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

 
We decided that the Plan does not have to pre-approve spinal surgery. 
 
You asked the Plan to pre-approve spinal surgery. You say that the requested spinal surgery is medically 
necessary. The Plan denied your request. The Plan says the requested spinal surgery 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 spinal surgery. Our reviewer says that 
the requested spinal surgery is not medically necessary. Our physician reviewer found this enrollee presents 
with complaints of low back and bilateral lower extremity pain. Clinical exam findings have documented 
absent lower extremity deep tendon reflexes. She is status post prior decompression laminectomy at L4-S1 with 
pedicle screw fixation L5/S1 and posterolateral fusion L4-S1 on 8/18/05. There is radiographic evidence of 3.5 
mm retrolisthesis of L4 over L5 with no documentation of motion on flexion/extension films. There is imaging 
evidence of mild bilateral lateral recess and foraminal stenosis at L4/5, and mild left foraminal stenosis at 
L5/S1 with no evidence of nerve root compression. She has reportedly failed conservative treatment, including 
rest, physical therapy, and medication. Under consideration is a request for lumbar spine surgery (CPT codes 
63090, 63091, 22558, 22845, and 22854) including vertebral corpectomy with posterior spinal fusion L4/5 and 
L5/S1 and anterior lumbar interbody fusion L4/5 and L5/S1. Medicare coverage criteria have not been met. 
There is no evidence of spinal instability, disc compression of the neural elements, or that revision surgery is 
required for pseudoarthrosis. Additionally, detailed evidence of a recent, reasonable and/or comprehensive non-
operative treatment protocol trial and failure has not been submitted. Therefore, the requested spinal surgery is 
not medically reasonable and necessary for treatment of the enrollees medical condition 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 spinal surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve spinal surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device (33289). 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has 
not been met. 
 
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 CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this circumstance therapy change based on data obtained from a CardioMEMs 
device has been demonstrated in only one trial to help reduce hospital readmission compared to standard 
medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the 
results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading 
authorities and not recommended in current guidelines for the treatment of heart failure. Medicare coverage 
criteria are not met since the device should still be considered experimental or investigational. 
 
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 CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device (33289).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine transportation (A0120). 
 
You asked the Plan to pre-approve routine transportation. You say that the services are necessary. The Plan 
denied your request. The Plan says the requested service is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. 
The Plan follows the same rule.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Medicare rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve routine transportation (A0120).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. 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. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found based on the medical records provided daily 
skilled services are not required. You do not require the services on an inpatient basis, in a skilled nursing 
facility setting. Services in the long-term care facility on a part time basis appears appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond 
August 21, 2020. 
 
You asked the Plan to pre-approve the continued SNF care. You say that this should be covered. The Plan 
denied your request. The Plan says the enrollee is no longer making progress and does not require daily skilled 
care to maintain her condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 continued SNF care. Our reviewer 
says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is a 75 year old 
female with a history of stroke with left hemiparesis and dysphagia admitted to the SNF. From a nursing 
perspective, the beneficiary received enteral nutrition and medications and insulin. The beneficiary had stable 
vital signs. She had barrier cream to her rectum and uncomplicated dressings to an abrasion. Regarding 
rehabilitation services, the beneficiary received PT, ST and OT in the SNF.  By the dates in question, the 
beneficiary required moderate to maximal assist for bed mobility and a mechanical lift for transfers and was 
non-ambulatory. The beneficiary required varying assist with ADLs.  
 
 
 
There are no identifiable skilled therapy service needs. There are identifiable skilled nursing service needs; 
however, these services are not required on a daily basis. This beneficiary does not meet severity of illness or 
intensity of service criteria for an inpatient basis in a skilled nursing facility 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 the continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care beyond August 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-thermal radiofrequency facet joint denervation. 
 
You asked the Plan to pre-approve facet joint procedure. You say that this service is now covered by Medicare, 
and the enrollee would prefer this procedure for its minimally invasive nature. The Plan denied your request. 
The Plan says the denial of authorization for this service is correct, because Medicare does not support the use 
of this technique for the indication requested and it is considered experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that non-thermal radiofrequency modalities for facet 
joint denervation are not covered by Medicare.  
 
We looked at the file and Medicare rules. You specifically requested procedure code 64625 which represents 
non-thermal radiofrequency modalities for facet joint denervation and is not covered by Medicare. Based on 
this information, we decided that Medicare rules for coverage of facet joint procedure have not been met. 
Therefore, we decided that the Plan does not have to pre-approve non-thermal radiofrequency facet joint 
denervation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network provider. 
 
You asked the Plan to pre-approve these services. You say that the Plan does not have an appropriate provider. 
The Plan denied your request. The Plan says the services are available from network providers. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan confirmed that there is a dental 
provider available in-network to provide the requested services. We found no exception that would require the 
Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a 
referral to an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Estradiol. 
 
You asked the Plan to pre-approve these services. You say that you have been stable on this medication for 
years. The Plan denied your request. The Plan says self-administered drugs are not a covered benefit. 
 
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 Estradiol.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Proton Beam Radiation Therapy (PBRT) (77525). 
 
You asked the Plan to pre-approve PBRT. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been 
met. 
 
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 PBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the need for proton therapy for advanced lung cancer needs to be established an on individual 
basis with a plausible rationale as to why proton therapy is needed in lieu of more standard 3D conformal 
radiation or IMRT. Without this information, the rationale for the need for proton therapy is not justified. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Proton Beam Radiation Therapy (PBRT) (77525).
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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 records do not indicate that there are significant, or complex medical/nursing issues 
that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other 
medication management, skin care, and daily therapy can be provided at a SNF. In this case, the enrollee is 
mostly total/maximum assist for functional transfers and activities of daily living (ADL?s) and a less intensive, 
longer duration of therapy may be more appropriate. It is not clear the enrollee would be able to fully benefit 
and/or participate in an IRF 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve physical therapy. You say that you are requesting for the enrollee to 
continue with prescribed physical therapy at your office because he does not drive and requires use of public 
transportation. The Plan denied your request. The Plan says the denial of authorization for these services is 
correct, because this provider is out-of-network with the Plan and the enrollee can be treated by an in-network 
provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the medical services to be provided by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve routine transportation. You say that you need additional trips to go to your 
doctors. The Plan denied your request. The Plan says the denial of authorization for additional routine 
transportation is correct, because routine transportation beyond 60 one-way trips per calendar year is not 
covered by the Plan. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 60 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You have already received 60 one-way 
trips of routine transportation. Based on this information, we decided that you have exhausted the Plan 
maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to 
pre-approve additional routine transportation.
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 care in an LTACH is medically 
necessary because of the complexity of his medical needs and the requirement of daily physician visits. You 
say that the enrollee would benefit from LTACH for continued vent weaning, nutritional support, and physical 
therapy. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan 
says that the care needed can be provided in the current inpatient hospital. 
 
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 documentation does not support that the enrollee in this case requires services at 
the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no 
required medical services identified that are available at the LTACH, that are not available at the current health 
care setting being offered by the health plan. Consequently, the requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental extraction, reconstruction, imaging, and 
anesthesia. 
 
You asked the Plan to pre-approve dental services. You say that you need to remove all of your teeth and your 
mouth is getting very sore. The Plan denied your request. The Plan says the denial of authorization for these 
services is correct, because these dental services are not covered by Medicare or the Plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve dental extraction, 
reconstruction, imaging, and anesthesia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural injection. 
 
You asked the Plan to pre-approve an epidural injection. You say that the requested epidural injection is 
medically necessary. The Plan denied your request. The Plan says the requested epidural injection 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 epidural injection. Our reviewer says 
that the requested epidural injection is not medically necessary. Our physician reviewer found this enrollee 
presents with complaints of intermittent posterolateral neck pain radiating cross the upper back to the bilateral 
scapulae and intrascapular region. Pain interfered with activities of daily living. Clinical exam findings do not 
evidence a focal neurologic deficit. There is reported imaging evidence of a broad-based disc herniation at C4/5 
with moderate neuroforaminal narrowing. She has failed to improve with rest, Tylenol, and on-going 
chiropractic treatment. She had a prior C6/7 interlaminar steroid injection in April 2019 with resolution of her 
headaches and 80% improvement in her neck pain, lasting 5-6 months. Under consideration is a request for 
repeat C6/7 interlaminar steroid injection. Current evidence based medical literature supports pain management 
with epidural steroid injection for the treatment of cervical radiculopathy. In this case, there is no current 
documentation of signs/symptoms correlated with clinical exam and imaging to support a diagnosis of cervical 
radiculopathy. Therefore, this request for cervical epidural steroid injection is not medically reasonable and 
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 an epidural injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an epidural injection.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) services. 
 
You asked the Plan to pre-approve the CT scan. You say that the records provided support the need for the 
requested CT scan. The Plan denied your request. The Plan says the CT imaging was ordered as a screening 
test for heart disease. The Plan says that the requested CT scan is not medically necessary or covered because it 
is not for the diagnosis or treatment of an illness or injury. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CT scan. Our reviewer says that the 
requested CT scan is not medically necessary. Our physician reviewer found there is no indication given or 
documentation to justify a CT scan. The documentation does not show that the enrollee has any symptoms that 
warrant a CT scan. 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve computed tomography (CT) services.