Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fourteen hours of home health aide per week (G0156). 
 
You asked the Plan to pre-approve home health aide services. You say that you need home health aide services. 
The Plan denied your request. The Plan says rules for home health aide services have not been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health aide services. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the services requested 
do not meet the definition of home health aide services as the documentation does not support that the home 
health aide services are reasonable and necessary for the treatment of your illness or injury by the skilled 
professional staff. 
 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health aide services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve fourteen hours of home health aide per week (G0156).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an UPWalker Lite (E1399). 
 
You asked the Plan to pre-approve an UPWalker Lite. You say that the item is 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. Medicare rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an UPWalker Lite have not been met. Therefore, we decided that the Plan does not have to pre-
approve an UPWalker Lite (E1399).
Appeal type: Surgery
Decision: Favorable

We decided that the Plan does not have to pre-approve spinal fusion for the enrollee.
You asked the Plan to pre-approve spinal fusion for the enrollee. You say that this treatment is medically
necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus
overturned the Plans denial. The Plan requested a reopen and stated Maximus did not apply the correct criteria.
Our Medical Director reviewed the case file and the reopen request. At issue is coverage for lumbar spinal
fusion surgery. The Maximus Physician Reviewer determined that Medicare coverage indications were met in
the setting of L4/5 spondylolisthesis with significant radicular pain. The enrollee had significant functional
impairment in ambulation, with evidence of failure of conservative treatment since May 2020. Therefore, the
enrollee has a covered indication for the requested lumbar spinal fusion. However, the Plan requested a reopen
stating the records do not show the enrollee completed 3 months of conservative care. The Plan states, "the
member chose not to complete the required 3-months of conservative management as required by the CMS
Local Coverage Determination."
Our Medical Director days that the records show the enrollee has a diagnosis of lumbar spondylolisthesis with
radiculopathy, and lumbar canal stenosis without neurogenic claudication. The records show on June 12, 2020
the enrollee was evaluated for a four-week history of severe radicular low back pain. He was taking ibuprofen
at night for the pain. On June 12, 2020 the notes state "really hasn't had any conservative treatment at this
time." The enrollee underwent an initial physical therapy evaluation on July 9, 2020 and was discharged on
July 22, 2020 after 3 sessions because he was unable to tolerate therapy. The enrollee experienced a significant
increase in pain with basic exercises, and modification of activity did not change his pain status. On August 10,
2020 it is documented that the enrollee had 80% temporary relief after ESI, and no relief with PT. Based on
this information, the plan is correct in this case. The documentation is insufficient to demonstrate that the
coverage criteria were met regarding the conservative therapy requirement. 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 fusion for the enrollee have not been met. Therefore, we decided that the Plan does not have to preapprove
spinal fusion for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continued stay in a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve continued stay in a SNF. You say that you need SNF care. The Plan denied 
your request. The Plan says the continued SNF care is not medically necessary and a lower level of care would 
be appropriate starting January 7, 2021. 
 
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 continued stay in a SNF. Our reviewer 
says that daily skilled services are not necessary. Our physician reviewer found after January 7, 2021, you do 
not require any skilled nursing or rehab services on a daily basis. You are not expected to make measurable 
gains within a reasonable and predictable period of time, and you do not require skilled therapy to prevent 
deterioration with mobility or activities of daily living.  You do not require skilled therapy to establish a safe 
and effective maintenance program. As a practical matter, you do not require any skilled services on an 
inpatient basis, at a SNF level of care during the period of care under review. As of January 7, 2021, your 
function was at or near her prior level of function and she could be discharged to a lower level of care for 
further 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 continued stay in a SNF have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the continued stay in a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MyoPro 2, motion G orthotic device (CPT Code 
L8702). 
 
You asked the Plan to pre-approve the device. You say that the device is necessary. The Plan denied your 
request. The Plan says this device is considered to be experimental/investigational. 
 
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 device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found Medicare does not pay for any items or services that are not reasonable and necessary for the 
diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. The 
MyoPro is not known to be effective, based on scientific evidence, professional standards and expert opinion, 
in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on scientific 
evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long term 
outcomes for this patient, improve hemiparetic arm function, or be safe for long term use. There is insufficient 
evidence in the literature that this device will increase patient participation in bimanual activities. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve MyoPro 2, motion G orthotic device (CPT Code L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) on a power 
mobility device. 
 
You asked the Plan to pre-approve the power seat elevation feature. You say that the seat lift is medically 
necessary. The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and 
power standing feature (E2301) are non-covered because they are not primarily medical in nature. 
 
We looked at the file and Medicare rules. The requested item is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the power seat elevation feature have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) on a power mobility 
device.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve stereotactic body radiation therapy (SBRT). 
 
You asked the Plan to pre-approve the requested services. You say that the treatment is medically necessary to 
control at least 2 isolated sites of disease. The Plan denied your request. The Plan says that it has not been 
shown that the enrollee's cancer type has responded well to the requested treatment. 
 
The Plan follows Medicare rules. Medicare rules say that SBRT is only covered under certain medical 
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 the requested services. Our physician 
reviewer found that the enrollee has limited metastatic disease amenable to SBRT, with on lesion in the field of 
prior radiotherapy. SBRT doses are effective and SBRT techniques facilitate normal tissue sparing. The greater 
effectiveness may be more relevant to prostate cancer given its likely relative radiation resistance. Therefore, 
the requested services are 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 requested services have been met. Therefore, we decided that the Plan has to 
pre-approve stereotactic body radiation therapy (SBRT).  
 
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: 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 medically necessary. 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 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 that you do not require skilled nursing and/or 
skilled therapy services on a daily basis. You are medically stable and can receive further rehab services at a 
lower level of care. Although further rehab services would be appropriate to improve function, as a practical 
matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing 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 SNF care have not been met. Specifically, the level of care you require can be 
done at a custodial level in the facility you were previously residing. This means that SNF care is not 
reasonable or necessary. Therefore, we decided that the Plan does not have to pre-approve skilled nursing 
facility (SNF) care.
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 the complexity of your nursing, medical and rehabilitation needs require an acute 
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status currently 
does not require intensive physician and nursing supervision in an IRF. While you may benefit from additional 
physical and occupational therapy the documentation does not support that you require this therapy on an IRF 
level. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hydraulic knee (L5814), a stance flexion feature 
addition (L5845), a knee extension assist (L5850), a flex foot system (L5980), and a multi-axial rotation unit 
(L5986). 
 
You asked the Plan to pre-approve a hydraulic knee, a stance flexion feature addition, a knee extension assist, a 
flex foot system, and a multi-axial rotation unit. You say that these items are medically necessary. The Plan 
denied your request. The Plan says these items exceed your needs. 
 
The Plan follows Medicare rules. Medicare rules say that a hydraulic knee, a stance flexion feature addition, a 
knee extension assist, a flex foot system, and a multi-axial rotation unit are covered when medically necessary 
per the above guidelines. 
 
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 hydraulic knee, a stance flexion 
feature addition, a knee extension assist, a flex foot system, and a multi-axial rotation unit. Our reviewer says 
that the criteria for coverage of the requested items have not been met. Our physician reviewer found the 
records do not show the patient's functional level is 3 or above for L5814 and L5980. There are no detailed 
objective findings on the treating medical physician notes that support that the patient is a K3 ambulator. The 
documentation does not support that the physical therapy notes indicate patient is a K3 ambulator. As the 
hydraulic knee (L5814) and a flex foot system (L5980) are not supported, multi-axial rotation unit (L5986), 
stance flexion feature addition (L5845), and knee extension assist (L5850) are 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 a hydraulic knee, a stance flexion feature addition, a knee extension assist, a 
flex foot system, and a multi-axial rotation unit have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a hydraulic knee (L5814), a stance flexion feature addition (L5845), a knee extension 
assist (L5850), a flex foot system (L5980), and a multi-axial rotation unit (L5986).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ophthalmology services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that you have been seeing this provider for 
treatment of your cornea. The Plan denied your request. The Plan says there are in-network cornea specialists 
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 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 
ophthalmology services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown, pontic, pulp cap, and core buildups. 
 
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 services are not covered. 
 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
retainer crown, pontic, pulp cap, and core buildups.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services (D2950 and D3220) 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 this 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
dental services (D2950 and D3220) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an advanced knee, foot and ankle prosthetic. 
 
You asked the Plan to pre-approve an advanced knee, foot and ankle prosthetic. 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 an advanced knee, foot and ankle 
prosthetic. 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 medical records provided there is no 
documentation that the advanced knee, foot and ankle at issue in this case are medically reasonable and 
necessary. The provided medical history and exam in the December 1, 2020, office visit note do not support the 
need for the advanced knee, foot and ankle. 
 
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 advanced knee, foot and ankle prosthetic have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an advanced knee, foot and ankle prosthetic.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve FreeStyle Libre 14 Day Reader Device. 
 
You asked the Plan to pre-approve FreeStyle Libre 14 Day Reader Device. You say that the device is 
necessary. The Plan denied your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results. 
 
We looked at the file and Medicare rules. While your provider states in one place "patient is adhering to an 
insulin injection regimen as outlined by their health care record", the provider records show the patient is on 
two (2) oral medications for glycemic control and not on insulin. This is confirmed by your medication 
provider. You check blood sugars at "random times". Therefore, the Medicare criteria are not met according to 
the LCD. Based on this information, we decided that Medicare rules for coverage of FreeStyle Libre 14 Day 
Reader Device have not been met. Therefore, we decided that the Plan does not have to pre-approve FreeStyle 
Libre 14 Day Reader Device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet block injections (CPT Code 64493) and (64494). 
 
You asked the Plan to pre-approve the facet block injections. You say that the services are necessary. 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 facet block injections have not been met. You had a therapeutic 
injection of the facet joints on both sides at L3/4 and L4/5 on October 19, 2020, with steroid and anesthetic 
medication. At the follow up appointment at your pain clinic one week later (October 26, 2020), you told your 
doctor that your injection on October 19, 2020 gave you a "minimal amount of relief." Under Medicare 
guidelines, your request is not medically necessary because your records show you did not describe at least 
50% pain relief for at least 3 months. You said that you had only a minimal amount of relief after your last 
injection. Therefore, we decided that the Plan does not have to pre-approve facet block injections (CPT Code 
64493) and (64494).