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

 
We decided that the Plan does not have to pre-approve Leqembi. 
 
You asked the Plan to pre-approve Leqembi. 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 monoclonal antibodies directed against amyloid for 
the treatment of AD is covered under certain circumstances.  
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 Leqembi. Our reviewer says that the 
services are not medically necessary Our physician reviewer found in this case, the enrollee is not receiving the 
drug in a CMS-approved prospective comparative study. Therefore, the requirements of the NCD would not be 
met at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Leqembi have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Leqembi.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary. The 
Plan denied your request. The Plan says the enrollee is unstable to be transferred 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 that the documentation does not support that the enrollee has need for complex 
medical treatment in a LTACH (e.g., multiple and prolonged intravenous therapies, monitoring of significantly 
medically active conditions requiring clinical assessment 6 or more times a day, multiple and frequent 
intervention of at least 6 or more times a day, like ventilator management, cardiac monitoring, complex wound care for multiple wounds stages 3 and above, the need for specialized high-tech equipment like cardiac 
monitors, on-site dialysis, or surgical suites). The enrollee does not require services at the LTACH that are not 
available at the acute care hospital or the skilled nursing facility. The requested treatments are not medically 
necessary at the LTACH level of care. The enrollee has improved medically and can receive further care at the 
current acute care hospital or a lower level of care when deemed appropriate.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of plaque and insertion of stents in artery of 
leg (37228, 37229, 37230, 37231).  
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says there are no atherosclerotic obstructive lesions of the lower extremities.  
 
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 services. Our physician reviewer 
found the documentation does not meet coverage criteria and does not support the medical necessity of the 
treatments in question. The coverage criteria specifically exclude endovascular tibial artery intervention. For 
tibial artery intervention to be considered medically necessary there would need to be clear evidence of limb 
threat. In this case, the documentation of symptoms does not suggest a limb threatening issue. Pain in the knee 
at rest is not ischemic rest pain particularly with cardiac computed tomography angiography (CTA) evidence of 
arterial patency. The enrollee also has other etiologies for their leg pain including a history of osteoarthritis. An 
objective physiologic measurement of lower extremity arterial perfusion such as an ankle-brachial index (ABI) 
is not provided. The only objective information provided is the report of the CTA demonstrating no evidence of 
significant disease. The documented pulse examination is also nonspecific. Therefore, in the absence of 
satisfactory documentation and objective information such as an ABI unable to overturn the Health Plan 
determination. Tibial artery intervention in the absence of clear limb threat is generally not advisable as there is 
a significant chance of doing more harm than good. 
 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the removal of plaque and insertion of stents in artery of leg (37228, 37229, 37230, 
37231).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested home health services.  
 You asked the Plan to pre-approve home health services. You say that the enrollee requires additional OT 
visits.  The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee is 
receiving home health care, and nine additional occupational therapy (OT) visits have been requested. Clinical 
documentation shows that enrollee has met all appropriate home health occupational therapy goals; thus, the 
records do not show that 9 additional home health occupational home health skilled therapy sessions would be 
required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of 
function, or to establish/perform a maintenance program to maintain the enrollee's level of function and/or 
prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the requested home health 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 the services are necessary for the enrollee as they are 
failing to meet their maximum function. The Plan denied your request. The Plan says the enrollee does not 
meet the criteria 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 enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical 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: 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 requires therapy services since being in 
the hospital that they have not received yet. The Plan denied your request. The Plan says the enrollee does not 
meet the criteria 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 enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical 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: 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 the enrollee remains deconditioned and given their 
advanced age, would benefit from ongoing skilled physical therapy with plans for home transfer. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for SNF care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is functioning at a home care level. Daily skilled 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 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: 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 services are medically necessary. The Plan 
denied your request. The Plan says that you do not meet the criteria 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 you do not require treatment by multiple therapies. While the medical record 
supports a need for physical 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 procedure codes 96365, 96366, and 96521 rendered on 
February 22, 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 denied codes remain not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
The records show that progressive infusion was rendered in this case. This is considered outpatient intravenous 
insulin treatment. 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 codes 96365, 96366, and 
96521 rendered on February 22, 2023.
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 the best opportunity for the 
enrollee to regain baseline quality of life and is clinically stable for discharge. The Plan denied your request. 
The Plan says the enrollee's condition does not meet these Medicare criteria. Services needed may be provided 
safely in a lower level of care.  
 
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 enrollee is medically stable and does not need Physical Medicine and 
Rehabilitation physician's supervision three (3) times a week in an IRF. At the current functional level, the 
enrollee does not need specialized and intensive therapies consisting of at least three (3) hours of therapy per 
day at least five (5) days per week with multidisciplinary approach in an IRF. The documentation does not 
support necessity for admission to an IRF. The complexity of the enrollee's medical, rehabilitation, and nursing 
needs (combined complexity) does not require an acute hospital inpatient rehabilitation stay with an 
interdisciplinary approach to rehabilitative care. The enrollee's rehabilitation needs can be safely provided in an 
alternate and low intensity setting such as in a skilled nursing facility. 
 
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 IRF admission and services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Tempus Liquid Biopsy CGP Panel (81455) provided February 27, 
2023. 
 
You asked the Plan to pay for the Tempus Liquid Biopsy CGP Panel. You say that you request reconsideration 
this determination and coverage of the Tempus Liquid Biopsy CGP Panel test at the In-Network benefit level 
The Plan denied your request. The Plan says that this test is not Food and Drug Administration (FDA)-
approved and cannot be covered.  
 
Please note: We reviewed the Plans rationale and find it has been misinterpreted. While FDA-approved 
testing is nationally covered, testing that meets the NCD criteria that is not FDA-approved may be covered 
under individual consideration of medical necessity. 
 
The Plan follows Medicare rules. Medicare rules say that NGS testing may be covered when the criteria listed 
in the rules section 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 pay for the Tempus Liquid Biopsy CGP Panel. Our 
reviewer says that this lab testing was medically reasonable and necessary.  Our physician reviewer found this 
enrollee has appendiceal cancer that is metastatic. Per the National Comprehensive Cancer Network (NCCN) 
Guidelines molecular profiling such as for colon cancer should be done to evaluate if targeted therapies would 
be beneficial. The service was reasonable and 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 Tempus Liquid Biopsy CGP Panel have been met. Therefore, we decided 
that the Plan has to pay for the Tempus Liquid Biopsy CGP Panel (81455) provided February 27, 2023.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network wound care debridement 
provided from February 6, 2023, to March 6, 2023. 
 
You asked the Plan to waive the copayment for an in-network wound care debridement. You say that this was 
just for dressing changes, not an actual procedure. This should be a specialist copayment at most. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment for outpatient hospital services.  
 
You had four of these services, resulting in a $1300 total copayment ($325 x 4 procedures = $1300 total).  
You have been asked to pay a $1300 total copayment for an in-network wound care debridement.  This item/service falls within the outpatient hospital services benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for an in-network wound care debridement provided from February 6, 2023, to March 
6, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the outpatient neuroablation - Intracept procedure 
 
You asked the Plan to pre-approve Intracept procedure. You say that the enrollee has tried and failed 
conservative treatment without relief. The Plan denied your request. The Plan says the enrollee has tried and 
failed conservative treatment without relief. 
 
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 Intracept procedure. Our reviewer says 
that the requested surgery is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee was being treated for vertebrogenic low back pain. In this case, there are multiple 
plausible pathologic sources of significant pain generation. The low back pain with pain into the bilateral 
buttocks and thighs, the noted pain-aggravating factors (physical activity, sitting, standing, walking, bending, and twisting), the diminished and painful spinal motion (in all directions), and lack of neurological exam 
were/are all non-specific to any pathologic entities. Overall, the documentation is lacking regarding reasonably 
detailed and/or evidenced findings supportive of the spinal vertebral bodies as being the overwhelming primary 
generators of the enrollees chronic persistent pain. There is no compelling rationale or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
Intracept intraosseous basivertebral nerve ablation at L4-S1, in this case, 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 Intracept procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the outpatient neuroablation - Intracept procedure
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service February 27, 
2023, to March 25, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that these services were medically necessary and 
were ordered by an in-network provider. The Plan denied your request. The Plan says the billed code is invalid 
for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service February 27, 2023, to March 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (D9310) provided on May 23, 2023. 
 
You asked the Plan to pay for the dental service. You say that you could not find an in-network provider. The 
Plan denied your request. The Plan says the denial of payment for this service is correct, because the 
consultation is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit even if provided by an in-network provider. Therefore, we decided that 
the Plan does not have to pay for a consultation (D9310) provided on May 23, 2023.