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

 
We decided that the Plan does not have to pre-approve an Intracept procedure 
 
You asked the Plan to pre-approve an Intracept procedure. You say that this treatment fills a gap for those that 
do not receive adequate relief from traditional conservative methods and do not have instability to indicate that 
fusion is the appropriate treatment. You also say that the enrollee tried and failed conservative treatment 
without relief. 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 an 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 indicates the enrollee is experiencing neurologic 
symptoms in their legs. The reviewer found that the Intracpet procedure is not indicate for this. 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 an Intracept procedure 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 the shoulder joint replacement surgery (23472RT, 
64708RT and 64721RT) and inpatient hospital care. 
 You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the Plan did not make a decision in time. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found detailed documentation is not evident regarding formal diagnostic imaging studies fully 
corroborating the pathology of the right shoulder that could potentially benefit from the requested procedure. 
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 shoulder joint replacement surgery, 
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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the shoulder joint replacement surgery (23472RT, 64708RT and 64721RT) and inpatient 
hospital care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tumor imaging (78800) and single photon emission 
computed tomography (SPECT) scan (78803). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the medical records do not show that a rare disease that occurs when a 
protein called amyloid builds up in organs (amyloidosis (AL)) has been ruled out. The Plan also says that 
therefore, tumor imaging and the SPECT scan are 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 the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the review of the current professional medical literature considers the requested imaging modality as investigational and in need of further verification by larger randomized clinical trials for 
sensitivity, and specificity. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a tumor imaging (78800) and single photon emission computed tomography (SPECT) scan 
(78803).
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 an IRF admission is necessary because a lower level 
of care is not safe, sufficient, or equipped to address the enrollee's needs related to their comorbidities and 
allow them the opportunity to regain their prior level of functioning to improve their quality of life. 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 that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may benefit from physical therapy 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that you cannot stand for very long 
without having to sit down and you cannot walk because of back pain. You say that your provider said this 
injection is the last thing that can be done to manage your back pain before potentially having surgery. The 
Plan denied your request. The Plan says the requested epidural steroid injection does not meet the Medicare 
LCD coverage criteria. 
 
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 an epidural steroid injection. Our 
reviewer says that the requested epidural steroid injection is not considered medically necessary in this case. 
Our physician reviewer found that in this case there is no mention of an objective pain scale in the submitted 
documentation and no objective neurologic abnormality or neurologic symptoms other than pain to suggest 
neurogenic claudication. The review has determined that the requested epidural steroid injection does not meet 
the Medicare LCD coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
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 requested LTACH is necessary 
because you need intravenous medication administration. The Plan denied your request. The Plan says you do 
not meet the Medicare guidelines for admission to an LTACH. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for contact lenses (V2500) purchased on January 24, 2023. 
 
You asked the Plan to pay for contact lenses. You say that you did not realize this provider was out-of-network 
and you were looking for a good deal. The Plan denied your request. The Plan says these contact lenses were 
purchased from an out-of-network provider. Only vision hardware purchased from a network provider is 
eligible for reimbursement. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when they are received through the Plans specified vendor network. 
 
We looked at the file and the Plan's rules. The contacts at issue were purchased from an out-of-network vendor. 
Based on this information, we decided that the Plan's rules for coverage of contact lenses have not been met. 
Therefore, we decided that the Plan does not have to pay for contact lenses (V2500) purchased on January 24, 
2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services blood draw. 
 You asked the Plan to pre-approve the home health services. You say that per a statement from your primary 
care physician, you are homebound and rarely leave your home, you are blind in one eye, use a walker and it 
takes you a long time to get around. The Plan denied your request. The Plan says the services are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care 
services to be 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 home health services blood draw. Our 
reviewer says that the services are not medically reasonable and necessary. Our physician reviewer found blood 
draws alone are not considered to be an indication for home health services. As such, the home health skilled 
nursing service is not medically necessary, reasonable or coverable. 
 
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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services blood draw.
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 is medically ready for the 
next level of care and cannot transfer to a Skilled Nursing Facility. The Plan denied your request. The Plan says 
your records do not show you need continued treatments and care that can only be given in a hospital setting. 
 
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 current health care setting being offered by the health plan. 
 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee's records 
do not show the rehabilitation needs are complex. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
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 pay for the services (99284) provided on October 31, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the submitted 
documentation supports one unit of code 99284, which was previously approved/paid. 
 
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 use of code 99284 is 
not supported by the records provided. Our reviewer found that the record supports one unit of code 99284 
performed on the date of service in question. 
 
We looked at this coder's review, the file, and Medicare rules. The records show that one unit of code 99284 
was already processed and paid by the Plan. The additional billed unit is not supported. 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 the services (99284) provided on October 31, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tiering exception for Orthovisc 15MG/ML syringe 
(J7324). 
 
You asked the Plan to pre-approve a tiering exception for the medication. You say that the medication is too 
expensive for you to afford. The Plan denied your request. The Plan says you cannot get a tiering exception for 
very high-cost drugs on a specialty tier. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the medication have not been met. Review of the file shows that 
this is a very high-cost drug on a specialty tier; therefore, you do not qualify for a tiering exception per 
Medicare rules. Therefore, we decided that the Plan does not have to pre-approve a tiering exception for 
Orthovisc 15MG/ML syringe (J7324).
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 needs intense therapy from multiple 
disciplines to maximize their functional independence with self-care, mobility, and transfers and to foster a safe 
return home. The Plan denied your request. The Plan says the enrollee does not meet all the requirements 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 that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While enrollee may benefit from physical therapy 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic manipulative treatments (98940, 98941). 
 
You asked the Plan to pre-approve these services. You say that the requested services are medically necessary 
for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of 
the requested services. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
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 enrollee does not meet criteria for coverage of the requested services. Our physician reviewer found that in 
this case, the record indicates that the enrollee has low back pain and spondylosis. The record provided does 
not establish the presence of a subluxation of the spine demonstrated by either physical examination or 
radiographic images. The elements of the coverage criteria 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve chiropractic manipulative treatments (98940, 98941).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo (J2777). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says they do not have a record from the enrollee's prescriber that shows the enrollee has tried the preferred drug bevacizumab (Avastin) and it has not worked, or that the enrollee has 
medical reasons that prevent them from using it. 
 
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 physician reviewer 
found there is no indication that the enrollee has tried and failed the required drug(s). Based on the medical 
records provided and the Medicare-approved major drug compendia there is no indication that the Plan's 
required drug(s) 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Vabysmo (J2777).