Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint fusion. 
 
You asked the Plan to pre-approve the sacroiliac joint fusion. You say that the enrollee had great results from 
the injections, however those results only last for a short period of time only providing minimal relief.  The 
Plan denied your request. The Plan says the sacroiliac joint fusion is not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the sacroiliac joint fusion. Our reviewer 
says that the enrollee does not meet the coverage criteria. Our physician reviewer found that there is no 
documentation of how much pain relief was achieved with the sacroiliac joint injection. Therefore, the 
sacroiliac joint fusion for back pain without instability is experimental. 
 
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 sacroiliac joint fusion have not been met. Therefore, we decided that the 
Plan does not have to pre-approve sacroiliac joint fusion.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services provided on February 14, 2023. 
 
You asked the Plan to pay for the chiropractic services. You say that the service should be covered. The Plan 
denied your request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the chiropractic services provided on February 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 81162, 81201, 
81218, 81292, 81295, 81298, 81307, 81317, 81321, and 81351 for date of service February 28, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the claim is not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be billed with a 
performing provider. 
 
We looked at the file and Medicare rules. Review of the file shows that the claim was billed without a 
performing (rendering) provider listed. The claim is not payable as billed. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services billed with codes 81162, 81201, 81218, 81292, 
81295, 81298, 81307, 81317, 81321, and 81351 for date of service February 28, 2023.
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 the enrollee still requires an IRF level of care. The 
Plan denied your request. The Plan says the enrollee does not meet Medicare guidelines for services in 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services provided on December 6, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim is not 
payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that Contractors shall deny a chiropractic claim 
(containing CPT codes 98940, 98941, or 98942) with a date of service on or after October 1, 2004, that does 
not contain the AT modifier.   
We looked at the file and Medicare rules. In this case, the chiropractic claim was billed with code 98941 and 
was not billed with modifier AT as required by LCA A58412. 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 the chiropractic services provided on December 6, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 14, 2022, to 
September 8, 2022. 
 You asked the Plan to pay for the home health services as billed. You say that that the claim should be 
reprocessed because the NOA was sent and acknowledged by the Plan on May 25, 2022. The Plan denied your 
request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from August 14, 2022, to 
September 8, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) service provided on December 
19, 2022. 
 
You asked the Plan to pay for SNF services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the provider is not eligible to bill Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that in order to receive payment for covered 
Medicare items or services from either Medicare or a Medicare beneficiary, a provider or supplier must be 
enrolled in the Medicare program. You can find this rule in 42 Code of Federal Regulations (CFR) Section 
424.505. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pay for 
skilled nursing facility (SNF) service provided on December 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), of diagnostic or therapeutic substance(s), 
not including neurolytic substances, including needle or catheter placement, interlaminar epidural or 
subarachnoid, lumbar or sacral; with imaging guidance (62323). 
 
You asked the Plan to pre-approve injections. You say that pain management is needed for the enrollee. The 
Plan denied your request. The Plan says the request is not medically necessary because the records show the 
enrollee does not have evidence that this same injection helped him, and there is no documentation of at least 
50% improvement in pain or function. 
 
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 injections. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has spinal stenosis with neurogenic claudication. The enrollee had an interlaminar 
ESI at this L5-S1 level twice in June 2021, but had "no relief." The enrollee has also had transforaminal 
approach ESI at this L5-S1 level on January 27, 2020, and February 10, 2020, without any lasting pain relief. 
The LCD does not support repeating ESI when there has been no prior relief.  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 injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve injection(s), of diagnostic or therapeutic substance(s), not including neurolytic substances, 
including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral; with imaging 
guidance (62323).
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 enrollee will require a multi-
disciplinary approach to help manage their multiple medically and physically complex issues. You say an 
LTACH level of care provides services that cannot be expected at an alternative level of care. The Plan denied 
your request. The Plan says the requested LTACH services do not meet the requirements for approval.  
 
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 all medically necessary care is being provided in the current acute care setting.  
 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 Plan. The Plan has approved ongoing care in the current acute care setting.  
The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve the peripheral nerve block.  
 
You asked the Plan to pre-approve the peripheral nerve block. You say that  The Plan denied your request. The 
Plan says the peripheral nerve block is considered experimental.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the peripheral nerve block. Our 
reviewer says that that the peripheral nerve block is not medically necessary. Our physician reviewer found that 
the enrollee has bilateral knee osteoarthritis. However peripheral nerve blocks for knee arthritis are considered 
experimental. Therefore, the request is 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 peripheral nerve block have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the peripheral nerve block.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided July 7, 2022, to 
July 30, 2022. 
 You asked the Plan to pay for acute inpatient hospital care. You say that this admission was medically 
necessary. The Plan denied your request. The Plan says this was not an emergency admission. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the procedure could have been completed when the enrollee returned to the US. The 
out of the country services were not medically necessary and reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided July 7, 2022, to July 30, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous decompression device. 
 
You asked the Plan to pre-approve an interspinous decompression device. You say that an interspinous 
decompression device is medically necessary. The Plan denied your request. The Plan says an interspinous 
decompression 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 an interspinous decompression device. 
Our reviewer says that the requested interspinous decompression device is not considered medically reasonable 
and necessary. Our physician reviewer found that interspinous decompression devices are experimental. More 
research is needed. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an interspinous decompression device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an interspinous decompression device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transurethral waterjet ablation of prostate (0421T). 
 
You asked the Plan to pre-approve transurethral waterjet ablation of prostate. You say that this procedure is 
medically necessary. The Plan denied your request. The Plan says the criteria for coverage of this procedure are 
not met as the enrollee's prostate volume exceeds what is allowed per the Local Coverage Determination. In 
addition, the enrollee has not received treatment with medications for 3 months or longer. 
 
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 transurethral waterjet ablation of 
prostate. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the prostate volume in this case is 264 cc which exceeds 
the required volume of 30-150 cc as required for coverage. In addition, the maximum urinary flow rate (Qmax) 
must be =15 mL/s4 (which it is) based upon a voided volume greater than 125 cc which is not the case here.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transurethral waterjet ablation of prostate have not been met. Therefore, we 
decided that the Plan does not have to pre-approve transurethral waterjet ablation of prostate (0421T).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bulking injection procedure. 
 
You asked the Plan to pre-approve a bulking injection procedure. You say that you are losing urine all day due 
to bladder issues and you need to see specialist for this because you are constantly using the bathroom all day.  
The Plan denied your request. The Plan says you do not have records of completing a cystometrogram, an 
abdominal leak point pressure test, and a collagen sensitivity test. Additionally, there is no diagnosis of 
intrinsic sphincter deficiency. 
 
The Plan follows Medicare rules. Medicare rules say that in female patients, the evaluation must include a 
complete history and physical examination (including a pelvic exam) and a simple cystometrogram to rule out 
abnormalities of bladder compliance and abnormalities of urethral support. 
 
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 bulking injection procedure. Our 
reviewer says that the requested bulking injection procedure is not considered medically necessary. Our 
physician reviewer found that the records do not confirm that you have intrinsic sphincter deficiency that must 
be demonstrated with a simple cystometrogram, and abdominal leak point pressure test. In addition, if the 
bulking agent chosen is collagen, then a skin test for collagen sensitivity must be administered and evaluated 
over a 4-week period. 
 
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 bulking injection procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a bulking injection procedure.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Procrit. 
 
 You asked the Plan to pre-approve Procrit. You say that there is a nationwide Retacrit shortage, forcing you to 
use Procrit.  The Plan denied your request. The Plan says 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 Procrit. Our reviewer says that the step-
therapy criteria for Epoetin Alfa has not been met as the enrollee has not tried and failed the alternative 
medications Aranesp and Retacrit. Our physician reviewer found based on the medical records provided and 
the Medicare-approved major drug compendia there is no indication that the plan's required drugs would be 
less effective or have adverse effects for the enrollee. A search of the Food and Drug Administration (FDA) 
Drug Shortages database reveals no documented shortage of Retacrit.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Epoetin Alfa have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Procrit.
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 intense 
therapy and recovery. The Plan denied your request. The Plan says the request for an IRF admission 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 the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record 
supports a need for physical 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.