Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested neuro-specialized physical therapy. 
 
You asked the Plan to pre-approve the neuro-specialized physical therapy. The Plan denied your request. The 
Plan says you must receive care from in-network providers with the exception of emergency or urgent care, 
dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network 
provider, which requires prior authorization from the plan.  
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the 
requested neuro-specialized physical therapy.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the pelvis. 
 
You asked the Plan to pre-approve an MRI of the pelvis. You say that the requested MRI of the pelvis is 
medically necessary. The Plan denied your request. The Plan says the requested MRI of the pelvis is not 
medically necessary. 
 
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 an MRI of the pelvis. Our reviewer says 
that the requested MRI of the pelvis is not medically necessary. Our physician reviewer found the enrollee is 
with a history of renal mass mid pole on observation. The records show now on CT a new right upper pole 
lesion. The enrollee is with a history of prostate cancer. In this case, an MRI of the pelvis is not medically 
reasonable or necessary. An MRI of the kidneys should be considered. 
 
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 MRI of the pelvis have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an MRI of the pelvis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you are not able to stand without a walker and 
you will fall in the shower. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve portable oxygen concentrator (CPT Code E1392). 
 
You asked the Plan to pre-approve DME. You say that you need oxygen when you leave your home. The Plan 
denied your request. The Plan says you were previously provided with a home oxygen system, including a 
home oxygen concentrator and size M6 portable oxygen tanks for your oxygen needs within the home. 
 
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 DME have not been met. The Plans records reflect that you 
were previously provided with a home oxygen system, including a home oxygen concentrator and size M6 
portable oxygen tanks, on May 20, 2020 for your oxygen needs within the home. Therefore, we decided that 
the Plan does not have to pre-approve portable oxygen concentrator (CPT Code E1392).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve emergency response system; service fee, per month 
(excludes installation and testing) (S5161). 
 
You asked the Plan to pre-approve the emergency response system. You say that you are requesting review of 
denial of services. The Plan denied your request. The Plan says this item is not covered under Medicare or the 
Health Plan. 
 
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 emergency response system have not been met. The rules say 
that Telephone Alert Systems are not covered because emergency communications systems do not serve a 
diagnostic or therapeutic purpose. Therefore, we decided that the Plan does not have to pre-approve emergency 
response system; service fee, per month (excludes installation and testing) (S5161).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve powered pressure-reducing air mattress (E0277RR). 
 
You asked the Plan to pre-approve the DME. You say that this should be covered by the Plan as the member 
has chronic congestive heart failure. The Plan denied your request. The Plan says the Medicare rules have not 
been met. 
 
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 DME have not been met. Review of the file show that there is 
no documentation the member has multiple stage 2 or 3 pressure ulcers located on the trunk or pelvis, nor has 
had a myocutaneous flap or skin graft to the trunk or pelvis within the last 60 days. Therefore, we decided that 
the Plan does not have to pre-approve powered pressure-reducing air mattress (E0277RR).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device. 
 
You asked the Plan to pre-approve the Vertiflex device. You say that the requested Vertiflex device is 
medically necessary. The Plan denied your request. The Plan says the requested Vertiflex device 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 the Vertiflex device. Our reviewer says 
that the requested Vertiflex device is not medically necessary. Our physician reviewer found this enrollee 
presents with complaints of low back pain radiating down the left lower extremity with numbness, tingling and 
weakness. He reports a 5-month history of pain following a fall. He was diagnosed with an L3 osteoporotic 
compression fracture and underwent L3 kyphoplasty on 6/4/20. There is imaging evidence of spinal stenosis at 
all levels from L2-S1, with severe canal stenosis at L3/4 and L5/S1. He has reportedly failed conservative 
treatment, including activity modification, medications, and epidural steroid injection. Under consideration is a 
request for the Superior Vertiflex interspinous device at L3/4 and L4/5. AnchorCurrent evidence based medical 
guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 
gold standard of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome 
studies to support the use of this device for this enrollee's medical condition as discussed above. FDA 
indications include implantation of the Superion device at one or two adjacent lumbar levels in patients with 
moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, from L1 to L5. 
This enrollee has spinal stenosis at all levels from L2-S1, including severe canal stenosis at L3/4 and L5/S1, 
which does not meet the FDA indications. Additionally, FDA contraindications include osteoporosis (which is 
clearly present in this case) with recent osteoporotic compression fracture treatment noted at the L3 level. 
Therefore, this request for the Superior Vertiflex interspinous device at L3/4 and L4/5 is not medically 
reasonable and necessary for treatment of this enrollee's medical condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Vertiflex device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex device.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for SNF 
admission. 
 
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 the 
requested admission to a SNF is medically necessary. Our physician reviewer found the enrollee is with a past 
medical history of diabetes, hypertension and hyperlipidemia who was in an acute hospital and then an 
inpatient rehabilitation facility for a stroke in August and September 2020. She was discharged from the 
rehabilitation facility to home with home health services on 09/18/2020. She was walking 150 feet with a 
walker and was stand-by/supervision for transfers and activities of daily living at time of discharge from the 
rehabilitation facility. Records indicate that she had been medically stable. Reportedly she was having 
difficulty managing back in her home. No home health evaluation occurred. She was admitted to a skilled 
nursing facility on 09/23/2020. Occupational therapy notes dated 09/23/2020 now show the enrollee to be 
moderate to maximum assist for activities of daily living and mobility and balance. 
 
Based on the medical records provided there is no documentation that the enrollee requires skilled nursing 
services on a daily basis. The enrollee does; however, require skilled therapy services on a daily basis. This 
enrollee does require the services on 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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 foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ninlaro. 
 
You asked the Plan to pre-approve Ninlaro. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says the requested drug is 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 Ninlaro.  
 
Benefits for Ninlaro 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional cervical epidural steroid injection. 
 
You asked the Plan to pre-approve the requested service. You say that the enrollee is in tremendous pain. The 
Plan denied your request. The Plan says the service is not medically necessary prior to the assessment of 
effective of the prior injection. 
 
The Plan follows Medicare rules. Medicare rules say that epidural injections are only covered under certain 
medical indications. 
 
The file shows that 2 epidural injections were requested for the enrollee. The Plan has agreed to pre-approve 1 
injection. 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 additional injection. Our 
physician reviewer found that the enrollee has chronic neck pain with cervical radiculopathy. He reports new 
onset bilateral shoulder pain radiating into both upper extremities. The pain is achy, sharp and dull in nature, 
associated with numbness and tingling in both hands. This request is for repeat epidural steroid injection prior 
to the assessment of the effectiveness of the prior injection. Response to each epidural injection should be 
determined prior to determining the value of a repeat injection. Therefore, an additional epidural steroid 
injection is not medically reasonable and necessary for the enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested service have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an additional cervical epidural steroid injection.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve upper endoscopy. 
 
You asked the Plan to pre-approve upper endoscopy. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that upper endoscopy is only covered for certain 
indications. 
 
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 upper endoscopy. Our reviewer says 
that the documentation does not support that the requested upper endoscopy is medically reasonable or 
necessary. Our physician reviewer found the enrollee has a history of a large polyp removed surgically 5 years 
ago. The enrollee's Gastrointestinal Review of Systems is entirely negative, and the enrollee's abdominal 
examination on July 30, 2020 was normal as documented. While the enrollee may require long-term Plavix 
therapy, no documentation of GI blood loss was provided. Therefore, the enrollee does not meet criteria for the 
requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of upper endoscopy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve upper endoscopy.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 
admission. 
 
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 admission to a SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee is with a past medical 
history of hypertension, seizure disorder and alcohol abuse who presented to the acute hospital on 09/17/2020 
with generalized weakness, atrial flutter, acute kidney injury, diverticulitis and abdominal pain. He was treated 
in the hospital with intravenous fluids, antibiotics, metoprolol and therapy. He is weak and deconditioned and 
is working with physical and occupational therapy. He is walking 150 feet with a wheeled walker with contact 
guard assist and is stand-by assistance for transfers and activities of daily living. He is medically stable. 
 
Based on the medical records provided there is no documentation that the enrollee requires skilled nursing 
services or skilled therapy services on a daily basis. Based on the medical records provided this enrollee does 
not require the services on 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 admission to a SNF have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat right-sided L3-S1 epidural steroid injection 
(ESI). 
 
You asked the Plan to pre-approve the ESI. You say that it is felt this ESI is necessary. The Plan denied your 
request. The Plan says criteria for a repeat ESI are not met at this time. 
 
The Plan follows Medicare rules. Medicare rules say that ESIs may be covered when necessary to treat pain 
that is severe enough to affect function.  
 
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 ESI. Our reviewer says that the 
documentation does not support that this ESI is reasonable and necessary. Our physician reviewer found the 
enrollee previously had a right L3-S1(Lower Back) Transforaminal Epidural Steroid Injections (TFESI) on 
7/14/2020 and the pain got better by75-80%. Presently the enrollee has back pain and is being treated with a 
Non-steroidal Anti-Inflammatory medication and Physical Therapy. 
 
There is no specific clinical rationale for the requested right L3-S1 Transforaminal Epidural Steroid Injections 
(TFESI). Per the coverage criteria specifically, there is no documentation indicating that the pain is severe 
enough to cause some degree of functional deficit and there has been no failure of at least four weeks of non-
invasive 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 ESI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a repeat right-sided L3-S1 epidural steroid injection (ESI).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cardio workout with a trainer. 
 
You asked the Plan to pre-approve the cardio workout with a trainer. The Plan denied your request. The Plan 
says a cardio workout with a trainer is not a covered benefit. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
The Plan's rules for coverage of gym benefits have not been met because a cardio workout with a trainer is not 
a covered benefit. Therefore, we decided that the Plan does not have to pre-approve cardio workout with a 
trainer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Lite diabetic supplies. 
 
You asked the Plan to pre-approve Freestyle Lite diabetic supplies. You say that you requested to change from 
Arkray to Freestyle Lite. Freestyle Lite is not covered. The Plan denied your request. The Plan says Freestyle 
Lite is not covered by the Plan. 
 
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 Freestyle Lite diabetic supplies have not been met. Review of the file shows that you have been 
approved for Arkray diabetic. However, you are requesting to change from Arkray to Freestyle Lite. Freestyle 
Lite is not covered by the Plan. Your EOC states, "you must receive your Diabetic supplies by mail order 
through Mini Pharmacy. Glucometers are limited to the following Arkray meters: GLUCOCARD Shine and 
GLUCOCARD Expression. The GLUCOCARD Expression will be available for those who require an 
audio-enabled (Spanish and English) monitoring system." Therefore, we decided that the Plan does not have to 
pre-approve Freestyle Lite diabetic supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you are unable to stand for long periods of 
time. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the seat lift mechanism of a seat lift chair. 
 
You asked the Plan to pre-approve the seat lift mechanism of a seat lift chair. You say that your physical 
therapist recommended a power lift recliner. The Plan denied your request. The Plan says that you are unable to 
walk independently. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed above are met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the seat lift mechanism of a seat lift chair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the seat lift mechanism of a seat lift chair.