Persius/hicric huggingface dataset:
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 an IRF admission to regain 
prior independence and strength. The Plan denied your request. The Plan says the IRF services requested do not 
meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the 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 or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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. 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ursodiol. 
 
You asked the Plan to pre-approve ursodiol. You say that the enrollee would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says that self-administered drugs do not fall under 
Medicare Part B coverage. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve ursodiol.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar spinal fusion. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documented evidence of instability. 
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that detailed documentation regarding a trial and failure of recent, reasonable, comprehensive, less 
invasive conservative care measures is not evident. Dynamic flexion/extension films are not provided in order 
to potentially assess the amount of movement (instability) at the requested surgical level. Detailed 
documentation is not evident regarding potential impending/inevitable temporary intra-operative instability. There are limited large-scale, long-term references showing the safety and efficacy of the requested surgery in 
this clinical setting. No compelling rationale is presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the requested lumbar spinal fusion at L3-4 and L4-
5, 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 the surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve lumbar spinal fusion.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan.  
 
You asked the Plan to pre-approve the PET scan. You say that the requested PET scan is medically necessary. 
The Plan denied your request. The Plan says all other uses of FDG-PET for patients with a presumptive 
diagnosis of dementia-causing neurodegenerative disease for which CMS has not specifically indicated 
coverage continue to be non-covered. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the requested PET scan is not medically necessary. Our physician reviewer found in this case, the enrollee is 
not readily suspected of having AD or FTD (let alone both). Rather, the provider is considering dementia of 
Lewy bodies-a condition for which the NCD does not support the use of imaging. In as much based on the 
information provided the request would not meet the NCD requirements for coverage. In as much this service would not be 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a PET scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty walker (E0149). 
 
You asked the Plan to pre-approve a walker. You say that your current walkers seat is broken, and you need a 
new one. The Plan denied your request. The Plan says the enrollee does not meet the weight criterion for a 
heavy-duty walker. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The records show that the enrollee's current weight is 206 pounds. Therefore, the enrollee does not meet the criteria for the requested heavy-duty walker. Based on this 
information, we decided that Medicare rules for coverage of a walker have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a heavy-duty walker (E0149).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an in-network exception for the requested 
out-of-network facility. 
 
You asked the Plan to pre-approve an in-network exception for the requested out-of-network facility The Plan 
denied your request. The Plan says hand specialist with privileges at in-network facilities specializing in hand 
surgeries have not been exhausted. The member could have the procedure performed at the requested facility 
using out-of-network benefits if the facility is willing to accept the patient.  
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan will cover services from either network or out-of-network providers, as long as the 
services are covered benefits and are medically necessary. However, if you use an out-of-network provider, 
your share of the costs for your covered services may be higher. The requested provider in this case is not a network provider with the Plan. The Plan says that the Plan will 
cover services from either network or out-of-network providers, as long as the services are covered benefits and 
are medically necessary. However, if you use an out-of-network provider, your share of the costs for your 
covered services may be higher. The Plan says that hand specialist with privileges at in-network facilities 
specializing in hand surgeries have not been exhausted. Therefore, we decided that the Plan does not have to 
pre-approve an in-network exception for the requested out-of-network facility.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of the intraosseous basivertebral 
nerve. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not considered reasonable and necessary in the treatment of vertebrogenic low 
back pain. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the magnetic resonance imaging (MRI) shows foraminal stenosis at multiple levels. There is also a 
disc protrusion hitting a nerve root. The exact cause of the back pain remains unclear. Intracept is not likely to be effective. 
 
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 thermal destruction of the intraosseous basivertebral nerve.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that other devices will not meet the patient's 
needs. The Plan denied your request. The Plan says a home ventilator is not medically necessary. The patient's 
needs can be met with a bilevel positive airway pressure (BiPAP) device with average volume-assured pressure 
support (AVAPS). 
 
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 a home ventilator is not medically necessary. Our physician reviewer found the female enrollee has a 
diagnosis of COPD. The medical records submitted indicate that she was prescribed a non-invasive ventilator 
(NIV) May 13th, 2023. The NIV was ordered in the iVAPS-AE mode. With this request for continuation of the 
NIV, there was no change in the order for the device, or in the settings requested according to the standard 
written order dated May 13th, 2023. The compliance data submitted by the durable medical equipment provider 
from the time period of May 14th, 2023, to June 12th, 2023, indicates the machine is being used in iVAPS-AE 
mode, and no other modes. Office visit notes state her breathing was about the same and that she was using the 
ventilator. The documentation submitted fails to indicate that the enrollee is requiring the NIV for use in other 
than bilevel positive airwaypressure (BiPAP) or BiPAP with AVAPS mode. The records received do not say 
that the enrollee has failed the use of BIPAP or BIPAP with AVAPS when she is at her baseline level of 
breathing.  
 
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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing described by procedure code 81456. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says payment for code 81456 is bundled into payment for code 81455. 
 
The Plan must follow Medicare rules. In this case, we have confirmed that code 81456 is a column II code to 
column I code 81455 with a modifier indicator of 0. The file shows that the enrollee previously received 
genetic testing from the same provider described by code 81455. The testing described by code 81456 therefore 
cannot be approved. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for genetic testing described by procedure code 81456.
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 services are medically necessary for 
the enrollee's complex medical needs. The Plan denied your request. The Plan says the enrollee is receiving 
appropriate inpatient acute care and does not require transfer to a 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 patient is a 76-year-old who was admitted to the acute care hospital with urinary 
tract infection, atrial fibrillation with rapid ventricular response treated with antibiotics, heparin, and 
amiodarone complicated by combativeness, subcutaneous emphysema, elevated troponin, needing PEG tube placement, electrolyte abnormalities, and generalized weakness. Colonoscopy revealed tubulovillous adenoma 
which was removed. Recent notes describe the patient as off antibiotics and tolerating room air but still 
requiring therapy. She does not require complex wound care. The patient appears to be improving with current 
treatment and should only require short-term additional acute care services that can safely be performed at the 
current facility until more appropriate for a lower level of care. The patient does not require services at the 
LTACH that are not already available at the current facility. There are no services at the LTACH that the 
patient requires that are not already available and covered at the current facility. Transfer to the LTACH is not 
medically necessary as it would not be clinically advantageous. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Zenfuse nerve treatment. 
 
You asked the Plan to pre-approve the treatment. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is an investigational treatment for chronic back pain. 
 
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 treatment. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that detailed documentation regarding dynamic flexion/extension films that show instability at 
the requested surgical level. Detailed documentation is not evident regarding potential impending/inevitable 
temporary intra-operative instability. Moreover, there is limited published, large-scale, long-term peer-
reviewed literature that shows ZenFuze to be an effective and/or safe treatment for the noted pathology. No compelling rationale is presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested Zenfuse nerve treatment, 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 the treatment have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Zenfuse nerve treatment.
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 medically necessary for the 
enrollee to return home with maximum level of function. The Plan denied your request. The Plan says the 
enrollee does not meet the requirements for an 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 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 or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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. 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron. 
 
You asked the Plan to pre-approve the medication. You say that the requested medication is to be used as a full 
therapeutic replacement for intravenous anti-emetic therapy that would have been administered at the time of 
the cancer chemotherapy treatment. You say that the enrollee is having increased nausea and vomiting from the 
treatment resulting in decreased oral intake. The Plan denied your request. The Plan says the medication is not 
covered as a medical benefit under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. The file indicates that this medication is prescribed as needed and will be continued for a 
period exceeding 48 hours from the time of treatment. Therefore, we decided that the Plan does not have to pre-
approve Ondansetron.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement graft for ridge preservation (D7953), 
guided tissue regeneration (D4267), cone beam CT capture and interpretation (D0364) and bone graft at time of 
implant placement (D6104). 
 
You asked the Plan to pre-approve the dental services. You say that you are requesting an appeal for the rest of 
your dental work to be covered. The Plan denied your request. The Plan says you are only covered for the 
dental services, codes and limits listed in the dental benefits chart. 
 
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 bone 
replacement graft for ridge preservation (D7953), guided tissue regeneration (D4267), cone beam CT capture 
and interpretation (D0364) and bone graft at time of implant placement (D6104).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for additional routine transportation trips. 
 
You asked the Plan to provide coverage for additional routine transportation trips. You say that the additional 
transportation is medically necessary. The Plan denied your request. The Plan says you have currently used 81 
trips. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 60 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. The file shows that you have used 81 trips 
this year. Based on this information, we decided that you have exhausted the Plan maximum benefit for 
coverage of routine transportation. Therefore, we decided that the Plan does not have to provide coverage for 
additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Rush Rogue foot prosthesis. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the requested procedure code is not appropriate for these services. 
 
The Plan must follow Medicare rules. Medicare rules say that codes L5987 and L5984 are used for a Rush 
Rogue foot. 
 
We looked at the file and Medicare rules. The file shows that the prosthesis at issue was incorrectly requested 
with procedure code L5986.  Based on this information, we decided that Medicare rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Rush Rogue 
foot prosthesis.