Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says IRF care is not medically necessary. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the medical records significantly comply with the requirements for IRF admission. Your condition is 
complex and fragile, and there is every reason to expect that you will participate in and benefit from services 
provided at an inpatient rehabilitation facility. Therefore, the requested inpatient rehabilitation facility 
admission is approved. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 16 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the PT visits. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the enrollee can continue with a home exercise program. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 PT visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the requested physical therapy is generally accepted as a specific and 
effective therapy for weakness and difficulty ambulating after stroke. The enrollee has had 76 sessions of 
physical therapy and is currently performing routine balance and strengthening exercises. The enrollee's motor 
strength and 5X sit to stand score have not significantly changed and their progress has plateaued. The enrollee 
can continue with a home exercise program and may require some level of assistance or supervision, but this 
does not require the services of a skilled therapist. Therefore, the 16 visits of additional physical therapy are not 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the PT visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 16 additional physical therapy (PT) visits.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve carotid endarterectomy (37215, 35301).

You asked the Plan to pre-approve carotid endarterectomy. You say that the services are necessary. The Plan
denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria
have not been met.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically necessary.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve carotid endarterectomy. Our reviewer
says that the requested items/services are considered medically reasonable and necessary in this case. Our
physician reviewer found the documentation supports the medical necessity of the procedure in question. There
is satisfactory documentation the enrollee has a >70% stenosis of the left internal carotid artery. This is verified
on duplex and the >70% stenosis represents a significant progression of disease from the previous study. The
proposed plan for carotid endarterectomy is reasonable and medically necessary. While some confusion is
understandable as there appears to be an error in the computed tomography (CT) scan dictation in the
impression section that does not match the findings section, and a possible right/left issue in the initial history
on one the progress notes, overall, it is clear on this review that the lesion and treatment are for a high grade
stenosis of the proximal left internal carotid artery.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of carotid endarterectomy have been met. Therefore, we decided that the Plan has
to pre-approve carotid endarterectomy (37215, 35301).

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.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necesary. The Plan 
denied your request. The Plan says you do not meet the criteria for IRF admission. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the Plan erred in its denial of IRF admission. 
 
Per Medicare Benefit Policy Manual Ch 1, 110, and 42 CFR 412.622, the medical record overall significantly 
complies with the various documentation requirements for IRF admission. Indeed, the enrollees condition is in 
fact complex and fragile, and there is every reason to expect that the enrollee will participate in and benefit 
from IRF-level services to include at minimum PT, OT, physician oversight of polypharmacy and infection 
risk, and case manager coordination of any additional services that might be needed to make a sustainable 
return home, as well as avoid further preventable readmissions to the acute hospital. 
 
Therefore, the requested inpatient rehabilitation facility admission is approved. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high dose rate electronic brachytherapy, skin surface 
application (0394T), therapeutic radiology simulation-aided field setting; simple (77280) and therapeutic 
radiology simulation-aided field setting; complex (77290). 
 
You asked the Plan to pre-approve electronic brachytherapy. You say that you are requesting reconsideration 
and submitted medical records for review. The Plan denied your request. The Plan says a review of the current 
medical literature does not support this high-dose rate electronic brachytherapy and related services to be 
reasonable and 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 electronic brachytherapy. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested high-dose rate electronic brachytherapy is not considered the standard 
of care for the type of skin cancer this enrollee has. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of electronic brachytherapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a high dose rate electronic brachytherapy, skin surface application (0394T), 
therapeutic radiology simulation-aided field setting; simple (77280) and therapeutic radiology simulation-aided 
field setting; complex (77290).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computer-assisted surgical navigation MAKOplasty 
(0055T). 
 
You asked the Plan to pre-approve computer-assisted surgical navigation MAKOplasty. You say that this is 
medically necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of 
MAKOplasty for robotic assistance in the setting of total joint arthroplasty has not been demonstrated in the 
peer-reviewed literature.  

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 computer-assisted surgical navigation 
MAKOplasty. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there are no large volume, long-term/high-quality clinical 
studies that confirm the clinical benefits (ultimate outcomes of functional improvement and pain reduction) of 
computer-assisted surgery over standard surgical approaches in total knee arthroplasty. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of computer-assisted surgical navigation MAKOplasty have not been met. 
Therefore, we decided that the Plan does not have to pre-approve computer-assisted surgical navigation 
MAKOplasty (0055T).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames, the progressive lens, the non-discountable items, 
the anti-resistant coating, the polycarbonate, and the photo plastic provided on April 8, 2023. 
 
You asked the Plan to pay for the vision items. You say that you had no idea that the provider was out-of-
network. You say that you have been going to this same provider for the past couple years and you were not 
aware that the provider status had changed. The Plan denied your request. The Plan says the services were not 
covered benefits. 
 
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 provided by a network provider. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the vision items have not been met. Therefore, we 
decided that the Plan does not have to pay for the frames, the progressive lens, the non-discountable items, the 
anti-resistant coating, the polycarbonate, and the photo plastic provided on April 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service January 18, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that this service was necessary and can be paid 
separately. The Plan denied your request. The Plan says payment for code 81456 is bundled into payment for 
code 81455. 
 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 81456 
is a column two code to column one code 81455 with a modifier indicator of 0. The column two code is 
therefore not payable. 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 code 81456 billed for date of service January 18, 
2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3. 
 You asked the Plan to pre-approve Gelsyn-3. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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 Gelsyn-3. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has bilateral knee pain due to bilateral primary osteoarthritis of knee. The documentation 
does not support that the enrollee has tried and failed Orthovisc, Supartz FX, Durolane, Monovisc, or Synvisc-
One. The documentation does not support that Orthovisc, Supartz FX, Durolane, Monovisc, or Synvisc-One 
would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the enrollee does 
not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gelsyn-3.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services (D4266, D7921, and D6011). 
 
You asked the Plan to pre-approve the dental services (D4266, D7921, and D6011). You say that you would 
like to request reconsideration of the denied claim and that the services requested are medically necessary. The 
Plan denied your request. The Plan says the services requested are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
dental services (D4266, D7921, and D6011).
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 requesting an expedited appeal for the denial 
of an IRF admission. The Plan denied your request. The Plan says the enrollee does not meet Medicare 
guidelines for services in an inpatient rehabilitation facility.  
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, at 
an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled therapy with 
ongoing safety concerns and a potential for functional improvement; however, the documentation doesnt 
support that they meet criteria for admission to an acute inpatient rehabilitation facility. The enrollee can 
receive further services at a lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious agent detection testing (87631) provided on 
December 15, 2022. 
 
You asked the Plan to pay for 87631. You say that this testing is used for clinical purposes and should not be 
regarded as investigational. The Plan denied your request. The Plan says respiratory pathogen panels of 6 or 
more pathogens are non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 87631 is infectious agent detection by nucleic acid; 
respiratory virus (e.g., adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, 
respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and 
multiplex amplified probe technique, multiple types or subtypes, 3-5 targets for service provided. 
 
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 87631. Our reviewer says that this code does not meet 
criteria for payment. Our reviewer found the laboratory report supports that more than 3 to 5 targets were 
tested. More than 5 targets are not covered by Medicare. Therefore, this procedure code cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 87631 have not been met. Therefore, we decided that the Plan does not have to 
pay for infectious agent detection testing (87631) provided on December 15, 2022.
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 meets Medicare criteria for IRF services 
and will benefit from IRF services that cannot be accomplished at a lower level of care. You would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the requested IRF 
services are not medically necessary.  
 
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 following uncomplicated hip fracture surgery, the enrollee made rapid progress 
with low level hospital rehabilitation during the immediate post operative period. The enrollee requires neither 
intensive nor complex rehabilitation services and does not require frequent physiatry oversight.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a laminectomy. 
 
You asked the Plan to pre-approve a laminectomy. You say that the enrollee was discharged from physical 
therapy due to lack of improvement. The Plan denied your request. The Plan says that the enrollee did not try 
and fail standard treatment, including supervised physical therapy. 
 
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 laminectomy. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that more conservative measures are needed, including physical therapy for back pain. 
 
 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 laminectomy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a laminectomy.