Persius/hicric huggingface dataset:
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 needs the level of care 
provided in an LTACH. The Plan denied your request. The Plan says the enrollee does not meet the 
requirements 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 the enrollee appears to be improving on current treatment but is still somewhat 
unstable and requires additional short-term acute care services that can safely be provided at the current facility 
until more appropriate for transfer to a lower level of care. The patient does not require services at the LTACH that are not already available and covered at the current facility. Transfer to the LTACH is neither medically 
necessary nor clinically advantageous. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(Intracept procedure). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee has tried and failed 
conservative treatments with no relief. The Plan denied your request. The Plan says this 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 there is no magnetic resonance imaging (MRI) showing only Modic changes 
without facet degenerative joint disease or stenosis. The reviewer found that there is not a clear cause of the enrollee's pain. Therefore, the reviewer found that the requested Intracept 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).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve levofloxacin. 
 
You asked the Plan to pre-approve levofloxacin. The Plan denied your request. The Plan says that self-
administered drugs do not fall under Medicare Part B coverage. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve levofloxacin.
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 is a medical necessity. The Plan denied 
your request. The Plan says based on Medicare guidelines, 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 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 
was admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. 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 and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an implanted loop recorder (ILR). 
 You asked the Plan to pre-approve the requested ILR procedure. You say that this device is going to be the 
most effective way to monitor for atrial fibrillation (a-fib) at all times. The Plan denied your request. The Plan 
says the records do not show that the enrollee has had a recent episode of syncope. 
 
The Plan must follow Medicare rules. Medicare rules say ILR placement may be considered medically 
necessary when it is needed to evaluate syncope that is thought to be cardiac-related but occurs too infrequently 
to be detected by traditional external monitors.  
 
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 ILR procedure. Our 
reviewer says that the requested ILR procedure is not medically reasonable and necessary based on NCD 
criteria. Our physician reviewer found the patient had no history of atrial fibrillation, nor were any significant 
cardiac arrhythmias noted on electrocardiogram (ECG) monitoring. Therefore, the reviewer found that the 
requested insertion of an ILR would not be considered medically appropriate and necessary in this patients 
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 ILR procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of an implanted loop recorder (ILR).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection. 
 
You asked the Plan to pre-approve an SI joint injection. You say that the enrollee is in pain and the request 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 an SI joint injection. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation on physical examination of three (3) or more positive test 
results. The clinical value and effectiveness of an SI joint injection in the absence of tenderness and negative 
provocative testing results have not been demonstrated in the peer-reviewed literature. The review has 
determined that the service at issue 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 SI joint injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a sacroiliac (SI) joint injection.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0482 billed for date of service June 6, 
2023. 
 
You asked the Plan to pay for the billed testing. You say that the medical records support the billed services. 
The Plan denied your request. The Plan says the billed code is not supported. 
 
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 G0482 is definitive drug testing of 15-21 drug classes. 
We find that CPT code G0482 is not supported in the medical record. Specifically, the records show that more 
than 21 drug classes were tested. There is a more applicable code that describes the services provided.  
 Based on this information, we decided that Medicare rules for coverage of the billed testing have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code G0482 billed for date of service 
June 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services described by code 
99235 performed on June 28, 2023. 
 
You asked the Plan to pay for 99235. You say that 99235 should be paid as billed because it is supported in the 
documentation. The Plan denied your request. The Plan says 99235 is denied because it is not supported in the 
documentation. 
 
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 99235 is hospital inpatient or observation care, for the 
evaluation and management of a patient including admission and discharge on the same date, which requires a 
medically appropriate history and/or examination and moderate level of medical decision making. When using 
total time on the date of the encounter for code selection, 70 minutes must be met or exceeded.  
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 99235. Our reviewer says that 99235 is not 
supported in the documentation. Our reviewer found that the enrollee presented to hospital for dizziness. 
Laboratory services and an electrocardiogram (EKG) were performed and reviewed. The enrollee was 
requesting discharge, however the medical record does not include documentation to support discharge services 
were performed on the same date of service, as this procedure was not included in documentation submitted. 
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 99235 have not been met. Therefore, we decided that the Plan does not have to 
pay for the evaluation and management services described by code 99235 performed on June 28, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is unable to stay of the 
ventilator and needs a feeding tube and trait. The Plan denied your request. The Plan says an LTACH 
admission is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is unable to be weaned from the ventilator and does not have a 
tracheostomy because of the lack of available ear, nose, and throat (ENT). The enrollee also is receiving tube 
feeds via nasogastric tube and has persistent hypotension. Therefore, the enrollee is not appropriate for transfer. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
You asked the Plan to pre-approve a home ventilator system. You say that the Life 2000 will provide the 
enrollee with the ventilatory support that they require. The Plan denied your request. The Plan says a home 
ventilator is not medically necessary for this patient because their needs can be met with an alternative device 
such as a BiPAP device with average volume-assured pressure support (AVAPS).  
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a home ventilator system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that the enrollee 
has chronic respiratory failure from chronic obstructive pulmonary disease. However, the documentation does 
not contain sufficient detailed information in the medical records to justify the treatment selected. The enrollee 
could be treated with a BiPAP machine with AVAPS capability and failure of such a device has not been 
documented. The records provided does not document that the enrollee will receive full ventilatory support 
from the requested device. Furthermore, ventilators fall under Frequent and Substantial Servicing (FSS) 
payment category, and payment policy requirements preclude FSS payment for devices used to deliver 
continuous or intermittent positive airway pressure, regardless of the illness treated by the device. Therefore, 
the elements of the coverage criteria are not satisfied, and the requested service cannot be 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 a home ventilator system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection (27096). 
 
You asked the Plan to pre-approve the SI joint injection. You say that you are in a lot of pain. You also say that 
your legs give out. The Plan denied your request. The Plan says the records do not show there is a sacroiliac 
joint problem. 
 
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 SI joint injection. Our reviewer says 
that the requested SI joint injection is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation on physical examination of three (3) or more positive tests 
results. The clinical value and effectiveness of an SI joint injection in the absence of tenderness and negative 
provocative testing results have not been demonstrated in the peer-reviewed literature. Therefore, the reviewer found that the requested SI joint injection 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 SI joint injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a sacroiliac (SI) joint injection (27096).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the use of Orthovisc Soln Pref Syr 30MG/2ML. 
 You asked the Plan to pre-approve the medication. You say that the use of Orthovisc will help reduce pain in 
the enrollee's knees. The Plan denied your request. The Plan says the enrollee has not met the step therapy 
condition for Orthovisc. The enrollee needs to try either Synvisc/Synvisc One or Euflexxa: Synvisc/Synvisc 
One or Euflexxa.  
 
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 requested service cannot be recommended. Our physician reviewer found the provided records do not 
indicate that the enrollee has tried and failed the Plan's preferred step one alternative. The record does not 
indicate that the enrollee has a contraindication to or would have an adverse effect from the Plan's preferred 
step one alternative.  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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the use of Orthovisc Soln Pref Syr 30MG/2ML.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee needs the SNF services to regain full 
mobility. The Plan denied your request. The Plan says the enrollee no longer requires SNF services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in an SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for unspecified preventive procedure (D1999) provided on 
September 18, 2023. 
 
You asked the Plan to reimburse for unspecified preventive procedure. You say that you are appealing because 
it denies you the right to reimbursement for the charges made to you by the provider for code D1999. The Plan 
denied your request. The Plan says this is not a covered benefit. 
 
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 reimburse for 
unspecified preventive procedure (D1999) provided on September 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the health club membership (S9970) purchased on January 1, 
2022. 
 
You asked the Plan to pay for the health club membership. You say that you have submitted a reimbursement 
every year, and have never been told it should be submitted for a certain date. The Plan denied your request. 
The Plan says your request is unable to be approved because it was confirmed you submitted your 2022 
reimbursement after the March 31st deadline of the following year.  
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only when the reimbursement request is received by the Plan by no later than March 31st of the following year. 
 
The Plans rules for coverage of gym benefits have not been met because your reimbursement request for the 
2022 plan year was not received until August 14, 2023, which is past the March 31st deadline. Therefore, we 
decided that the Plan does not have to pay for the health club membership (S9970) purchased on January 1, 
2022.