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

 
We decided that the Plan does not have to pre-approve a ganglion impar sacrococcygeal nerve block (64999). 
 
You asked the Plan to pre-approve a ganglion impar sacrococcygeal nerve block. The Plan denied your request. 
The Plan says this request does not meet the definition of medical necessity. 
 
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 a ganglion impar sacrococcygeal nerve 
block. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found a ganglion impar block is considered to be experimental 
and investigational because of insufficient evidence. This must be in the peer-reviewed medical journals. Our 
reviewer found that these articles must show better long-term health outcomes for people when this service is 
done. Enough good evidence was not found. Our physician reviewer also found that the service at issue 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 a ganglion impar sacrococcygeal nerve block have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a ganglion impar sacrococcygeal nerve block (64999).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint fusion with a LinQ device. 
 
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 detailed documentation is not evident 
regarding imaging or radiographic evidence supporting a sacroiliitis pathology for this enrollee. There is no 
clear history of SI joint pain onset or failure of conservative treatment directed to the SI joint. Multiple other 
plausible pain generators including at the lumbosacral spine are evident. Moreover, there are limited large-
scale, long-term references showing the safety and efficacy of the requested LinQ in this clinical setting. The services are therefore not reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacroiliac (SI) joint fusion with a LinQ device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the thoracic medical back brace (L0457) and cervical collar 
(L0174) provided on January 13, 2023. 
 
You asked the Plan to pay for the thoracic medical back brace and cervical collar. You say that these services 
were provided based on the physician's orders. The Plan denied your request. The Plan says the provider's 
office confirmed that the enrollee was not seen in the office on the date of service listed as the exam date in the 
medical records provided. The Plan also says that they stated that the enrollee was not seen for low back pain, 
and the provider did not order a back brace for the enrollee. 
 
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 pay for the thoracic medical back brace and cervical 
collar. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the provided records did not show that the enrollee was 
seen and examined at their physician's office within a few months. The provider's office confirmed that the 
enrollee was not seen in the office on the date of service listed as the exam date in October in the medical 
records provided. Our reviewer found that there was no evidence from the records that the enrollee had back or 
neck pain in October, or examination findings that would meet one of the 4 criteria for coverage for the back 
brace. The neck brace is not medically necessary. Our physician reviewer also found that the provided records 
do not contain sufficient documentation of the enrollee's condition to substantiate the need for the braces. 
 
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 thoracic medical back brace and cervical collar have not been met. 
Therefore, we decided that the Plan does not have to pay for the thoracic medical back brace (L0457) and 
cervical collar (L0174) provided on January 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a repeat epidural steroid injection rendered on October 26, 
2022. 
 
You asked the Plan to pay for the services. You say that the medical records justify the medical necessity. The 
Plan denied your request. The Plan says this request does not meet the requirements for approval. 
 
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 pay for 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 previous injection provided 100% pain relief, but for only two weeks. The enrollee did not 
receive the proper relief from the prior injection to indicate the repeat injection. The review has determined that 
the requested service 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for a repeat epidural steroid injection rendered on October 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets admission criteria, 
and their ongoing medical care warrants an LTACH level of care to achieve a safe and sustainable discharge.  
The Plan denied your request. The Plan says admission to the LTACH is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that all medically necessary care is being provided in the current acute care setting.  
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting.  The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve transforaminal epidural steroid injections (TFESIs) at two levels.  
 
You asked the Plan to pre-approve the TFESIs. You say that the requested injections are necessary to improve 
the enrollee's condition. The Plan denied your request. The Plan says that the enrollee has long-term nerve pain 
due to shingles not short-term pain. The Plan also says that the requested TFESIs are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when certain 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 the TFESIs. Our reviewer says that the 
requested TFESIs are medically necessary. Our physician reviewer found the provided documentation indicates 
the enrollee had an episode of Shingles 24 months ago. The reviewer found that there are several case reports 
of epidural steroids helping reduce pain after one year after the episode. Therefore, the reviewer found that the 
requested injections are 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 TFESIs have been met. Therefore, we decided that the Plan has to pre-
approve transforaminal epidural steroid injections (TFESIs) at two levels.   
 
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 an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires daily intensive physical therapy 
and occupational therapy, and it is unsafe for the enrollee to return home until a rehabilitation program is 
completed. The Plan denied your request. The Plan says the enrollee does not meet 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 have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that 
the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: 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 it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does 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 complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for frequent falls. Medical problems are stable. There are no complex nursing or 
rehabilitation needs.  
 
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 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that this 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Apos shoes (T1999). 
 
You asked the Plan to pre-approve Apos shoes. You say that you require these shoes because they are the only 
item that has been helping you with the treatment. You also say that these shoes provide balance, and you need 
them so you can walk properly. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve Apos shoes (T1999).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3 sessions of right leg sclerotherapy. 
 
You asked the Plan to pre-approve the outpatient services. You say that you continue to have right leg pain and 
swelling. You also say that the requested services are medically necessary. The Plan denied your request. The Plan says there is no evidence your mobility is significantly affected. The Plan also says a request for a series 
of surgeries is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that surgical treatment and sclerotherapy is indicated 
when certain criteria have been 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 the outpatient services. Our reviewer 
says that the requested sclerotherapy is not medically necessary. Our physician reviewer found the provided 
documentation does not indicate symptoms severe enough to limit mobility and there has not been a three-
month period of conservative effort since the enrollee's last intervention.  The reviewer found that the nature of 
the symptoms and response to previous treatments are unclear. Therefore, the reviewer found that the requested 
treatment 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 outpatient services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 3 sessions of right leg sclerotherapy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360, and 88377 billed for 
date of service November 4, 2022. 
 
You asked the Plan to pay for procedure code(s) 88341, 88342, 88360, and 88377. You say that the records 
prove medical necessity. The Plan denied your request. The Plan says the codes are not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient. Per the Physician Fee 
Schedule, there is a Professional/Technical indicator of 1 for CPT codes 88341, 88342, 88360, and 88377. This 
means there is both a professional and technical component for the CPT codes. In this case, an appropriate 
modifier to indicate the professional component has not been billed with CPT codes. Based on this information, 
we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code(s) 88341, 88342, 88360, and 88377 billed for date of service November 4, 
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 it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does 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 rehabilitation therapy services can be delivered in a wide variety of settings 
across the care continuum.  Post-acute settings differ in the types of available rehabilitation therapies, intensity 
of therapy, and the level of medical and nursing support. Acute inpatient rehabilitation facilities are settings 
were complex medical needs and functional needs combine. The requirements for admission to an inpatient 
rehabilitation facility (IRF) include a need for 24-hour rehabilitation nursing care, a minimum of three 
physician face-to-face visits per week and a minimum of three hours of therapy daily at least five days per 
week (or at least 15 hours over a seven-consecutive day period). Additionally, an individual requires multiple 
types of therapies one of which should be physical or occupational therapy. In this case, the complexity of the 
enrollees nursing, medical and rehabilitation needs do not require an acute rehab 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, at an intensive rehabilitation therapy 
program. The enrollee continues to have a need for skilled therapy with ongoing safety concerns and a potential 
for functional improvement however, the documentation doesnt support that the enrollee would meet criteria 
for admission to an acute inpatient rehabilitation facility. There is no indication that the enrollee would require 
skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a 
physician with at least 3 visits weekly to regain or maintain her functional status. The member can receive 
further services 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vacuum Assisted Socket System (VASS) (L5781). 
 
You asked the Plan to pre-approve a VASS. You say that this technology is not new, and is most beneficial for 
the enrollee and limb health. The Plan denied your request. The Plan says experimental and investigational 
items are not covered by Medicare. 
 
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 a VASS. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the use of elevated vacuum pumps for residual limb volume management and moisture 
evacuation systems among lower extremity amputees is unproven and not medically necessary due to 
insufficient evidence of safety and/or efficacy. The elevated vacuum system is not proven more beneficial than 
a standard socket. Our reviewer also found that the requested L5781 is not 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 VASS have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Vacuum Assisted Socket System (VASS) (L5781).