Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting IRF services because you live 
independently and do not have any support if you go home. The Plan denied your request. The Plan says the 
Medicare criteria for admission to an IRF have not been met. 
 
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 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. While you may benefit from physical therapy and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. There is not a reasonable expectation 
that you 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an elastic abdominal binder. 
 
You asked the Plan to pre-approve an abdominal binder. You say that you have been trying to get an abdominal 
binder approved. You say that you have a huge hernia and half of your stomach pulled out. You also say that 
you need to wear a binder daily. The Plan denied your request. The Plan says the requested item is not a 
covered benefit. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid physician order, or relevant medical records which support medical 
necessity for the requested items in this case. Therefore, we decided that the Plan does not have to pre-approve 
an elastic abdominal binder.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve the DME. You say that it is important that the enrollee gets a portable 
oxygen concentrator as soon as possible to be able to move around this facility, because the enrollee is a fall 
risk. The Plan denied your request. The Plan says duplicate items are not covered by Original Medicare or 
Health Plan. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the DME have not been met. Medicare and the Health Plan does 
not cover duplicate or redundant durable medical equipment such as oxygen device when the second item 
performs the same function as the one currently provided to the enrollee. There is no medical documentation to 
support the enrollee's need for a portable oxygen concentrator. Therefore, we decided that the Plan does not 
have to pre-approve the portable oxygen concentrator (E1392).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the noninvasive estimated coronary fractional flow 
reserve (FFR) (0503T). 
 
You asked the Plan to pre-approve the FFR. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that this service should be performed in patients with 
stable coronary symptoms. It should not be performed until after the base study (Coronary computed 
tomography angiography (CCTA)) has been completed and interpreted. If higher grade stenoses (i.e. greater 
than 90%) are present, this study is not medically necessary, as the patient should proceed to catheterization. 
Similarly, low-grade stenoses (less than 40%) do not require additional confirmatory data. This should be 
performed as an alternative to stress testing. 
 
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 for the FFR. Our reviewer says that the service is not 
medically necessary. Our physician reviewer found the claimant has significant aortic stenosis. As such, 
clinical guidelines for the use of noninvasive estimated coronary fractional flow reserve (FFR) have not been 
met. 
 
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 FFR have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the noninvasive estimated coronary fractional flow reserve (FFR) (0503T).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99233) provided on January 7, 2022, and 
January 8, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 
not supported. 
 
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 99233 is " Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit". 
 
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 the services. Our reviewer says that the use of code 99233 is 
not supported by the records provided. Our reviewer found that the records in this case do not document an 
evaluation and management note for January 7, 2022, with a detailed interval history, a detailed examination or 
medical decision making of high complexity, or 35 minutes spent at the bedside and on the patient's hospital 
floor or unit. The records also do not document an evaluation and management note for January 8, 2022, with a 
detailed interval history, a detailed examination or medical decision making of high complexity, or 35 minutes 
spent at the bedside and on the patient's hospital floor or unit. 
 
We looked at this coder'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 services (99233) provided on January 7, 2022, and January 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional acupuncture visits. 
 
You asked the Plan to pre-approve these services. You say that the requested services are medically necessary. 
The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
 
  
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case. 
 
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 requested services are not medically necessary. Our physician reviewer found that you have neck and 
shoulder pain following shoulder surgery. You are taking Tylenol and Duloxetine for pain. You had some brief 
physical therapy and trigger point injections. Additionally, you had acupuncture treatment and the progress 
notes state that you are getting 2-3 hours of pain relief. There is no documentation provided that indicates 
steady improvement in pain or a change in medications. Therefore, the requested services are deemed not 
medically reasonable or necessary. 
 
We looked at this physician's review, the file, and the Plans rules. Based on this information, we decided that 
the Plans rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 8 additional acupuncture visits.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for air ambulance services provided on July 23, 2022. 
 You asked the Plan to pay for the air ambulance services. You say that based on the clinical information 
documented during patient transport, this transport meets medical necessity guidelines. The Plan denied your 
request. The Plan says the data reviewed determined the air ambulance transport was not medically necessary. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air ambulance services. Our reviewer 
says that the air ambulance transport service was not medically necessary. Our physician reviewer found the 
enrollee had an isolated traumatic injury. The enrollee was stable. Transport by ground ambulance would not 
have endangered the enrollees condition. 
 
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 air ambulance services have not been met. Therefore, we decided that the 
Plan does not have to pay for air ambulance services provided on July 23, 2022.
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 meets full criteria for an IRF admission, 
and their current needs cannot be safely met at a lower level of care. You would like reconsideration based on 
the records submitted. 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 enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the enrollee may benefit from physical therapy and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Granix (J1447). 
 
You asked the Plan to pre-approve Granix. You say that Granix is a medical necessity for the enrollee. The 
Plan denied your request. The Plan says Granix has been prescribed for an off-label, not medically accepted 
use. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Granix. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
enrollee has a diagnosis of immunosuppressive drug-induced neutropenia in the setting of a kidney 
transplant. The FDA has not stated that the requested drug is indicated for the enrollee's condition. The 
Medicare-approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Granix have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Granix (J1447).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic manipulative treatments (98940, 98941). 
 
You asked the Plan to pre-approve these services. You say that the requested services are medically necessary 
for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of 
the requested services. 
 
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.  
 
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 enrollee does not meet criteria for coverage of the requested services. Our physician reviewer found that in 
this case, the record indicates that the enrollee has lumbar spondylosis and back pain. The records provided do 
not document the presence of a subluxation of the spine either by physical examination or radiographic images. 
The elements of the coverage criteria are not satisfied. The requested services are not 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve chiropractic manipulative treatments (98940, 98941).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88189 billed for date of service September 9, 
2022. 
 
You asked the Plan to pay for procedure code 88189. You say that this service was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this claim was not submitted with 
a diagnosis which supports the medical necessity of this service. 
 
The Plan must follow Medicare rules. Medicare rules say that there are certain diagnosis codes which support 
the medical necessity of code 88189. Any codes which are not listed are considered not medically necessary for 
code 88189. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 88189 have not been met. Specifically, this claim was submitted with only diagnosis code 
C71.9, which is not among those codes listed as medically necessary and appropriate for this service. Therefore, we decided that the Plan does not have to pay for procedure code 88189 billed for date of service 
September 9, 2022.
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 is stable and needs aggressive 
occupational therapy and physical therapy to regain maximum function. The Plan denied your request. The 
Plan says the enrollee does not meet the Medicare 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 that 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. While the enrollee may benefit from physical therapy 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the percutaneous vertebral augmentation (PVA) 
(Kyphoplasty) of lumbar vertebral body L1 (22514). 
 
You asked the Plan to pre-approve the surgical services. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service is not medically necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the surgical services. Our physician 
reviewer found imaging shows fracture retropulsion which is a contraindication to kyphoplasty. 
 
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 surgical services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the percutaneous vertebral augmentation (PVA) (Kyphoplasty) of lumbar 
vertebral body L1 (22514).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of a device that sends mild electrical 
signals near your nerves to treat pain (SPRINT PNS) (C1778 and 64555). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says your records show you do not have intractable pain as evidenced by the fact 
that you reported pain relief after your knee injection. The Plan states the review of current medical literature 
suggests that this device is not considered standard medical treatment for the enrollee's condition. 
 
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 physician reviewer 
found the use of SPRINT PNS for low back pain is the subject of an ongoing clinical trial. It is considered 
experimental/ investigational at this time. 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a device that sends mild electrical signals near your nerves to treat pain 
(SPRINT PNS) (C1778 and 64555).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient telehealth services to be provided by an OON 
provider. 
 
You asked the Plan to pre-approve outpatient telehealth services. You say that you are requesting 
reconsideration of the denied authorization. The Plan denied your request. The Plan says that out-of-network 
telehealth services are not covered. 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. The Plan contract 
also says that the POS benefit does not include out-of-network telehealth services. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
outpatient telehealth services to be provided by an OON provider.