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

 
We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process 
stabilization/distraction device (a Vertiflex device) (22869, 22870).  
 
You asked the Plan to pre-approve a Vertiflex device. You say that the enrollee has failed conservative 
approaches to treatment at this time. You say that the enrollee is a good candidate for this procedure. You also 
say that this is medically necessary for the enrollee's pain. The Plan denied your request. The Plan says the 
requested procedure 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 a Vertiflex device. Our reviewer says 
that the requested Vertiflex device is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested device is considered experimental as additional research is needed. Therefore, the reviewer found that the requested device 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 Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device (a 
Vertiflex device) (22869, 22870).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting an expedited 
reconsideration stating the enrollee clearly exceeds the criteria for a medically appropriate LTACH admission. 
The Plan denied your request. The Plan says the request for an LTACH admission 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 the enrollee appears to be improving with current treatment and should only 
require short-term additional acute care services that can safely be provided at the current facility until more 
stable and appropriate for transfer. There are no services at the LTACH that the enrollee requires that are not 
already available and covered at the current facility. Transfer to the LTACH would not be clinically 
advantageous and completion of treatment at the current facility is recommended.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: 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 enrollee 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 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 step therapy requirement is not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has not tried and failed the 
Plan's required drugs, intravenous (IV) and oral bisphosphonates. The records do not show that the required 
drugs would be contraindicated or less effective; therefore, Prolia is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prolia.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for Part B injectable drugs provided from August 5, 2022, to  
October 21, 2022. 
 
You asked the Plan to pay for Part B injectable drugs. You say that the Plan's authorization is clinically valid. 
The Plan denied your request. The Plan says that the drug is considered by the Plan to be experimental and 
excluded from coverage under the member's Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided a Medicare rule, a Plan rule or a coding 
rule to substantiate their denial. Therefore, we decided that the Plan has to pay for Part B injectable drugs 
provided from August 5, 2022, to October 21, 2022.  
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 You asked the Plan to pre-approve the medication. You say that the facility no longer carries the preferred 
medications. The Plan denied your request. The Plan says the enrollee has not tried and failed 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 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 medication. Our reviewer says that 
the requested medication does not meet the requirements for step therapy guidelines. Our physician reviewer 
found the enrollee has not tried and failed the required drugs. There is no evidence that those drugs would be 
less effective or has adverse effects. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Euflexxa.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the services provided from November 18, 2022, to November 30, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that services from 
nurse practitioner (NP) providers are not covered under open access unless preauthorized. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan argues that services from NP providers are not covered under open 
access unless preauthorized. However, the Plan has not provider a Medicare rule Plan rule supporting that an 
NP is not payable for the services provided in this case. Without supporting documentation, the Plan's denial 
cannot be substantiated. Therefore, we decided that the Plan has to pay for the services provided from 
November 18, 2022, to November 30, 2022.  
 
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 procedure codes 96374 and 96375 billed for date of service 
August 10, 2022. 
 
You asked the Plan to pay for the billed services. You say that the procedures are documented in the medical 
notes. The Plan denied your request. The Plan says the codes cannot be separately reimbursed. The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
We looked at the file and the rules. The medical records provided do not show that the services billed with the -
59 modifier were distinct procedural services. A modifier should not be appended just to bypass an edit. Based 
on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not 
been met.  Therefore, we decided that the Plan does not have to pay for procedure codes 96374 and 96375 
billed for date of service August 10, 2022.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for therapy services provided from April 8, 2021, to April 26, 2021. 
 
You asked the Plan to pay for therapy services. You say that this claim has been corrected and resubmitted. The 
Plan denied your request. The Plan says that this claim is denied. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided a clear reason for denial of the corrected 
claim in this case, and this reason has not been supported with evidence and a relevant citation. The Plan has 
not substantiated their denial in this case. Therefore, we decided that the Plan has to pay for therapy services 
provided from April 8, 2021, to April 26, 2021.  
 
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you require medical supervision for your fracture as 
you have no mobility. The Plan denied your request. The Plan says you can reasonably be expected to continue 
your recovery at a lower level of care with good success.  
 
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 you do 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on October 6, 2022. 
 
You asked the Plan to pay for the lab services. You say that the testing detects tumors after surgery. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. We looked at the file and Medicare rules. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on October 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).  
You asked the Plan to pre-approve a continuous glucose monitor (CGM). You say that you would like to 
request reconsideration of the denied authorization. The Plan denied your request. The Plan says the services 
requested are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia Based on this information, we decided that Medicare rules for 
coverage of a continuous glucose monitor (CGM) have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a continuous glucose monitor (CGM).
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 the IRF services are necessary to help you regain 
your strength in your legs. The Plan denied your request. The Plan says the enrollee does not meet the 
Medicare criteria for IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found 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 has multiple sclerosis and is living at home with left leg weakness and bladder and bowel 
incontinence. 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an angiogram and percutaneous revascularization of 
bilateral lower extremities. 
 
You asked the Plan to pre-approve an angiogram and percutaneous revascularization of bilateral lower 
extremities. You say that an angiogram and percutaneous revascularization of bilateral lower extremities are 
medically necessary. The Plan denied your request. The Plan says an angiogram and percutaneous 
revascularization of bilateral lower extremities 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 an angiogram and percutaneous 
revascularization of bilateral lower extremities. Our reviewer says that the requested angiogram and 
percutaneous revascularization of bilateral lower extremities are not considered medically reasonable and necessary in this case. Our physician reviewer found that the documentation does not support the medical 
necessity of the procedures in question. It is documented that the enrollee ambulates without difficulty and has 
palpable pedal pulses bilaterally. There is no evidence of significant occlusive disease on duplex that would 
explain burning pain from the knee down at rest; these symptoms are suggestive of a non-vascular etiology. 
Standard ankle-brachial index (ABIs) are not provided, and the QuantaFlo readings would not explain calf 
pain at rest. Intervention to prevent future progression of disease is not an indication for treatment as 
intervention may also hasten progression of disease.  
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an angiogram and percutaneous revascularization of bilateral lower extremities 
have not been met. Therefore, we decided that the Plan does not have to pre-approve an angiogram and 
percutaneous revascularization of bilateral lower extremities.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code G2078 for date of service November 13, 2022, to 
November 27, 2022. 
 
You asked the Plan to pay for code G2078. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the service is not payable as billed. 
 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 code code 
G2078 is an add-on code and has not been billed with an appropriate primary procedure code. Based on the 
claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have 
to pay for code G2078 for date of service November 13, 2022, to November 27, 2022.