Persius/hicric huggingface dataset:
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 to an IRF is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet all the requirements for admission to an 
IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the 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's 
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 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 25, 2023. 
 
You asked the Plan to pay for an office visit. You say that this was a follow-up visit, and should not require 
authorization. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on April 25, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs this level of care.  The 
Plan denied your request. The Plan says that the enrollee does not have clinical needs for LTACH services that 
cannot be treated in the current setting. 
 
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 considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee meets criteria for LTACH admission due to their complex medical problems. The 
enrollee requires daily physician rounding, high skilled nursing staff, respiratory therapists as well as support 
from a multidisciplinary team. In addition, an admission of 25 days or greater is expected.  
 
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 been met. Therefore, we decided that the Plan has to 
pre-approve long term acute care hospital (LTACH) services.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve service dog support (S5199). 
 
You asked the Plan to pre-approve service dog support. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the enrollee owns an emotional support dog that does not meet the use 
and criteria for a service dog as defined under the ADA.  
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. Dogs whose sole function is to provide comfort or emotional 
support do not qualify as service animals under the ADA. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of service dog support have not been met. Therefore, we decided that the Plan does not have to pre-
approve service dog support (S5199).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
array, epidural - CPT4 (63650). 
 You asked the Plan to pre-approve percutaneous implantation of neurostimulator electrode array, epidural - 
CPT4. You say that the enrollee's pain is affecting daily activities. The Plan denied your request. The Plan says 
the records do not show that this trial is a last resort or that the enrollee has exhausted multidisciplinary 
treatment modalities, including surgical or psychological options, to treat pain. 
 
The Plan follows Medicare rules. Medicare rules say that this service is covered when the criteria in the rules 
section of this letter 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 percutaneous implantation of 
neurostimulator electrode array, epidural - CPT4. Our reviewer says that the service is not medically necessary. 
Our physician reviewer found that the enrollee does not have an evidence-based indication for a spinal cord 
stimulation trial. The enrollee also has not had a psychological evaluation. 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 percutaneous implantation of neurostimulator electrode array, epidural - CPT4 
have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous implantation 
of neurostimulator electrode array, epidural - CPT4 (63650).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs inpatient rehabilitation to regain 
their maximum function and to return home safely. The Plan denied your request. The Plan says an IRF 
admission 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 the enrollees 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 acute inpatient rehabilitation facility (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 the IRF admission is medically necessary. The Plan 
denied your request. The Plan says you do not meet the 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 the complexity of your documented nursing, medical and rehabilitation needs would 
not be expected to require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 
care. The clinical documentation shown does not support the medical necessity of an intensive rehabilitation 
regimen in an IRF setting. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block. 
 
You asked the Plan to pre-approve the nerve block. You say that the enrollee has previously responded 
favorably to radiofrequency ablation of the genicular nerves of the right knee. The Plan denied your request. 
The Plan says based on the medical literature this procedure is considered experimental or investigational and 
has not been proven to be beneficial for your condition. 
 
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 nerve block. Our reviewer says that 
the requested genicular nerve block is not considered medically reasonable and necessary in this case. Our 
physician reviewer found genicular nerve blocks and genicular nerve ablation are considered investigational 
and not medically necessary for the treatment of chronic knee pain, including, but not limited to any of the following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a 
treatment following knee replacement; or as a treatment for individuals who are not candidates for knee 
replacement surgery. Therefore, the reviewer found that the requested genicular nerve radiofrequency ablation 
(RFA) is considered experimental in nature. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the nerve block have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a genicular nerve block.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Bimatoprost. 
 
You asked the Plan to pre-approve Bimatoprost. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Bimatoprost. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has a diagnosis of primary open-angle glaucoma of the right eye who reportedly 
previously received a Durysta (bimatoprost) implant in the right eye on February 8, 2023. Labeling for Durysta 
(bimatoprost) states: "Limit to a single implant without retreatment due to an increased risk of corneal adverse 
reactions" and "DO NOT retreat an eye that has already received an implant". Based on the medical records 
provided and the Medicare-approved major drug compendia there is no documentation that the Bimatoprost, 
intracameral implant, 1 microgram at issue in this case meets all Medicare criteria for safe and effective 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 Bimatoprost have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Bimatoprost.
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 the enrollee needs this level of care.  The 
Plan denied your request. The Plan says the enrollee's current medical needs do not require LTACH care and 
services can be provided at a different level of care.  
 
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's care can safely be provided at the current facility until more stable and 
appropriate for transfer.  
 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99220 billed for date of service October 3, 2022. 
 
You asked the Plan to pay for code 99220. You say that this service was coded correctly. The Plan denied your 
request. The Plan says code 99220 is not supported by the medical record. The records do not support a 
comprehensive history and medical decision making of high complexity. 
 
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 99220 is  initial observation care, per day, for the 
evaluation and management of a patient, which requires these 3 key components: a comprehensive history; a 
comprehensive examination; and medical decision making of high complexity. 
 
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 code 99220. Our reviewer says that code 99220 is not supported by the medical record. Our reviewer found the enrollee was a 55-year-old male who was evaluated 
on October 3, 2022, for depression and paranoia. He had passive suicidal ideations. In this case, the records do 
not support a comprehensive history and medical decision making of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99220 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99220 billed for date of service October 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a foldable power scooter. 
 
You asked the Plan to pre-approve the requested device. You say that the enrollee needs the scooter to 
complete activities of daily living. The Plan denied your request. The Plan says the enrollee does not meet the 
guidelines for coverage. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 The file shows that the enrollee has a scooter. Although heavier than the requested scooter, the enrollees 
current scooter serves the same purpose as the requested device. The records show that the enrollee uses a 
cane/walker around the home. The scooter appears to be for use outside of the home. Although this item may 
be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided 
that the Plan does not have to pre-approve a foldable power scooter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue additional payment for the crown-porcelain fused to high noble 
metal (D2750) and the core buildup, including any pins when required (D2950) provided on May 15, 2023. 
 
You asked the Plan to issue additional payment for these dental services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says your benefit for 
the services provided has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the services provided was exhausted on date of service May 15, 2023.  
  
 
 
 
 
Specifically, the Plans maximum allowable dental benefit per year is $1,250. The Plan issued payment for the 
total amount of $1,250 ($166 + $432 + $432 +$220) for dental services provided to you in the 2023 calendar 
year. Therefore, you have exhausted the allowable dental benefit for the services provided in this case. 
Therefore, we decided that the Plan does not have to issue additional payment for the crown-porcelain fused to 
high noble metal (D2750) and the core buildup, including any pins when required (D2950) provided on  
May 15, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan. 
 You asked the Plan to pre-approve Hyalgan. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
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 Hyalgan. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the documentation does not outline 
contraindications or reasons that Supartz was not considered or that the plans required drug would likely be 
less effective and/or likely have adverse effects for the enrollee. Without the support of the documentation, 
Hyalgan is not approved as step criteria is not 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 Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hyalgan.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rituxan. 
 You asked the Plan to pre-approve Rituxan. You say that the enrollee is pending treatment. The Plan denied 
your request. The Plan says that the step therapy requirements have 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 Rituxan. Our reviewer says that 
Rituxan is not medically necessary. Our physician reviewer found that the enrollee has not tried and failed the 
Plan's required drugs Ruxience or Riabni. Also, there is no indication that the Plan's required drugs would 
likely be less effective 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 Rituxan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Rituxan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a topical hyperbaric oxygen chamber, disposable 
(A4575). 
 
You asked the Plan to pre-approve a topical hyperbaric oxygen chamber. You say that the requested device is 
medically necessary. The Plan denied your request. The Plan says Medicare does not cover topical hyperbaric 
chambers. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a topical hyperbaric oxygen chamber have not been met. Specifically, Medicare rules say that 
topical hyperbaric oxygen chambers will be denied as not reasonable and necessary. Therefore, we decided that 
the Plan does not have to pre-approve a topical hyperbaric oxygen chamber, disposable (A4575).