Persius/hicric huggingface dataset:
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 this is medically necessary. The Plan 
denied your request. The Plan says the enrollees continued care needs include intravenous antibiotic and wound 
care. When they are ready to leave the hospital, they can safely receive this care in another setting, such as a 
Skilled Nursing Facility (SNF). 
 
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 
Health 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 LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the polymerase chain reaction (PCR) testing (87633) 
provided on October 3, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the testing is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that molecular syndromic panels are covered for the 
indications established in the applicable LCD. 
 
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 not medically reasonable and necessary in this case. Our physician reviewer found that 
the patient is a female who presented to a family medicine outpatient office with symptoms of upper respiratory 
infection with COVID-19 infection suspected upon evaluation of history and physical. Vitals were 
normal/stable. The patient was not immunocompromised. Based on the provided documentation, the patient 
was not seriously ill, and the testing was not ordered by a Pulmonologist or Infections Disease specialist. 
Therefore, the criteria in the LCD were not sufficiently met for this testing. 
 
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 pay for the polymerase chain reaction (PCR) testing (87633) provided on October 3, 2022.
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 needs to do speech therapy, occupational 
therapy, and physical therapy and is a fall risk. The Plan denied your request. The Plan says the enrollee's 
records show that it is not reasonable to expect that they can fully benefit from the intensity of services of an 
IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0117U for date of service March 9, 2023. 
 
You asked the Plan to pay for procedure code 0117U. You say that this code is an allowable code. The Plan 
denied your request. The Plan says the code billed is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that code 0017U is not covered. 
 
We looked at the file and Medicare rules. The code at issue is specifically not covered. Based on this 
information, we decided that Medicare rules for coverage of procedure code 0117U have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 0117U for date of service March 
9, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Kenevo microprocessor knee and flex-walk foot. 
 
You asked the Plan to pre-approve a Kenevo microprocessor knee and flex-walk foot. You say that the services 
are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage 
criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Lower Limb Prostheses are 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 a Kenevo microprocessor knee and 
flex-walk foot. Our reviewer says that the services are medically necessary. Our physician reviewer found in 
the case, lesser devices simply do not meet his functional needs and amount to substandard care. Therefore, the requested microprocessor knee (L5828, L5845, L5848, L5856) and foot (L5981) are 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 a Kenevo microprocessor knee and flex-walk foot have been met. Therefore, we 
decided that the Plan has to pre-approve a Kenevo microprocessor knee and flex-walk foot.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99379 billed for date of service August 15, 
2022. 
 
You asked the Plan to pay for procedure code 99379. You say that this service was medically necessary and 
appropriate. The Plan denied your request. The Plan says procedure code 99379 is 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 code 99379 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99379 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99379 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99379 billed for date of service August 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
March 21, 2023.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service March 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular nerve block. 
 
You asked the Plan to pre-approve the genicular nerve block. You say that you have had the procedure done to 
your back with 100% pain relief and would like to have the procedure done to your right knee so you can go 
without pain and pain medications.  The Plan denied your request. The Plan says  the genicular nerve block 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 genicular nerve block. Our reviewer 
says that the genicular nerve block is not medically necessary. Our physician reviewer found that genicular 
nerve blocks are considered experimental and investigational in nature. 
 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 genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the genicular nerve block.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SPRINT PNS System. 
 
You asked the Plan to pre-approve the SPRINT PNS System. You say that the SPRINT PNS System is 
medically necessary. The Plan denied your request. The Plan says the SPRINT PNS System is unproven and 
not medically necessary due to insufficient evidence of efficacy. Medicare only covers implanted PNS.  
 
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 SPRINT PNS System. Our reviewer 
says that the requested SPRINT PNS System is not considered medically reasonable and necessary in this case. 
Our physician reviewer found that you have left sided thoracic pain. You have tried trigger point injections as 
well as medial branch blocks without improvement. Orthopedics consultant believes this is muscular pain. The 
SPRINT PNS System would be deemed experimental for this painful condition. Therefore, it 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 the SPRINT PNS System have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the SPRINT PNS System.
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 the injection. 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 the injection. Our reviewer says that the 
enrollee does not meet the coverage criteria. Our physician reviewer found that the enrollee has chronic low 
back pain with radiculopathy and underwent a L5-S1 epidural steroid injection on June 23, 2023. According to 
the coverage criteria, a second epidural injection may be considered medically reasonable and necessary when 
the medical record documents at least 50% of sustained improvement in pain relief or improvement in function 
measured from baseline using same scale for at least 3 months. Therefore, the enrollee does not meet the LCD 
coverage criteria. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an epidural steroid injection.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Minuteman procedure. 
 
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 services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the Minuteman G3-R MIS Fusion Plate 
is intended for use with bone graft material and is not intended for stand-alone use. In addition, fusion 
indications within guidelines/literature for (existing or potential intraoperative) instability have not been 
documented and/or met in this case. 
In addition, there are multiple alternate pain generators plausibly significantly contributing to the clinical condition that have not been fully documented as having been excluded and/or ruled out. No compelling 
rationale is presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the requested Minuteman device 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Minuteman procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee does not meet the criteria for admission to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require the intensity of services provided at an IRF. The 
enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician 
evaluation. The enrollees care needs can be met at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for chiropractic care on February 08, 2023.  
 
You asked the Plan to waive the cost share for chiropractic care. You say that you were told that you were 
covered for chiropractic care. You did this prior to scheduling your appointment. The Plan denied your request. 
The Plan says this cost sharing was charged correctly. 
 
 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment per visit for Medicare-covered services for chiropractic services. Covered services include the plan 
covers only manual manipulation of the spine to correct subluxation. Manual manipulation of the spine to 
correct a subluxation is covered. Services other than Medicare covered chiropractic services are NOT 
covered. The provider billed in the amount of $39. The provider also billed in the amount of $28 and the 
allowed amount is $18.80 for the service. $39 + $18.80 = $57.80. Therefore, results in the total cost sharing 
amount of $57.80. 
 
You have been asked to pay a $57.80 cost share for chiropractic care. This item/service falls within the 
chiropractic services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the cost share for chiropractic care on 
February 08, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an injection, Faricimab, 0.1 mg (J2777). 
 
You asked the Plan to pre-approve an injection. You say that you disagree with the denial. The enrollee will  
be placed back on her prior treatment. The Plan denied your request. The Plan says the enrollee must first try or 
be unable to use the plans preferred medications. 
 
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 looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an injection have not been met. Therefore, we decided that the Plan does not have to pre-approve 
an injection, Faricimab, 0.1 mg (J2777).
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 the injection. 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 the injection. Our reviewer says that the 
enrollee does not meet the coverage criteria. Our physician reviewer found that the previous epidural steroid 
injection provided 75% pain relief for 60 days. Therefore, the enrollee does not meet the LCD coverage 
criteria. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an epidural steroid injection.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve insertion subcutaneous cardiac rhythm monitor. 
 
You asked the Plan to pre-approve insertion subcutaneous cardiac rhythm monitor. You say that insertion 
subcutaneous cardiac rhythm monitor is medically necessary. The Plan denied your request. The Plan says that 
based on the clinical information provided to us, the enrollee has not had any recent syncopal episodes. 
 
The Plan follows Medicare rules. Medicare rules say that insertion subcutaneous cardiac rhythm monitor is 
covered when the criteria listed in the Medicare rules section of this decision 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 insertion subcutaneous cardiac rhythm 
monitor. Our reviewer says that insertion subcutaneous cardiac rhythm monitor is considered medically 
necessary in this case. Our physician reviewer found that the enrollee has symptom of palpitation, history of 
hypertension (HTN), aortic atherosclerosis, transient ischemic attack (TIA x 2), obstructive sleep apnea, 
Barrett's esophagus, and dyslipidemia. The enrollee is on Aspirin only and a recent inconclusive noninvasive 
Holter monitoring (PVCs, a short run of atrial tachycardia) was recommended to have an implantable Loop 
Recorder to rule out a paroxysmal A. Fib, making him a candidate for full anticoagulation. The enrollee 
benefits from an invasive Loop Recorder implantation to decide if he benefits from full anticoagulation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion subcutaneous cardiac rhythm monitor have been met. Therefore, we 
decided that the Plan has to pre-approve insertion subcutaneous cardiac rhythm monitor.  
 
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.