service is not medically necessary. Our physician reviewer found that the 
medical record sent by the provider shows screening test results which are positive or inconsistent with 
prescription medications, or history and expected results. Definitive confirmation testing was medically 
necessary for only 2 drug class(es): Opiates; Oxycodone. The review has determined that the LCD coverage 
criteria were not met. 
 
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 definitive UDT for 22 or more drug classes have not been met. Therefore, 
we decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 22 or more drug 
classes (G0483) provided on March 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with single power option 
and accessories. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair with single power option. You say that the 
enrollee has a need in their home for a special wheelchair suspension. You say that the enrollee's occupational 
therapist indicates the advanced suspension of a Group 3 power wheelchair is necessary to mitigate the 
enrollee's significant pain. The Plan denied your request. The Plan says the notes do not show that the enrollee 
needs either power tilt or power recline. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with single power option 
may be covered when certain 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 a Group 3 power wheelchair with single 
power option. Our reviewer says that the request for a Group 3 power wheelchair with single power option is 
not medically necessary. Our physician reviewer found the provided documentation does not indicate that the 
enrollee has high risk for skin breakdown, use a catheter intermittently, has spasticity or requires an alternative 
means of managing power drive. Therefore, the reviewer found that the requested Group 3 power wheelchair 
with single power option 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 a Group 3 power wheelchair with single power option have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with single 
power option and accessories.
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 an LTACH admission is necessary for 
the enrollee. The Plan denied your request. The Plan says the enrollee does not meet the necessary 
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 while the record indicates the enrollee has ongoing medical issues and still requires 
acute care services. The record does not indicate that the enrollee requires services they are not currently 
receiving but would be available at an LTACH facility. 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve the medication. You say that you want this medication approved for your 
fatigue and so you can have a basic standard of life. The Plan denied your request. The Plan says that step 
therapy requirements have 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 the medication. Our reviewer says that 
the criteria for coverage of Injectafer have not been met. Our physician reviewer found that the Plan requires a 
trial of Infed and Venofer before they will approve the requested drug. In this case, you have not tried and 
failed the required drugs. There is no documentation provided indicating that the Plan's required drugs would 
likely be less effective or likely have adverse effects. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve Injectafer.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (procedure code 99152) rendered 
on March 27, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
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 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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation submitted did 
not indicate the presence of an independent trained observer during the procedure for the billed services. There 
was no anesthesiology record documenting intraoperative/intra-procedural monitoring of this patient (including blood pressure, heart rate, respiratory rate, electrocardiogram, oxygen saturation).  The review has determined 
that the use of CPT 99152 is not supported by the records provided. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for moderate sedation services (procedure code 99152) rendered on March 27, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of a cardiac contractility modulation (CCM) 
system (Optimizer Smart Implantable Pulse Generator) (0408T). 
 
You asked the Plan to pre-approve the Optimizer device. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says this is considered experimental and therefore is not 
covered. 
 
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 Optimizer device. Our reviewer 
says that the requested Optimizer device is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested device is considered experimental and investigational. Therefore, the 
reviewer found that the requested Optimizer device 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 Optimizer device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve insertion of a cardiac contractility modulation (CCM) system (Optimizer Smart 
Implantable Pulse Generator) (0408T).
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 an expedited appeal 
for the denial of an LTACH admission. 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 the enrollee appears to be improving with current treatment and should only 
require short-term additional acute care hospital services that can safely be provided at the current facility until 
more stable and appropriate for transfer to a lower level of care. There are no services at the LTACH that the 
enrollee requires that are not already available and covered at the current facility. Transfer to the LTACH 
would not be clinically advantageous at this time and completion of treatment at the current facility is 
recommended. 
 
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: 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 a transfer to long term acute care is 
medically necessary.  The Plan denied your request. The Plan says a transfer to long term acute care 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 the enrollee is receiving appropriate care in the current acute care setting provided by 
the Health Plan. Documentation does not support that LTACH services are medically appropriate 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 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: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve percutaneous transluminal angioplasty (PTA). 
 
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 that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PTA 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 medically necessary. Our physician reviewer found the enrollee has symptomatic disease with 
evidence of high-grade stenosis of the right vertebral artery and non-visualization of the left vertebral artery. 
These findings suggest high risk to the posterior circulation and stroke. The specialists who evaluated the 
enrollee's symptoms and angiographic findings recommend right vertebral artery intervention. The PTA is 
reasonable and 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 been met. Therefore, we decided that the Plan has to pre-
approve percutaneous transluminal angioplasty (PTA).  
 
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.