Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cerapedics I-Factor allograft (20930). 
 
You asked the Plan to pre-approve Cerapedics I-Factor allograft. You say that this is medically necessary. The 
Plan denied your request. The Plan says the clinical value and effectiveness of I-Factor allograft in the setting 
of a lumbar fusion procedure have 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 Cerapedics I-Factor allograft. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the provided medical records and review of the current peer-reviewed 
medical literature do not document that use of the Cerapedics I-Factor allograft (20930) has been shown in 
controlled studies in a Centers for Medicare and Medicaid Services approved journal to result in sustained long 
term health benefits in patients with spinal stenosis/spondylolisthesis with mild to moderate foraminal stenosis 
and lumbar radiculitis undergoing a transforaminal lumbar interbody fusion (TLIF) or that the allograft adds 
any therapeutic advantage over the procedures already approved by the health plan. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Cerapedics I-Factor allograft have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Cerapedics I-Factor allograft (20930).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you are non-ambulatory and require assistance with 
transfers. The Plan denied your request. The Plan says you have stabilized medically and are ready for 
discharge from the hospital. You do not require skilled nursing and/or skilled therapy services on a daily 
basis. You are medically stable and can receive further rehabilitation services at a lower level of care. Although 
further rehabilitation services would be appropriate to improve function, as a practical matter, the intermittent 
skilled services can be provided at a lower level of care than a skilled nursing facility. You are medically stable 
without any acute exacerbations of chronic medical problems. Your physical function is at or near your 
baseline and you can receive services at a lower level of care. Admission to a SNF for inpatient skilled 
rehabilitation services is not medically necessary. 
 
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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (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 skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that you are appealing the denial with 
supporting documentation. The Plan denied your request. The Plan says this device 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 a CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS device would not be considered medically appropriate and necessary in the 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 a CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continued use of a home ventilator. 
 
You asked the Plan to pre-approve the continued use of a home ventilator. You say that the records show that 
bilevel therapy is insufficient due to severity of disease and nocturnal and daytime volume ventilation required, 
targeted volume ventilation is needed to maintain adequate CO2 levels, without ventilator support the enrollee 
is at increased risk of hospitalization and death. 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 the continued use of a home ventilator. 
Our reviewer says that the item is not medically necessary. Our physician reviewer found that the provided 
records in this case document a diagnosis of chronic respiratory failure consequent to chronic obstructive 
pulmonary disease and obstructive sleep apnea. The records document that the home ventilator is being 
requested for use in intelligent volume assured pressure support (IVAPS) mode which is a modality that could 
be provided by a bilevel positive airway pressure (BiPAP) device with average volume assured pressure 
support (AVAPS) and a back-up rate. Provided records document trial and failure of bilevel therapy but do not 
document trial and failure of a BiPAP device with AVAPS and a back-up rate.  
 
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 continued use of a home ventilator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the continued use of a home ventilator.
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 the full criteria for an IRF 
admission. The Plan denied your request. The Plan says the enrollee does not meet the requirements for 
approval of the requested IRF services.  
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical or occupational therapy at an 
intensive rehabilitation therapy program. Medically necessary services can be provided 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 an IRF admission is medically necessary. The Plan 
denied your request. The Plan says the services the enrollee needs can be provided safely in other settings, for 
example, at a skilled nursing facility (SNF), at home with home health services or at home with outpatient 
therapy.  
 
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 in this case, the complexity of the enrollees nursing, medical and rehabilitation 
needs do not require an acute rehabilitation 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. 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 inpatient rehabilitation facility. 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 would meet criteria for admission to an acute inpatient rehabilitation 
facility.  There is no indication that the enrollee would require skilled rehabilitation in an IRF, participating in 
rehabilitation services 15 hours a week, under the supervision of a physician with at least three visits weekly to 
regain or maintain their functional status.  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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the use of Injectafer. 
 You asked the Plan to pre-approve Injectafer. You say that the use of Injectafer is medically necessary. The 
Plan denied your request. The Plan says the enrollee has not met the criteria for the use of Injectafer, as the 
enrollee has not tried or cannot use Infed and/or Venofer.  
 
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 Injectafer. Our reviewer says that the 
Plan requires a trial of drug Infed and/or Venofer before they will approve the requested drug. Our physician 
reviewer found the enrollee has not tried and failed the required drug(s). There is no documentation provided 
indicating that the Plan's required drug(s) would likely be less effective and/or likely have adverse effects for 
the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the use of Injectafer.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of a neurostimulator 
electrode array; of the peripheral nerves (64555 x 2). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested services are 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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that peripheral nerve stimulation for sciatica is considered experimental. 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous implantation of a neurostimulator electrode array; of the peripheral nerves 
(64555 x 2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a harness for upgrade to expandable controller (E2313), 
electronic connection between wheelchair controller and two or more power seating system motors (E2311), 
expandable controller (E2377), and adjustable angle footplates (K0040). 
 
You asked the Plan to pre-approve a harness, electronic connection, expandable controller, and adjustable angle 
footplates. 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 a harness, electronic connection, 
expandable controller, and adjustable angle footplates. Our reviewer says that the requested items/services are 
not considered medically reasonable and necessary in this case. Our physician reviewer found the requested 
electrical accessories are not medically necessary as the enrollee does have use of the upper extremity and can 
operate and control the power options using the switches that are included in the basic wheelchair. There is not 
a medical need for the upgraded electronics. 
 
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 harness, electronic connection, expandable controller, and adjustable angle 
footplates have not been met. Therefore, we decided that the Plan does not have to pre-approve a harness for 
upgrade to expandable controller (E2313), electronic connection between wheelchair controller and two or 
more power seating system motors (E2311), expandable controller (E2377), and adjustable angle footplates 
(K0040).
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 LTACH services. You say that the enrollee requires LTACH services. The 
Plan denied your request. The Plan says the enrollee does not meet the requirements for a LTACH admission. 
 
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 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 record indicates that the enrollee has ongoing acute medical issues and still 
requires acute care services before transitioning to a lower level of care. The enrollee continues to receive acute 
care services, and these have not been denied. The medical record does not indicate that the enrollee requires 
services that he is not currently receiving but that would be available at the LTACH facility. The elements of coverage rules are not satisfied. 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 LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH services.
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 admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the records do not show the enrollee's condition will 
probably require an average 25-day length of stay in the LTACH. The Plan says the enrollee is receiving the 
care needed in the current hospital and there is no need to transfer to the LTACH at this time. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. Given there are offered alternatives, LTACH is 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97750 rendered on August 2, 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 97750-GP (4 units) 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 97750 is "Physical performance test or measurement (eg, 
musculoskeletal, functional capacity), with written report, each 15 minutes." 
 
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 medical record does not include documentation of physical performance test or measurement, with written report, each 15 minutes. For 
CPT 97750, the provider evaluates the enrollee's physical performance, such as the musculoskeletal and 
functional capacity of the enrollee, through tests and activities of daily living. The provider assesses the 
physical performance of the patient and completes a written report. This procedure was not found in medical 
record, and therefore 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 97750 rendered on August 2, 2023.