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 you are requesting an expedited 
reconsideration for the denial of an LTACH admission. The Plan denied your request. The Plan says criteria for 
admission to the LTACH have not been met.  
 
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 appears to be improving with current treatment, is tolerating 
weaning, and should only require short-term additional acute care services that can safely be provided at the 
current facility until more stable and appropriate for transfer to a lower level of care. There are no services at 
the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer 
to the LTACH would not be clinically advantageous at this time and completion of treatment at the current 
facility is 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 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: 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 the services are medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet the criteria for admission 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 the enrollee is still unstable and requires additional acute care services that can safely 
be provided at the current facility until they are more stable for transfer. Completion of treatment at the current 
facility is 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a facet joint injection (procedure code 64493) rendered on February 16, 
2023. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says that this is considered to be experimental and investigational, and excluded from 
coverage. 
 
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 pay for the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the request meets the criteria, as the enrollee has chronic low back pain, andas fluoroscopic imaging 
demonstrates facet arthropathy at each injection site. The enrollee has received bilateral L4-L5 and L5-S1 
injections. This 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 the services have been met. Therefore, we decided that the Plan has to pay for a 
facet joint injection (procedure code 64493) rendered on February 16, 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 pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that the enrollee needs the injection 
again because the previous injection provided them pain relief. The Plan denied your request. The Plan says an 
epidural steroid injection 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 epidural steroid injection. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the LCD requires at least 50% pain relief for 3 months, which was not achieved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tepezza. 
 
You asked the Plan to pre-approve Tepezza. 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 must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 Tepezza. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a full course (8 infusions implied) was 
noted as already tried. Eight infusions per lifetime (one course) is the standard for this medication. Therefore, 
the documentation does not sufficiently support that the Tepezza is medically reasonable and necessary for the 
enrollee or that it is effective 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 Tepezza have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Tepezza.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you are requesting reconsideration due to 
medical necessity. The Plan denied your request. The Plan says the request for continued use of non-invasive 
ventilator (NIV) is not medically reasonable and necessary. 
 
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. 
 
 
 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found you have a diagnosis of chronic 
respiratory failure consequent to chronic obstructive pulmonary disease. Provided records document that the 
home ventilator is being requested for use in an 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 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits and procedures (99204, 99214, 69200, 
69210, 69220) with a specialist to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve office visits and procedures. You say that you would like to see the 
requested provider for a second opinion. The Plan denied your request. The Plan says you must use network 
providers to get your medical care and services. 
 
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. 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 
office visits and procedures (99204, 99214, 69200, 69210, 69220) with a specialist to be provided by an out-of-
network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug test, 22 or more drug classes, including 
metabolites if performed (G0483) provided on January 24, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that the service was medically necessary. The 
Plan denied your request. The Plan says the condition of the member did not meet the Medicare rules for 
approval of definitive urine drug testing (UDT) for 22 or more drug classes (Code G0483).  
 
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 there was no indication for definitive testing in this enrollee. The testing was 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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the definitive drug test, 22 or more drug classes, including metabolites if performed 
(G0483) provided on January 24, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the abdomen. 
 
You asked the Plan to pre-approve the MRI. You say that you believe you are having liver issues that can be 
identified with MRI. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 the MRI. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found there is no report of any cross-sectional 
imaging study done in the past concerning the liver. Absent such information the medical necessity of the 
requested MRI of the abdomen has not been established in the records provided. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the abdomen.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty (22513). 
 You asked the Plan to pre-approve kyphoplasty. 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 PVA (percutaneous vertebroplasty (PVP) or 
kyphoplasty (PKP) is covered when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve kyphoplasty. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found detailed documentation is not evident 
regarding an acute or subacute compression fracture, as the T9 vertebral fracture is noted to have been present 
since March 29, 2023. Additionally, a clear diagnosis of osteoporosis is not documented. Therefore, the 
enrollee does not meet the coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty (22513).
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 admission for IRF care is medically necessary. 
The Plan denied your request. The Plan says the records do not show that the enrollee's rehabilitation needs are 
complex and that he needs to be seen three times per week for evaluation of functional and medical goals and 
progress. 
 
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 was admitted for cholecystitis and sepsis and was transferred to skilled 
nursing on July 7, 2023. Medical problems are stable. There are no complex nursing or rehabilitation needs.  
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. 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. 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair, group 3 standard, single power 
option (K0856) and accessories (E0955, E0995, E1002, E1028, E2361, E2607, E2613, K0040). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that you are requesting 
reconsideration due to the enrollee's inability to ambulate and severe risk for injuries related to fall risk. The 
Plan denied your request. The Plan says the request for a power wheelchair cannot be approved. The enrollee 
already has a power wheelchair. The replacement of DME due to wear cannot be covered during the reasonable 
useful lifetime of the equipment (less than 5 years). 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
 
 
 
 The file shows that the enrollee received a group 3 standard, multiple power option wheelchair on June 21, 
2021. A group 3 standard, multiple power option wheelchair serves the same purpose as a power wheelchair 
single power option. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair, 
group 3 standard, single power option (K0856) and accessories (E0955, E0995, E1002, E1028, E2361, E2607, 
E2613, K0040).
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 you need round the clock care as well as 
physical therapy. You say the clinical team at the hospital will send over clinical documentation to support the 
care needed at the LTACH facility. The Plan denied your request. The Plan says you do not meet the guidelines 
for care in 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 you appear to be improving with current treatment, and you should only 
require short-term additional acute care services that can safely be provided at the current facility until you are 
more stable and appropriate for transfer to a lower level of care. There are no services at the LTACH that you 
require that are not already available and covered at the current facility. Transfer to the LTACH would not be 
clinically advantageous at this time and completion of treatment at the current facility is 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 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says admission to an IRF is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that 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 therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy 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. 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 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 an IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extractions and related anesthesia services (D7140, 
D9239, D9243). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your dental benefits. 
 
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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
extractions and related anesthesia services (D7140, D9239, D9243).