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

 
We decided that the Plan does not have to pre-approve Minuteman G3R Interspinous device to L4-L5 (22840 
and 22612). 
 
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 the clinical value and effectiveness of the Minuteman interspinous device in 
the setting of lumbar radiculopathy have not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Minuteman device is experimental. More research is needed. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Minuteman G3R Interspinous device to L4-L5 (22840 and 22612).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97110, & 97112 billed for date of service 
January 24, 2023. 
 You asked the Plan to pay for procedure codes 97110, & 97112. You say that this service was medically 
necessary. The Plan denied your request. The Plan says payment for codes 97110, & 97112 is bundled into 
payment for code 97150. 
 
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, we have confirmed that codes 
97110, & 97112 are a column II code to column I code 97150. This claim has not been billed with an 
appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 97110, & 97112 billed for 
date of service January 24, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 You asked the Plan to pre-approve Prolia. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 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 Prolia. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee has not tried and failed the 
required drugs. There is no documentation provided indicating that the plan's required drugs would likely be 
less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the submitted medical records support 
the need for LTACH admission. 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 enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medical necessary care is being provided 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 are 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 the LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ozempic. 
 
You asked the Plan to pre-approve the medication. You say that the requested medication is medically 
necessary for the enrollee. 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. Therefore, we decided that the Plan does not have to pre-approve Ozempic.
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 a skilled nursing facility does not have enough care 
that you are needed. The Plan denied your request. The Plan says you do not meet the requirements for 
inpatient rehabilitation. Services needed may be provided safely in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve the injection procedure for sacroiliac (SI) joint, anesthetic/steroid, 
with image guidance (fluoroscopy or CT) including arthrography when performed (27096). 
 
You asked the Plan to pre-approve the injection. You say that the injection is medically necessary. The Plan 
denied your request. The Plan says that your request is not medically necessary because the enrollee's records 
show the enrollee does not have pain duration of at least three months. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the injection. Our physician reviewer 
found the request meets ALL of the criteria of the LCD.  Being unable to complete physical therapy (PT) due 
to pain is not disqualifying. The request is 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 injection have been met. Therefore, we decided that the Plan has to pre-
approve the injection procedure for sacroiliac (SI) joint, anesthetic/steroid, with image guidance (fluoroscopy 
or CT) including arthrography when performed (27096).  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (87507) provided on October 3, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that this test was necessary and is supported in 
the medical record. The Plan denied your request. The Plan says there is insufficient information to support the 
medical necessity of this testing. The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the laboratory service have been met. 
Specifically, the limited records include only test results and an order form with an illegible signature. There 
are no physician notes included in this case to support that the ordering physician was treating the enrollee, 
intended for this testing to be performed, and to support medical necessity. Additional information is needed. 
Therefore, we decided that the Plan does not have to pay for the laboratory service (87507) provided on 
October 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided by an out-of-network (OON) 
provider on February 17, 2023. 
 
You asked the Plan to pay for OON nursing facility care. You say that the enrollee did not have a choice of 
providers. The Plan denied your request. The Plan says this was not authorized. 
 
The Plan must follow Medicare rules. Medicare rules say that Health Maintenance Organizations (HMOs) may 
offer a Point of Service (POS) option as a mandatory or optional supplemental benefit and may either require 
or waive prior authorization rules for obtaining POS services. The Plan contract says that out-of-network 
services require authorization. 
 
We looked at the file and Medicare rules. The service at issue was not authorized. Based on this information, we decided that Medicare rules for coverage of OON nursing facility care have not been met. Therefore, we 
decided that the Plan does not have to pay for nursing facility care provided by an out-of-network (OON) 
provider on February 17, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Denosumab (Prolia) (J0897). 
 
You asked the Plan to pre-approve the drug. You say that the drug is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not have a history of failure, contraindication, or intolerance to both an oral bisphosphonate (for example, Alendronate, Risedronate) and an injectable bisphosphonate (for 
example, Pamidronate, Zoledronic Acid), there is no reason enrollee cannot take alternatives and this is not a 
continuation of therapy in the past 365 days. 
 
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 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 drug. Our physician reviewer found 
the Plan requires a trial of drug an oral bisphosphonate (for example, Alendronate, Risedronate) and an 
injectable bisphosphonate (for example, Pamidronate, Zoledronic Acid), before they will approve the requested 
drug. In this case, the enrollee has not tried and failed the required drugs. There is no documentation provided 
indicating that the Plans required drugs would likely be less effective and/or likely have adverse effects for the 
enrollee. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Denosumab (Prolia) (J0897).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9083 billed for date of service December 5, 
2022. 
 
You asked the Plan to pay for procedure code S9083. The Plan denied your request. The Plan says the billed 
code is invalid for Medicare purposes.  
 
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 S9083 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code S9083 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9083 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9083 billed for date of service December 5, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme (Q0138). 
 
You asked the Plan to pre-approve the drug. You say that the drug is medically necessary. The Plan denied 
your request. The Plan says the enrollee has not tried and failed the preferred step therapy drug(s) Venofer (iron sucrose). The Plan states there is no indication our preferred drug(s) would likely be: less effective, and/or 
cause adverse effects for the enrollee. 
 
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 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 drug. Our physician reviewer found 
the Plan requires a trial of drug Venofer (iron sucrose), before they will approve the requested drug. In this 
case, the enrollee has not tried and failed the required drug. There is no documentation provided indicating that 
the Plans required drug would likely be less effective and/or likely have adverse effects for the enrollee. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme (Q0138).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport and ground mileage provided on September 21, 2022. 
 
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport and ground 
mileage. You say that this was a medical necessity transport due to the enrollee being deconditioned and a high 
fall risk.  The Plan denied your request. The Plan says the appeal does not support coverage as the enrollee was 
not transported to the closest appropriate facility. There are multiple closer facilities. The destination was 
requested by family.  
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance service, basic life support, 
non-emergency transport and ground mileage.  Our reviewer says that the ambulance transport services were not medically necessary. Our physician reviewer 
found the transportation via ambulance from the hospital was not medically necessary. The enrollee did not 
require the expertise of trained personnel or the equipment available only on an ambulance in order to 
effectuate a safe transport.  Transportation could have been provided by other means (stretcher van, wheelchair 
van, private car, taxi) without endangering the enrollee's 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 ambulance service, basic life support, non-emergency transport and ground 
mileage have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, 
basic life support, non-emergency transport and ground mileage provided on September 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you require IRF services in order to overcome 
functional deficits. The Plan denied your request. The Plan says the request is not medically necessary. 
 
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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says there is no documented need for intensive rehabilitation services. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the services provided to you on January 30, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that your primary care 
physician billed the services incorrectly. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided the services by a contract provider. The file does not show that the Plan provided notice 
that the services would not be covered. Under Medicare rules, this means the services is considered approved 
by the Plan. Therefore, we decided that the Plan has to pay for the services provided to you on January 30, 
2023.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for or waive the deductible for an office visit and manual 
manipulation service provided by a chiropractor on February 1, 2023. 
 
You asked the Plan to pay for or waive the deductible for chiropractic services. You say that the Plan gives you 
chiropractic coverage but did not make any payment toward this claim. The Plan denied your request. The Plan 
says the office visit is not covered when performed by a chiropractor, and the chiropractic manipulative 
treatment applied to your Plan deductible.  
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. The rules say a plan must disclose to its enrollees in 
clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $226 
deductible which applies to in-network and out-of-network chiropractic services in 2023. At the time this claim 
was processed, $77.96 of the $226 deductible had been met. The allowed amount of the chiropractic 
manipulative treatment is $38.98, resulting in a deductible amount of $38.98. 
 
The records show that the office visit service at issue is not manual manipulation of the spine. Therefore, it is 
not covered when performed by a chiropractor. Additionally, you have been asked to pay $226 deductible for 
the covered chiropractic manipulative treatment. Chiropractic manipulative treatment 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 that you agreed to when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to pay for or waive the deductible for an 
office visit and manual manipulation service provided by a chiropractor on February 1, 2023.