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's current condition requires 
an LTACH admission. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-
patient acute care and does not require a transfer 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 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. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. The enrollee is 
receiving appropriate care at the present acute care hospital. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee scooter (code E0118). 
 
You asked the Plan to pre-approve a knee scooter. You say that you are having foot surgery and you will need 
a knee scooter for help with mobility afterwards. You said that you cannot use crutches due to a shoulder 
injury. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that knee scooters are not covered.  Although this 
item may be helpful for you following surgery, neither Medicare nor your Plan covers this item. Therefore, we 
decided that the Plan does not have to pre-approve a knee scooter (code E0118).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous radiofrequency ablation (ERFA) of right 
posterior tibial vein (36475).  
 
You asked the Plan to pre-approve the ERFA procedure. You say that the requested service is necessary for the 
enrollee. The Plan denied your request. The Plan says the documentation does not show that you have an active 
venous ulcer in the right lower extremity. The Plan also says that this service is not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that ultrasound-guided foam sclerotherapy (UGFS) and 
endovenous thermal ablation with either radiofrequency or laser energy sources will be considered reasonable 
and necessary with an active venous ulcer. 
 
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 ERFA procedure. Our reviewer says 
that the requested ERFA procedure is not medically necessary. Our physician reviewer found for perforator 
vein ablation to be considered medically necessary, there needs to be evidence of an ulcer in the vicinity of the 
perforator vein to be treated. The reviewer found that the provided documentation does not include evidence of 
ulceration. Therefore, the reviewer found that the risks of perforator vein cannot be justified on the basis of 
medical necessity. 
 
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 ERFA procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve endovenous radiofrequency ablation (ERFA) of right posterior tibial vein 
(36475).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 6, 2023, billed with 
codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335, 81479, and 81238. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says panel 
testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
February 6, 2023, billed with codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 
81335, 81479, and 81238.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical food nutrition complete. 
 
You asked the Plan to pre-approve medical food nutrition complete. You say that the enrollee is in a clinical 
study. You also say that in order to maintain a healthy weight, the enrollee must increase caloric intake. The 
Plan denied your request. The Plan says the requested items are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve medical food nutrition complete.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty, extra-wide hospital bed described by code 
E0301. 
 
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 criteria for coverage are not met. 
 
The Plan must follow Medicare rules. The rules say that a heavy duty extra wide hospital bed (E0301, E0303) 
is covered if the beneficiary meets one of the criteria for a fixed height hospital bed and the beneficiary's 
weight is more than 350 pounds, but does not exceed 600 pounds.  
 
We looked at the file and Medicare rules. The file shows that your current weight is 229 pounds. 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 heavy-duty, extra-wide hospital bed described by code 
E0301.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(BVN) (Intracept procedure) (64628).  
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee has tried conservative 
treatment without any relief. The Plan denied your request. The Plan says the requested procedure is not 
medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that thermal destruction of the intraosseous BVN will be 
considered medically reasonable and necessary for the treatment of chronic low back pain (cLBP) when certain 
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 the Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not medically necessary. Our physician reviewer found the 
provided documentation does not include imaging to suggest only Modic changes without facet degenerative 
joint disease or foraminal stenosis. The reviewer found that the documentation does not clearly indicate the 
cause of the enrollee's back pain. Therefore, the reviewer found that the 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 (BVN) (Intracept 
procedure) (64628).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 21299 billed for date of service February 20, 
2023. 
 
You asked the Plan to pay for procedure code 21299. You say that this service was reported correctly and is 
supported in the medical records. The Plan denied your request. The Plan says this code is not appropriate to be 
furnished in an ambulatory surgical center setting. 
 
The Plan must follow Medicare rules. Medicare rules say that the list of procedures which may be covered in 
an Ambulatory Surgical Center (ASC) setting are detailed in a list provided by the Centers for Medicare and Medicaid Services (CMS).  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 21299 have not been met. Specifically, the procedure requested in this case was 
performed in an ambulatory surgical center setting; however, this code is not among those listed as eligible for 
coverage when performed in this setting. Therefore, we decided that the Plan does not have to pay for 
procedure code 21299 billed for date of service February 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on January 03, 2023, to January 27, 
2023. 
 
You asked the Plan to pay for the home visit. You say that at the time of service the enrollee was residing in an 
assisted living facility. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 
not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the home visit provided 
on January 03, 2023, to January 27, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve injection, anesthetic agent; stellate ganglion (cervical sympathetic) 
(64510). 
 
You asked the Plan to pre-approve a stellate ganglion nerve block. You say that this treatment is effective in 
treating symptoms for post-traumatic stress disorder (PTSD) such as fight or flight reaction, irritation, agitation, 
depression, anxiety, intrusive thoughts, flashbacks, nightmares, all of these symptoms which you suffer from. 
You also say that despite different forms of treatment over the last 28 years, these symptoms still exist. The 
Plan denied your request. The Plan says that the requested sympathetic nerve block is considered 
experimental/investigational. 
 
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 a stellate ganglion nerve block. Our 
reviewer says that the requested stellate ganglion nerve block is considered medically reasonable and necessary 
in this case. Our physician reviewer found the requested nerve block is a sympathetic nerve block and not a 
peripheral nerve block. The reviewer found that a sham-controlled randomized clinical trial shows 2 stellate 
ganglion block treatments 2 weeks apart were effective in reducing clinician-administered PTSD scale for 
DSM-5 total symptom severity scores over eight weeks. The study also shows that the adjusted mean symptom 
change was 12.6 points for the group receiving stellate ganglion blocks, compared to 6.1 points for those 
receiving sham treatment. Therefore, the reviewer found that the request for a stellate ganglion nerve block is 
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 stellate ganglion nerve block have been met. Therefore, we decided that the 
Plan has to pre-approve injection, anesthetic agent; stellate ganglion (cervical sympathetic) (64510).  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a PET-CT scan (78815) provided on February 6, 2023. 
 
You asked the Plan to pay for a PET-CT scan. You say that you have billed the services at issue correctly. The 
Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT code 78815 is not supported. Specifically, the service at issue has been billed with diagnosis 
codes C79.9, C80.1 and Z01.89. These diagnoses are not listed in the rules as appropriate for PET scans. Based 
on this information, we decided that Medicare rules for coverage of a PET-CT scan have not been met. Therefore, we decided that the Plan does not have to pay for a PET-CT scan (78815) provided on February 6, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a platelet rich plasma injection. 
 
You asked the Plan to pre-approve the injection. You say that the injection is medically necessary. The Plan 
denied your request. The Plan says a platelet rich plasma injection is a non-covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that all platelet rich plasma injections and/or 
applications as a means of managing musculoskeletal injuries and/or joint conditions are non-covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
platelet rich plasma injection.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve Prolia. You say that Prolia is a new therapy for the enrollee who has had the 
Forteo therapy for two years. The Plan denied your request. The Plan says that the step therapy requirements 
have not been met. 
 
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 Prolia. Our reviewer says that Prolia is 
not medically necessary. Our physician reviewer found that the enrollee has not tried and failed the require 
drugs alendronate, ibandronate, pamidronate, risedronate, and zoledronic acid. There is also no indication that 
the Plan's required drugs would likely be less effective 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
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 reconsideration for the denial of 
an IRF admission based on medical necessity. The Plan denied your request. The Plan says 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 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 would 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 stair lift.  
 
You asked the Plan to pre-approve a stair lift. You say that the enrollee has to go up and down 36 stairs in total 
and it is difficult for him. You said that he often has to stop and rest and you are in fear of him falling. The Plan 
denied your request. The Plan says stair lifts are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair lift.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a NexWave transcutaneous electrical nerve stimulator 
(TENS) unit (E0745, A4595, A4630, A4557) to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a NexWave TENS unit. You say that you were told that this would be 
covered under your Plan with your durable medical equipment (DME) benefit but was unaware that the supplier is non-participating. The Plan denied your request. The Plan says enrollees must receive their medical 
services from an in-network provider with the exception being urgent or emergent services. Non-emergent 
services with non-contracted providers require prior authorization before services being rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. Medicare states that TENS is covered for 
acute post-operative pain. The notes do not indicate that the enrollee has had any surgical procedure to the 
back. In addition, Medicare states that TENS therapy for chronic low back pain will be denied as not 
reasonable and necessary. As your back pain is not a result of post-operative (surgery) pain but for chronic low 
back pain (lasting more than 3 months), Medicare criteria are not met We found no exception that would 
require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-
approve a NexWave TENS unit (E0745, A4595, A4630, A4557) to be provided by an out-of-network (OON) 
provider.
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 only thing that will help the enrollee and provide 
significant relief is for the enrollee to do significant rehabilitation to strengthen muscles around the spine and to 
provide much more significant mobility to regain maximum function. The Plan denied your request. The Plan 
says that the enrollee does not meet the Medicare criteria for admission to an inpatient rehabilitation facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that 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 does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that this 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.