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

 
We decided that the Plan does not have to pre-approve pre-operative magnetic resonance image (MRI) of the 
left knee. 
 
You asked the Plan to pre-approve the MRI. You say that you are requesting reconsideration as the doctor feels 
it is medically necessary to obtain the exact dimensions for an accurate fit. The Plan denied your request. The 
Plan says the pre-operative MRI of the left knee is not medically necessary. Medical studies do not support the 
use of an MRI to plan for this type of surgery. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the medical necessity of patient-specific instrumentation for the enrollee's total knee 
arthroplasty is not supported by evidence based peer-reviewed literature. There are no large volume, high 
quality clinical trials that confirm the clinical benefits (ultimate outcomes of functionally improvement and 
pain reduction) of patient-specific instrumentation over standard surgical approaches in total knee arthroplasty. 
Therefore, this request for pre-operative MRI of the left knee would not be considered 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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve pre-operative magnetic resonance image (MRI) of the left knee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair ramp. 
 
You asked the Plan to pre-approve a wheelchair ramp. You say that a wheelchair ramp is a needed elderly 
disability necessity to get in and out of your home. The Plan denied your request. The Plan says a wheelchair 
ramp is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Medicare does 
not cover home modifications. Also, the item at issue in this appeal is 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 wheelchair ramp.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vagus nerve stimulation. 
 
You asked the Plan to pre-approve Vagus nerve stimulation. You say that having considered all treatment 
options, you consider FDA approved VNS therapy to be the best and most viable treatment option for the 
enrollee and it is therefore medically necessary. The Plan denied your request. The Plan says the records 
submitted do not show the medical necessity for Vagus nerve stimulation. 
 
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 Vagus nerve stimulation. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this case the member has been referred from their behavioral health provider to a 
neurosurgeon to undergo implantation of a VNS device for use in the management of the member's depression.  
The applicable NCD indicates that a VNS is only covered for use in medically refractory epilepsy that is not 
amenable to surgery. The enrollee in this case has not been prescribed a VNS for such a condition. 
 
With regards to depression, the applicable NCD states: " VNS is non-covered for the treatment of TRD when 
furnished outside of a CMS-approved CED study. All other indications of VNS for the treatment of depression 
are nationally non-covered ".   
 
The request is not case is not for coverage of a VNS unit in the setting of a CMS-approved CED study. 
Therefore the use of the requested VNS device would be considered to be non-covered per the NCD and thus 
not eligible for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vagus nerve stimulation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Vagus nerve stimulation.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve physical therapy. You say that you have to go to someone local. The Plan 
denied your request. The Plan says there are in-network providers available for these services. 
 
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 
physical therapy to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a POV for the enrollee. 
 
You asked the Plan to pre-approve the POV. You say that the POV is medically necessary. The Plan denied 
your request. The Plan says the records do not describe the enrollee's physical abilities or wheelchair needs. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the POV have not been met. The records do not describe the 
enrollee's physical abilities or wheelchair needs. We need these records to see if a wheelchair will be covered 
and what kind of wheelchair would be best for the enrollee. As a result, we cannot approve this request at this 
time. Therefore, we decided that the Plan does not have to pre-approve a POV for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
and supplies. 
 
You asked the Plan to pre-approve a Freestyle Libre CGM and supplies. You say that you have a meter and 
need a replacement. The Plan denied your request. The Plan says you are not currently insulin treated. 
 
The Plan must follow Medicare rules. Medicare rules say that a CGM is covered when the beneficiary is 
insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-covered continuous 
subcutaneous insulin infusion (CSII) pump.  
 
We looked at the file and Medicare rules. The record does not show that you are treated with multiple daily 
injections of insulin. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre continuous glucose monitor (CGM) and supplies.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an outpatient surgery to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve an outpatient surgery. You say that you would like to see this out-of-
network provider. The Plan denied your request. The Plan says there are in-network providers available. 
 
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 
an outpatient surgery to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) services. 
 
You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary to determine whether 
surgery is necessary. You say that you are also going to go to therapy. The Plan denied your request. The Plan 
says that the records do not show that the enrollee has tried at least six weeks of pain medication or physical 
therapy. The Plan says that the records do not show that there are plans for spinal injections or surgery. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the 
requested MRI is medically necessary. Our physician reviewer found surgery may be indicated. Our physician 
reviewer found that an MRI is indicated, as it is to be used for a decision on whether to intervene surgically. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
magnetic resonance imaging (MRI) 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the core buildup (D2950).

You asked the Plan to pre-approve the core buildup (D2950). You say that the procedure is needed to put the crown in place. You say that the handbook clearly states a $595 copayment to receive a crown. The Plan denied your request. The Plan says the service is not a covered benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the core buildup is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the core buildup (D2950).
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 disagree with the denial. The Plan denied your 
request. The Plan says the services are 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 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 medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital for management of an intentional overdose by medication. His medical problems are stable. There are 
no complex nursing or rehabilitation needs. He does not require treatment by multiple therapies, including 
either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not  a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Toric Intraocular Lenses (V2787). 
 
You asked the Plan to pre-approve the lenses. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the Toric lenses are not an approved lens per Medicare. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a 
conventional IOL.  
 
While an A-C IOL may be appropriate for the enrollee, neither the Plan nor Medicare covers the astigmatism-
correcting feature of an IOL. Therefore, we decided that the Plan does not have to pre-approve Toric 
Intraocular Lenses (V2787).
Appeal type: Practitioner Services
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 epidural injections. You say that you are appealing with records. The Plan 
denied your request. The Plan says the denial of authorization for this service 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay 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 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 based on review of the available records, you do not meet criteria for IRF admission. 
You were medically stable with no evidence of need for supervision by a Physical Medicine and Rehabilitation 
(PM&R) Physician or needs acute rehab nursing care. You may benefit from further physical therapy (PT) and 
occupational therapy (OT) but do not require an intensive therapy program. IRF admission is not medically 
necessary based on lack of medical complexity. 
 
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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CPAP battery backup. 
 
You asked the Plan to pre-approve a CPAP battery backup. You say that you need battery backup for your 
CPAP during hurricane season. The Plan denied your request. The Plan says alternate power sources are not 
considered by Medicare as durable medical equipment. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Medicare will not 
pay separately or make any additional payment for backup equipment.  
 
 
 
 
 
 
 
 
 
 
Therefore, we decided that the Plan does not have to pre-approve a CPAP battery backup.
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 would like reconsideration because 
the LTACH admission is medically necessary. The Plan denied your request. The Plan says you do not meet 
the requirements for LTACH admission approval. 
 
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 you do not require any services at the LTACH that are not already available at the 
current facility. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MRI of the neck and spine (72141). 
 
You asked the Plan to pre-approve the MRI. You say that you would like reconsideration because the MRI is 
medically necessary. The Plan denied your request. The Plan says the member does not meet Medicare 
coverage criteria for the MRI. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the 
MRI is not medically reasonable and necessary. Our physician reviewer found there is no documentation of 
prior treatment. The reported physical examination was normal and there are no red flag findings. The enrollee 
has not had a trial of conservative management. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve MRI of the neck and spine (72141).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission.
You asked the Plan to pre-approve the SNF admission. You say that you would like reconsideration because
the SNF admission is medically necessary and your family is no longer able to care for you at home. The Plan
denied your request. The Plan says you do not require daily skilled nursing services or daily skilled therapy.
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 SNF admission. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found you do 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 SNF admission have not been met. Therefore, we decided that the Plan does
not have to pre-approve SNF admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay 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 patient does not require services at the LTACH that are not available at the acute 
care hospital where the patient is currently receiving care. There are not services at the LTACH that the patient 
requires that are not available at the health care setting being offered by the health plan. The requested LTACH 
services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the patient 
and able to be furnished safely and effectively only on an inpatient basis. The patient does not currently have 
complex medical management that requires LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.