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

 
We decided that the Plan does not have to pre-approve Enhertu (J9358). 
 
You asked the Plan to pre-approve Enhertu. The Plan denied your request. The Plan says this drug is not 
covered per Medicare rules. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
 
 
 
 
 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 Enhertu. Our reviewer says that 
Enhertu is not medically reasonable and necessary for the enrollee. Our physician reviewer found the FDA has 
not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug 
compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical 
situation. Our reviewer found that no literature from Medicare approved cancer journals were submitted for 
review. The elements of the coverage criteria are not satisfied. Our physician reviewer also found that the 
requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Enhertu have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Enhertu (J9358).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 27245-RT billed for date of service April 16, 
2023. 
 
You asked the Plan to pay for procedure code 27245-RT. You say that this service was necessary and is 
supported as billed. The Plan denied your request. The Plan says this code is not supported in the records 
provided. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 27245-RT is treatment of intertrochanteric, 
peritrochanteric, or subtrochanteric femoral fracture; with intramedullary implant, with or without interlocking 
screws and/or cerclage. The "-RT" modifier indicates that a procedure was performed on the right side of the 
body. We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 27245-RT. Our reviewer says that modifier 
RT is not supported, and therefore this service cannot be verified as billed. Our reviewer found that the 
documentation does report treatment of right femoral fracture; however, the operative report provided describes 
procedures performed on the left femur. The documentation does not include procedures performed on the right 
side. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 27245-RT have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 27245-RT billed for date of service April 16, 2023.
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 services are medically necessary. The Plan 
denied your request. The Plan says the records do not show that the enrollee requires daily skilled nursing or 
therapy services. 
 
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 does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nasal airway remodeling using the Vivaer ARC Stylus. 
 
You asked the Plan to pre-approve the nasal airway remodeling. You say that Original Medicare covers nasal 
airway remodeling. You also say that this should be covered. The Plan denied your request. The Plan says this 
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 nasal airway remodeling. Our 
reviewer says that the requested nasal airway remodeling is not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has nasal obstruction and 
congestion.  There is insufficient literature to support the safety and efficacy of the requested service for the 
enrollee's specific conditions.  The record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service. Therefore, the reviewer found that the 
requested nasal airway remodeling 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 nasal airway remodeling have not been met. Therefore, we decided that the 
Plan does not have to pre-approve nasal airway remodeling using the Vivaer ARC Stylus.
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 IRF admission to medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for the IRF admission. 
 
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 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. 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 as 
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's home is not handicap accessible, 
unable to walk, and needs inpatient rehabilitation. The Plan denied your request. The Plan says the enrollee's 
condition does not meet the Medicare guidelines.  The Plan says that the 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 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.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L3-L4 lumbar fusion procedure with implantation of the 
Minuteman G3R Interspinous device to L3-L4 (20930, 22612, 22840). 
 
You asked the Plan to pre-approve L3-L4 lumbar fusion procedure with implantation of the Minuteman G3R 
Interspinous device to L3-L4. You say that this is medically necessary. The Plan denied your request. The Plan 
says the clinical value and effectiveness of the Minuteman interspinous device in the setting of lumbar 
radiculopathy have not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve L3-L4 lumbar fusion procedure with 
implantation of the Minuteman G3R Interspinous device to L3-L4. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the Minuteman device is 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 L3-L4 lumbar fusion procedure with implantation of the Minuteman G3R 
Interspinous device to L3-L4 have not been met. Therefore, we decided that the Plan does not have to pre-
approve L3-L4 lumbar fusion procedure with implantation of the Minuteman G3R Interspinous device to L3-
L4 (20930, 22612, 22840).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee's records do not show the care required 
(wound care/wound vacuum management, Foley catheter care, continued medical management of your 
diabetes and hypertension and physical therapy), can only be given in a hospital setting. The Plan says when 
you are ready to leave the hospital, your needs may be safely received in another setting. 
 
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 receiving appropriate care in current acute care setting as provided by the Plan. Documentation does not support that LTACH services are medically appropriate 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 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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a partial upper denture (D5211) for tooth #10. 
 
You asked the Plan to pre-approve the dental service. You say that you have had the previous denture longer 
than 5 years. The Plan denied your request. The Plan says that the denial of authorization for this service is 
correct, because the records the dentist provided does not show the denture is not older than 5 years or it does 
not appear to be unrepairable. 
 
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. The Plan covers the dental 
service when the services are medically necessary and reasonable. 
 
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 dental service. Our reviewer says 
that coverage for a new prosthesis has been met. Our physician reviewer found that a review of the 
documentation indicates the presence of two maxillary teeth #2 and #16. The enrollee indicates that the current 
prosthesis is more than 5 years old. There was no claim with the enrollee's current insurance company that this 
prosthesis is less than 5 years old. The insurance company cannot assume the criteria of a 5 year wait period 
has not been met without definite proof. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental service have been met. Therefore, we decided that the Plan has to 
pre-approve a partial upper denture (D5211) for tooth #10.  
 
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: 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 meets criteria for placement. 
The Plan denied your request. The Plan says the enrollee's care can be provided in the current inpatient 
hospital. 
 
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 receiving appropriate care in current acute care setting as provided by 
the Plan. Documentation does not support that LTACH services are medically appropriate 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 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes G0156 and G0299 billed for date of service 
February 17, 2023. 
 
You asked the Plan to pay for procedure codes G0156 and G0299. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says procedure codes G0156 and G0299 are considered bundled 
and not separately payable.  
 
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 codes G0156 and G0299 have a status indicator of B on the Physician Fee Schedule. 
This means that procedure code G0156 and G0299 is not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure codes G0156 and G0299 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes G0156 and G0299 billed for date of service 
February 17, 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 you are spending most of the time in the bed and not 
really benefiting from just sitting there, an inpatient rehabilitation will make you walk, do things and not accept 
no as an answer. The Plan denied your request. The Plan says the enrollee's condition does not meet the 
Medicare guidelines.  The Plan says that the 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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cervical radiofrequency ablation (RFA) (64634, 64633). 
 
You asked the Plan to pre-approve cervical RFA. 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 for each covered spinal region no more than two (2) 
radiofrequency sessions will be reimbursed per rolling 12 months. 
 
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 cervical RFA. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found this request would exceed that limit. 
There is no extraordinary reason stated to exceed this limitation. 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 cervical RFA have not been met. Therefore, we decided that the Plan does not 
have to pre-approve cervical radiofrequency ablation (RFA) (64634, 64633).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transcatheter tricuspid valve repair (TTVR). 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has severe tricuspid 
regurgitation. The Plan denied your request. The Plan says there is not enough data to support the use of the 
service.  
 
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 requested services. Our physician 
reviewer found that the enrollee has a history of severe tricuspid regurgitation, chronic congestive heart failure, 
and preserved left ventricular function. There are insufficient randomized clinical data at this time to support 
the use of TTVR in this setting. At the current time, the requested TTVR is not medically necessary in this 
enrollees clinical management. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a transcatheter tricuspid valve repair (TTVR).
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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says you do not meet the criteria for IRF admission. 
 
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 does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. It is not clear that you can tolerate the intensity of therapies provided on acute 
inpatient rehabilitation as you had difficulty participating in therapy due to fatigue. 
 
 
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.