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 you are requesting an expedited appeal as the 
enrollee meets the full criteria for an acute IRF stay. The Plan denied your request. The Plan says criteria for 
admission to the acute inpatient rehabilitation 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 enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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.  
 
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 pre-approve genicular nerve branch injection (64454). 
 
You asked the Plan to pre-approve the service. You say that the enrollee is a bad candidate for surgery due to 
health issues this is medically necessary. 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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered an experimental/ investigational procedure. It is the subject of ongoing 
clinical trials. Therefore, the request is deemed not medically reasonable and necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genicular nerve branch injection (64454).
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 these services are medically necessary. The Plan 
denied your request. The Plan says the required services can be provided in an alternate setting.  
 
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 does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical problems 
are stable. There are no complex nursing or rehabilitation needs. While the medical record supports a need for 
physical or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary services can be provided in a different level of care. There is not a reasonable expectation that you 
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: 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 as 
the enrollee currently meets full IRF criteria. The Plan denied your request. The Plan says the enrollee does not 
meet 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 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. 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.  
 
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 chiropractic manipulative treatment; extraspinal provided 
on July 11, 2023. 
 
You asked the Plan to pay for the chiropractic manipulative treatment; extraspinal. You say that your insurance 
should have paid for the services you received. The Plan denied your request. The Plan says the service you 
received is not covered under Medicare. 
 
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.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the chiropractic manipulative treatment; extraspinal provided on July 11, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on May 17, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on May 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug test(s), 22 or more drug class(es), including 
metabolite(s) if performed (G0483) provided March 13, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the number of definitive urine drug classes requested are not 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 pay for the laboratory service. Our physician 
reviewer found the enrollee only required 9 drug classes related to opiates/opioids as the enrollee was not on 
nor was there evidence to suggest any other drug classes were being used/abused. Also, there was no abnormal 
urine drug screening results indicating a need for follow-up with 22+ drug classes based on the results. 
Therefore, the number of drug classes were not sufficiently supported and will be considered 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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the drug test(s), 22 or more drug class(es), including metabolite(s) if performed 
(G0483) provided March 13, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implantation of the Barostim Neo system. 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested service 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 this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that Baroreflex stimulation devices have been considered potential alternative treatments for resistant 
hypertension and heart failure. The Barostim Neo system is an electronic pulse generator implanted underneath 
the clavicle with a lead tunneled under the skin to the carotid sinus in the neck.  
  
 
 
The pulse generator delivers electrical impulses, analogous to a cardiac pacemaker, to the baroreceptors of one 
of the carotid arteries. In August 2019, the Food and Drug Administration (FDA) approved the system for use 
in patients with refractory heart failure who remain symptomatic despite treatment with guideline-directed 
medical therapy, are New York Heart Association (NYHA) Class III, have an ejection fraction less than 35%, 
and are not candidates for bi-ventricular pacing. This was based on a clinical study demonstrating improvement 
in normal daily activities, distance walked, quality of life, and improved cardiac levels biomarker levels. There 
remains an absence of randomized, blinded clinical studies examining long-term clinical outcomes establishing 
the value of Barostim Neo in patient management. As a result, at this time the Barostim Neo system would not 
be considered medically reasonable  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the implantation of the Barostim Neo system.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of a StabiLink MIS Interlaminar Spinal 
Fixation System. 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this service 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 this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee was being treated for anterolisthesis of the lumbar spine, lumbar radiculopathy, and 
lumbar degenerative disc disease. She presented having had 100% reduction in pain post-procedure for a few 
hours. She has stabbing pain into her thighs and lumbar spine with radiation into the bilateral legs.   
 
 
The pain is rated 10/10. The exam reveals lumbar facet tenderness at L3-4, L4-5, and L5-S1. There is pain with 
anterior flexion and extension. The straight leg raise is positive on the left and Kemps is positive bilaterally. 
The treatment plan included the Stabilink procedure at the L4-5 level. However, there is limited published, 
large-scale, long-term peer-reviewed literature that shows this request to be an effective and/or safe treatment 
for the noted pathology. Further studies are needed to demonstrate that Stabilink is as good or better than 
standard treatments. Moreover, this device is not intended for a stand-alone procedure. No compelling rationale 
is presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the requested StabiLink MIS Interlaminar Spinal Fixation System 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 this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the insertion of a StabiLink MIS Interlaminar Spinal Fixation System.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a microprocessor-controlled ankle foot system (L5973) 
 
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the request for a microprocessor foot does not meet the criteria being reasonable and 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of foot. 
 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 item. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the plan has erred in its denial of L5973. The medical records provided establish that a number of 
physiological changes have occurred that have rendered a previously safe prosthesis inherently unsafe for this 
enrollee, given his overlapping set of functionally limiting, progressive comorbidities. Therefore, replacement 
of the previous foot, whose warranty cannot make it functional for this enrollee, is reasonable and necessary. 
 
The medical record also establishes the enrollee's K3-activity level, and specific reasonableness and necessity 
of the requested microprocessor foot. LCD L33787 explicitly establishes that L5973 is covered for K3-level 
ambulators, without further specific documentary requirements, since this foot is part of the mainstream 
standard of care for an ambulator like this 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 item have been met. Therefore, we decided that the Plan has to pre-approve 
a microprocessor-controlled ankle foot system (L5973)  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Erleada tablet. 
 
You asked the Plan to pre-approve Erleada. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the medication is not covered as a medical benefit under 
the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The requested self-administered drug is an anticancer drug without a non-selfadministrable 
version. The self-administered drug requested here is not among the types which are covered by Medicare Part 
B. Therefore, we decided that the Plan does not have to pre-approve treatment with Erleada tablet.  
 
Benefits for Erleada may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occupational therapy services provided on May 17, 2023, to 
May 31, 2023. 
 You asked the Plan to pay for occupational therapy services. You say that the enrollee was not enrolled in 
hospice at the time of service. The Plan denied your request. The Plan says Original Medicare is responsible for 
payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on May 10, 2023. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for occupational therapy 
services provided on May 17, 2023, to May 31, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a facet injection (64493). 
 
You asked the Plan to pre-approve a facet injection. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Facet Joint Interventions are considered medically 
reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet certain criteria. 
 
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 facet injection. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the LCD criteria specifically state that 
the presence of untreated radiculopathy precludes the performance of facet blocks. Therefore, the request is 
deemed not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a facet injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a facet injection (64493).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for a psychiatric diagnostic evaluation with medical 
services, an office visit and psychotherapy provided from March 22, 2023, to May 2, 2023.  
 
You asked the Plan to reimburse you for a psychiatric diagnostic evaluation with medical services, an office 
visit and psychotherapy. The Plan denied your request. The Plan says the services were obtained from a 
provider who is not under contract with the health Plan and is not certified for Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for 
a psychiatric diagnostic evaluation with medical services, an office visit and psychotherapy provided from 
March 22, 2023, to May 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99214-25 rendered on May 23, 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 Current Procedural Terminology (CPT) code 99214-25 (1Unit) remains 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 99214 is "Office or other outpatient visit for the 
evaluation and management of an established patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using time for code selection, 30-39 
minutes of total time is spent on the date of the encounter." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the enrollee was seen on 5/23/23 
for hysteroscope and endometrial biopsy for postmenopauseal bleeding. The examination was appropriate and 
an expanded focus. The procedure was performed including biopsy without reported complication, and the 
enrollee had 25 minutes of face-to-face time discussing treatment options. The records do not support the CPT 
99214 was a significant and separately identifiable evaluation from CPT 58558 as the records do not support 
30-39 minutes of separate time spent with the enrollee for this encounter or a moderate level of medical 
decision making.  
 
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 procedure code 99214-25 rendered on May 23, 2023.