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 the requested IRF services will help you recover to 
the best of your abilities and return to home at the level you need to be at. The Plan denied your request. The 
Plan says you meet guidelines for care in a skilled nursing 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 your nursing, medical, and rehabilitation needs do not require an 
acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, at an 
intensive rehabilitation therapy program. You continue to have a need for skilled therapy with ongoing safety 
concerns and a potential for functional improvement. However, the documentation does not support that you 
would meet criteria for admission to an IRF.  There is no indication that you  would require skilled 
rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, under the supervision of a 
physician with at least 3 visits weekly to regain or maintain your functional status.  The member 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: 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 reconsideration for 
the denial of an IRF admission. The Plan denied your request. The Plan says criteria for admission to the acute 
IRF setting have not been met.  
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee orthosis described by code L1845. 
 
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. Medicare rules say that a knee orthosis 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 not medically necessary. Our physician reviewer found the enrollee has cerebral palsy with 
spastic diplegia. He cannot functionally ambulate and uses a power mobility device for mobility. He performs 
stand pivot transfers and is noted to have knee instability for which custom knee orthoses. However, there is a 
lack of physical examination findings demonstrating knee instability and he has not had a recent knee surgery or injury. He was referred to orthopedics, but this documentation is not available. It is unclear why standard 
orthoses or braces cannot be utilized for assistance with transfers versus custom fabricated ones. The requested 
orthosis 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 a knee orthosis described by code L1845.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nalu peripheral nerve stimulation (PNS) System and 
associated procedures (64590, L8679, L8680, 64555 x2, and 95972). 
 
You asked the Plan to pre-approve Nalu PNS System and associated procedures. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
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 Nalu PNS System and associated 
procedures. 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 the enrollee is participating in a 
clinical trial. The clinical value and effectiveness of Nalu PNS System in the setting of chronic knee pain has not been demonstrated. The requested item is not considered a standard of care for the treatment of knee pain. 
The review has determined that the items/services at issue in this case are 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 Nalu PNS System and associated procedures have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Nalu peripheral nerve stimulation (PNS) System and 
associated procedures (64590, L8679, L8680, 64555 x2, and 95972).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan. 
 You asked the Plan to pre-approve the medication. You say that records have been provided to show medical 
necessity. The Plan denied your request. The Plan says the enrollee has not tried and failed preferred 
medications. 
 
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 medication does not meet the requirements for step therapy guidelines. Our physician reviewer 
found the record indicates that the enrollee has osteoarthritis of the knee. The requested medication is a new 
start. 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. 
 
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 Hyalgan.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve micro-invasive glaucoma surgery. 
 
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. Medicare rules say that micro-invasive glaucoma surgery 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 not medically necessary. Our physician reviewer found the records do not show that the 
enrollee has mild to moderate open-angle glaucoma. The enrollee has severe open-angle glaucoma, which does 
not meet the criteria for coverage. The services 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve micro-invasive glaucoma surgery.
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 acute inpatient rehabilitation. The Plan denied your request. The Plan says the enrollee does not meet 
Medicare guidelines for services in 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 the complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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: 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 have the potential to decline without a multi-
disciplinary team approach and medical oversight of a rehabilitation physician. The Plan denied your request. 
The Plan says an IRF admission 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not meet criteria for admission to an acute inpatient rehabilitation facility. 
The complexity of your nursing, medical and rehabilitation needs do not require an acute rehab hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. You 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for stereotactic computer-assisted (navigational) procedure; 
spinal (List separately in addition to code for primary procedure) rendered on April 4, 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. 
 
In this case, the CPT Code Manual definition of code 61783 is "Stereotactic computer-assisted (navigational) 
procedure; spinal (List separately in addition to code for primary procedure)." 
 
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 more detail in the operative note 
is needed to support the use of this code. There needs to be a better description of the surgeon's work with the 
O-arm. 
 
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 stereotactic computer-assisted (navigational) procedure; spinal (List separately in addition to 
code for primary procedure) rendered on April 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiofrequency ablation provided on April 25, 2023. 
 
You asked the Plan to pay for  the radiofrequency ablation. You say that  the claim should be reprocessed. The 
Plan denied your request. The Plan says the radiofrequency ablation 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 pay for the radiofrequency ablation. Our reviewer 
says that the radiofrequency ablation is not medically necessary. Our physician reviewer found that the 
radiofrequency ablation is considered experimental due to the wide variation in efficacy reported in the peer-
reviewed literature. 
 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 radiofrequency ablation have not been met. Therefore, we decided that the 
Plan does not have to pay for  the radiofrequency ablation provided on April 25, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  
 
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 provider has reported skilled services with the incorrect PDPM Health Insurance Prospective 
Payment System (HIPPS) Score. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We asked our 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 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 doesnt 
support the correct PDPM was submitted by the skilled nursing facility. The documentation available for 
review that pertains to the appropriate look-back period does not support the enrollee required parenteral/IV 
feeding in the preceding 7 days. The 3rd alphanumeric character in the PDPM was not correct. The partial 
adjustment to PDPM KDKD1 was appropriate. 
 
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
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a microprocessor foot (L5973) and vacuum pump system (L5781) 
for a lower limb prosthesis. 
 
You asked the Plan to pre-approve microprocessor foot and vacuum pump system. You say that these 
components are necessary for the enrollee. The Plan denied your request. The Plan says that these components 
are not medically necessary. 
 
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 microprocessor foot and vacuum pump 
system. Our reviewer says that the requested items/services are considered medically reasonable and necessary 
in this case. Our physician reviewer found the practitioners note, appeal letter, and corroborating primary care 
physicians note more than satisfy Medicare requirements for documenting the enrollees level 3 functional 
status as well as the need for a new prosthesis generally and the foot and vacuum assisted socket system 
(VASS) specifically. This enrollee is most definitely a level 3 ambulator. As for the Plans arguments regarding 
VASS, we note it bases its arguments not on Medicare policy, but on its own Omnibus Codes policy, which 
declares this technology to be experimental and generally non-covered. On review, we note that all of the 
Omnibus Codes cited studies reported on the benefits of using vacuum suspension in properly selected amputee 
patients, most with statistically significant findings. This renders moot the Plans objections about sample size. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of microprocessor foot and vacuum pump system have been met. Therefore, we 
decided that the Plan has to pre-approve a microprocessor foot (L5973) and vacuum pump system (L5781) for 
a lower limb prosthesis.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint fusion procedure  (27279). 
 
You asked the Plan to pre-approve the sacroiliac joint fusion procedure. You say that this service is medically 
necessary. The Plan denied your request. The Plan says the requested procedure is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the sacroiliac joint fusion procedure. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the records show no joint instability, fracture, or lesion. Use of this 
procedure for degenerative back pain is still investigational.  
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 sacroiliac joint fusion procedure have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a sacroiliac joint fusion procedure  (27279).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacral nerve stimulation.  
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. Medicare rules say that sacral nerve stimulation for urinary incontinence 
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 criteria for coverage are not met. Our physician reviewer found the enrollee has urinary incontinence, 
overactive bladder, urgency, and frequency. He also has benign prostatic hyperplasia (BPH). The records do 
not show that he is an appropriate surgical candidate such that implantation with anesthesia can occur. He also 
has an underlying neurological condition of cerebral infarction and transient ischemic attack. The criteria for 
coverage are not met and the services 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacral nerve stimulation.