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

 
We decided that the Plan does not have to pre-approve superion interspinous spacer. 
 
You asked the Plan to pre-approve superion interspinous spacer. 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 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 superion interspinous spacer. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee presents with complaints of persistent low back pain and 
neurogenic claudication that continued to affect her activities of daily living. The enrollee reported relief of 
symptoms with rest and flexion. Clinical exam findings document a focal neurologic deficit consistent with 
updated imaging evidence of L4/5 nerve root compression. There is evidence of severe spinal canal stenosis at 
the L4/5 level. There is radiographic evidence of a grade 1 spondylolisthesis at L4/5 with minimal motion on 
flexion/extension. The enrollee has reportedly failed conservative treatment. Current 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 severe central canal stenosis at the L4/5 level that would not meet FDA indications. 
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 superion interspinous spacer have not been met. Therefore, we decided that the 
Plan does not have to pre-approve superion interspinous spacer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed for the enrollee. 
 
You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no information or exam documentation showing the need for frequent position 
changes. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 bed. Our reviewer says that the 
requested bed is not medically reasonable or necessary. Our physician reviewer found the documentation does 
not clearly reveal that the enrollee's condition has failed positioning of the bed in ways not feasible in an 
ordinary bed or why positioning of the bed in other ways is not feasible. The documentation does not support a 
need for an immediate change in body position or frequent change in position or special attachments that 
cannot be fixed on an ordinary bed. The documentation does not reveal that the head of the bed needs to be 
elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or 
problems with aspiration. The request for a semi-electric hospital bed is not medically necessary for this 
enrollee. 
 
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 bed have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a semi-electric hospital bed for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda 100mg/4ml for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical studies have not proven that this drug is helpful for treatment of glioblastoma. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found there is no compendia 
basis for this request. There is no literature support for this request. Keytruda is not supported for glioblastoma. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda 100mg/4ml for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orencia (CPT Code J0129). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says step therapy encourages the member to try the Plan's preferred, equally effective 
drug(s): Inflectra or Remicade, and Simponi Aria. 
 
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 the medication. Our physician reviewer 
found the provided records do not show that the patient has tried and failed Remicade or Inflectra and Stelara. 
The preferred drugs (Remicade, Inflectra, Stelara) would essentially provide equal effectiveness and safety, 
based on current literature, and there was no unique circumstances stated by the prescribing physician to justify 
avoiding trial of one of the preferred medications. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Orencia (CPT Code J0129).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography angiography to be provided by 
the out-of-network provider. 
 
You asked the Plan to pre-approve the computed tomography angiography. The Plan denied your request. The 
Plan says the enrollee is required to use doctors that are part of the health 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 a 
computed tomography angiography to be provided by the out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed. 
 
You asked the Plan to pre-approve a semi-electric hospital bed. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested item is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi-electric hospital bed. Our 
reviewer says that the documentation does not support that the requested semi-electric hospital bed is medically 
reasonable or necessary. Our physician reviewer found you have a diagnosis of multiple sclerosis with 
generalized muscle weakness and have been confined to a wheelchair for quite some time.  
 
The documentation does not support that your condition requires position of the body in ways not feasible in an 
ordinary bed. The documentation does not support that you require frequent changes in body position or a need 
for immediate changes in body position. Therefore, you do not meet criteria for the requested item. 
 
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 semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan has to pre-approve upper partial denture (D5211). 
 
You asked the Plan to pre-approve the partial denture. You say that you would like to appeal the denial of an 
upper partial denture. This is a replacement partial denture for the enrollee. The old one being more than 8 
years old. The Plan denied your request. The Plan says that the enrollee has a sufficient number of teeth 
remaining in the maxilla to fully and properly masticate food. Replacement of the existing maxillary partial 
denture would be for aesthetic purposes. 
 
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. The Plan covers the partial 
denture when the services are medically necessary and reasonable. 
 
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 partial denture. Our reviewer says 
that the requested items/services is considered medically reasonable and necessary in this case. Our physician 
reviewer found a replacement partial replacing the missing maxillary teeth meets the criteria for coverage.  
Abutment teeth retaining the old partial (placed more than 8 years ago) have been extracted and the partial is no 
longer functional. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the partial denture have been met. Therefore, we decided that the Plan has to 
pre-approve upper partial denture (D5211).  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for MRI of the spinal canal and contents (72148) provided on 
May 20, 2020. 
 
You asked the Plan to pay for the MRI of the spinal canal and contents. You say that you would like 
reconsideration because the MRI is medically necessary. The Plan denied your request. The Plan says there are 
no findings to indicate 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 pay for the MRI of the spinal canal and contents. 
Our reviewer says that the MRI was not medically reasonable and necessary. Our physician reviewer found the 
record does not show any new weakness or neurologic findings that would be an indication for repeat MRI in a 
patient with a known disease. 
 
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 of the spinal canal and contents have not been met. Therefore, we 
decided that the Plan does not have to pay for MRI of the spinal canal and contents (72148) provided on May 
20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intermittent limb compression device. 
 
You asked the Plan to pay for intermittent limb compression device. You say that the claim should be paid. The 
Plan denied your request. The Plan says the documentation does not indicate services are necessary for 
treatment of the enrollee's condition. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. The information provided with the appeal does not mention the requested equipment or what they 
were used for.  Therefore, we decided that the Plan does not have to pay for intermittent limb compression 
device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve interim partial dentures (D5820). 
 
You asked the Plan to pre-approve the interim partial dentures. The Plan denied your request. The Plan says 
interim partial dentures are 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 
interim partial dentures (D5820).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient care provided from December 30, 2019, to 
January 4, 2020. 
 
You asked the Plan to pay for the inpatient care. The Plan denied your request. The Plan says the enrollee was 
stable for transfer. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 pay for the inpatient care. Our reviewer says that the 
requested inpatient care is considered post-stabilization care. Our physician reviewer found that on December 
29, 2019, it is documented that the enrollee was "unstable for transfer due to small bowel pneumatosis; rule out 
ischemia vs infarcted small bowel." The documentation supports that the enrollee in this case was stable for 
transfer to an in-plan hospital by 10:00am on December 30, 2019. 
 
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 inpatient care have not been met. Therefore, we decided that the Plan does 
not have to pay for the inpatient care provided from December 30, 2019, to January 4, 2020.
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 records show that this patient is stabilizing and although requires additional short 
term acute care for additional stabilization and treatment, this should take less than 25 days, and could safely be 
completed at the current facility. The patient does not require services at the LTACH that are not already 
available at the current setting. There are no services at the LTACH that the patient requires that are not already 
available and covered at the current setting. Therefore, this request for LTACH services will be considered not 
medically necessary. Transfer to a lower level of care may be considered when treatment has completed. 
 
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.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT, heart, without contrast material, with quantitative 
evaluation of coronary calcium (CPT Code 75571). 
 
You asked the Plan to pre-approve the CT scan. You say that the service is necessary. The Plan denied your 
request. The Plan says the clinical information submitted appears to describe a request for screening and is not 
covered. 
 
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 CT scan. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documentation to support the study ordered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve CT, heart, without contrast material, with quantitative evaluation of coronary calcium 
(CPT Code 75571).
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 does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. The medical record supports a need for physical and occupational therapy but it 
does not support a need for an intensive rehabilitation therapy program. There is not a reasonable expectation 
that you 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the back brace provided on May 12, 2020. 
 
You asked the Plan to pay for the back brace. You say that all documentation shows that this item is medically 
necessary. The Plan denied your request. The Plan says all diagnostic x-ray tests, diagnostic laboratory tests, 
and other diagnostic tests must be ordered by the physician who is treating the beneficiary, that is, the 
physician who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the 
results in the management of the beneficiary's specific medical problem. There is no evidence that this enrollee 
has an established relationship with this provider. 
 
The Plan must follow Medicare rules. Medicare rules say that durable medical equipment must be ordered by a 
treating physician/practitioner. 
 
In this case, the plan indicates that there is no claims history showing that the enrollee has been seen by the 
ordering provider in this case. The record provided does not show that the enrollee has been fully evaluated, 
including objective exams, to support that the physician is treating the enrollee. Therefore, we decided that the 
Plan does not have to pay for the back brace provided on May 12, 2020.