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

 
We decided that the Plan does not have to pre-approve insertion or replacement of permanent cardiac 
contractility modulation system, including contractility evaluation when performed, and programming of 
sensing and therapeutic parameters; pulse generator with transvenous electrodes (CPT Code 0408T). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service 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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on the records the patient has congestive heart failure. In this circumstance treatment 
with the Optimizer System (CPT0408T) device has been demonstrated in only one trial to help reduce hospital 
readmission compared to standard medical therapy (reference 1).  Moreover, the trial was very small (only 160 
patients) and the results for the composite endpoint barely reached statistical difference (p=0.048). Therefore, 
the efficacy of the Optimizer System (CPT0408T) is still uncertain at this time according to leading authorities 
(reference 2) and not recommended in current guidelines for the treatment of heart failure (reference 3). 
Medicare coverage criteria are not met, in my opinion, 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 the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve insertion or replacement of permanent cardiac contractility modulation system, including 
contractility evaluation when performed, and programming of sensing and therapeutic parameters; pulse 
generator with transvenous electrodes (CPT Code 0408T).
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. The Plan denied your request. The Plan says the enrollee has not 
tried Ruxience and Truxima. 
 
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 physician reviewer found 
that the enrollee has stage 3 chronic kidney disease, and primary membranous glomerulonephritis via biopsy. 
He has failed conservative therapy. According to the notes provided, the enrollee has not yet tried Truxima or 
Ruxience. Rituxan, Truxima and Ruxience, each have similar efficacy, safety, immunogenicity, and 
pharmacodynamics which would make either one appropriate for this enrollee. There were no unique 
circumstances provided in the records to suggest otherwise. Therefore, Truxima or Ruxience would not likely 
be less effective or produce an increased adverse event risk over Rituxan. 
 
 
 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services beyond 
September 17, 2020. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the continued services are not medically necessary. 
 
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 these services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the SNF on 
August 28, 2020. He received oral, inhaled, and topical medications and had stable vital signs. He was treated 
for gout pain. He received physical, occupational, and speech therapy services in the SNF and is independent to 
set-up level with bed mobility and transfers. He needs varied levels of assistance with activities of daily living. 
He has no skilled nursing or skilled therapy needs. He does not require skilled nursing or skilled therapy on a 
daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis at 
the SNF 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued skilled nursing facility (SNF) services beyond September 17, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 further physical therapy (PT) visits. 
 
You asked the Plan to pre-approve these services. You say that you need to improve strength and decrease your 
fall risk. The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the submitted records show that you have been receiving outpatient 
PT. The Plan has approved two further visits. The records do not support that 10 additional visits are generally 
accepted as specific and effective therapy for your condition. You have not made significant improvement with 
the therapy you have received and there is no documentation of a potential to further improve. You do not 
require the unique skills of a professional therapist to safely and effectively provide treatment or that the 
services can be safely and effectively performed only by a therapist or by or under the supervision of a 
therapist. The services are not reasonable or medically necessary. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 10 further physical therapy (PT) visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gastroenterology services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the OON services. You say that you cannot wait longer to get a 
colonoscopy. The Plan denied your request. The Plan says you receive care from providers who are part of 
your network. 
 
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 OON services. Therefore, we decided that the Plan does not have to pre-approve 
gastroenterology services to be provided by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional ten physical therapy visits for the enrollee. 
 
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee's condition has not significantly improved, and detail is lacking 
in the need for further treatment by a physical therapist. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the requested therapy is not generally accepted as specific and 
effective therapy for the enrollee's condition. The enrollee has made some progress in therapy but the records 
do not indicate she requires the ongoing unique skills of a professional therapist to safely and effectively 
provide treatment to treat her functional deficits. Services do not need to safely and effectively be performed 
only by a therapist, or under the supervision of a therapist. The patient has had 12 PT visits for this condition 
and was trained in a home exercise program. The requested services are not part of a maintenance program and 
the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or 
deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. 
 
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 additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an additional ten physical therapy visits for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Bioness L300 Go Lower system 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is only covered for treatment of disuse atrophy. 
 
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 system. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the limited documentation does not support that the enrollee in this case has intact lower motor units (L1 
and below) (both muscle and peripheral nerve), and muscle and joint stability for weight bearing at upper and 
lower extremities that can demonstrate balance and control to maintain an upright support posture 
independently. There is no documentation of brisk muscle contraction to NMES with sensory perception 
electrical stimulation sufficient for muscle contraction. 
 
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 system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Bioness L300 Go Lower system
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient behavioral services for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is a lack of engagement with treatment, and a lack of significant improvement. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found based upon a 
review of the records provided, the enrollee does not meet the criteria for treatment in an acute inpatient mental 
health treatment facility beyond the date in question. The enrollee could have been treated in a lesser restrictive 
setting, as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations (denied by 
the enrollee), and was not showing any behaviors or aggression. The enrollee was cooperative and compliant, 
while not showing any acute threats to safety. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve inpatient behavioral services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator for the enrollee. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee started on BiPAP with some improvement, which indicates that there 
was no failure of the BiPAP. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found the enrollee 
has COPD with acute-on-chronic hypoxic and hypercarbic respiratory failure. The enrollee may benefit from 
home BiPAP support at night. There is no documentation of failure of BiPAP to maintain the pCO2 when the 
enrollee is at home and stable. Medicare does not cover a home ventilator when used as BiPAP, and certain 
BiPAP devices are capable of providing the AVAPS mode that has been ordered. A home ventilator is not 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Single Photon Emission Computed Tomography 
(SPECT) test of the brain. 
 
You asked the Plan to pre-approve SPECT test. You say that SPECT is indicated to further clarify the enrollee's 
condition. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because this test is not appropriate for changes in thinking or cognitive loss and a Positron Emission 
Tomography (PET) beta amyloid scan may be more appropriate. 
 
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 SPECT test. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the results of neuropsychological testing are not available. It has not been demonstrated that the 
requested SPECT imaging is likely to impact the treatment and management 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 SPECT test have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Single Photon Emission Computed Tomography (SPECT) test of the brain.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom upper arm myoelectric orthosis (L8702). 
 
You asked the Plan to pre-approve a custom upper arm myoelectric orthosis. You say that this will restore the 
enrollee's arm strength and range of motion. The Plan denied your request. The Plan says this device is 
experimental. 
 
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 custom upper arm myoelectric 
orthosis. Our reviewer says that the requested item is not considered medically reasonable and necessary in this 
case. Our physician reviewer found at this time the requested orthosis is not proven to be more beneficial for 
treatment of the patient's hemiparesis post stroke than any available standard therapy. There is insufficient 
evidence in the literature that indicates that this orthosis is effective for hemiparesis due to a stroke. 
 
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 custom upper arm myoelectric orthosis have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a custom upper arm myoelectric orthosis (L8702).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 additional botox injections. 
 
You asked the Plan to pre-approve 2 additional botox injections. You say that the 2 additional botox injections 
are medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
2 additional botox injections. 
 
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 2 additional botox injections. Our 
reviewer says that the enrollee does not meet criteria for the 2 additional botox injections. Our physician 
reviewer found the enrollee has a diagnosis of persistent daily headache, with a cervicogenic contribution. It is 
noted that the enrollee suffers more than 15 headache days daily, and that at least 8 of them are migrainous. 
 
Per LCD L35172, Botulinum toxin is covered for prophylaxis of headaches in adult patients with chronic 
migraine. The documentation does not support that the enrollee has a diagnosis of chronic migraine. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 2 additional botox injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 2 additional botox injections.
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 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 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. He was 
intubated for respiratory failure on August 11, 2020. 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. The requested LTACH services are not medically necessary, reasonable, and appropriate for the 
diagnosis and condition of the enrollee at this time. Our physician reviewer found the enrollee was admitted to 
the hospital on July 27, 2020 with sepsis. 
 
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 pre-approve destruction by neurolytic agent, genicular nerve with 
imaging guidance (64624). 
 
You asked the Plan to pre-approve destruction by neurolytic agent. You say that your PCP approved this 
procedure because you are experiencing a lot of pain in your knee. The Plan denied your request. The Plan says 
the enrollee does not meet the criteria as genicular radiofrequency ablations are not covered for knee pain due 
to knee replacement and the enrollee had a total knee arthroplasty in 2012. 
 
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 destruction by neurolytic agent have not been met. Therefore, we decided that the Plan does not 
have to pre-approve destruction by neurolytic agent, genicular nerve with imaging guidance (64624).