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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's needs are custodial. 
 
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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approvedestruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint (CPT Code 64635).You asked the Plan to pre-approvethe services. You say that you are in pain.The Plandenied your request. The Plan says you exceeded the recommended number of radiofrequency ablation (RFA).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 services have not been met. You exceeded the recommended number of RFA. The rules say that for each covered spinal region (cervical/thoracic or lumbar), no more than two (2) thermal RF sessions will be reimbursed in any rolling 12-month year, involving no more than four (4) joints per session, e.g., two (2) bilateral levels or four (4) unilateral levels.Therefore, we decided that the Plan does not have to pre-approvedestruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint (CPT Code 64635).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special urine catheter called the Purewick External 
Catheter System. 
 
You asked the Plan to pre-approve the special urine catheter. You say that you are asking for coverage of the 
special urine catheter for the treatment of urinary incontinence. The Plan denied your request. The Plan says 
this item is not covered under Medicare or the Health Plan. The Plan states that a standard external catheter 
system that is covered by Medicare will be considered if the request is made. 
 
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 the special urine catheter have not been met. As per the company's website, this system is not 
covered by Medicare. Medicare guidance indicates that only devices that meet the coverage criteria are 
covered. Therefore, we decided that the Plan does not have to pre-approve special urine catheter called the 
Purewick External Catheter System.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the inpatient rehab level of intensive therapy exceeds the member's 
need. 
 
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. The 
enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to 
require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care 
needs can be met at a lower level of care. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for IRF 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 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 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process 
stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar; single level (CPT Code 22869) and insertion of interlaminar/interspinous process 
stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar; second level (CPT Code 22870). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not 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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the device is still experimental. More research is needed to show safety and efficacy of the 
device. 
 
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 insertion of interlaminar/interspinous process stabilization/distraction device, without open 
decompression or fusion, including image guidance when performed, lumbar; single level (CPT Code 22869) 
and insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression 
or fusion, including image guidance when performed, lumbar; second level (CPT Code 22870).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet injections. 
 
You asked the Plan to pre-approve facet injections. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that facet injection are covered for the above 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 facet injections. Our reviewer says that 
the requested facet injections are not medically reasonable and necessary. Our physician reviewer found that 
there is documentation of radiculopathy in this case. The requested facet injections are not medically 
reasonable or necessary according to the coverage criteria established in the above LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet injections.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approvehome health aide services (G0156).You asked the Plan to pre-approvehome health aide services. You say that the enrollee needs home health services.The Plan denied your request. The Plan says this is not medically necessary.The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or 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 home health aide services. Our reviewer says that the requested services are not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that the home health aide services are reasonable and necessary to the treatment of the patient's illness or injury by the skilled professional staff as there is no detailed documentation as to how much assistance the patient needs with activities of daily livings such as dressing, bathing and toileting.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-approvehome health aide services (G0156)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal maintenance (D4910). 
 
You asked the Plan to pre-approve the periodontal maintenance. You say that you recommend the enrollee 
have four-month recalls due to heavy calculus build up. You also say that periodontal maintenance is essential 
to restore and maintain gum and bone health. The Plan denied your request. The Plan says this service is not a 
covered benefit. The Plan also says that the enrollee did not elect to purchase an optional supplemental dental 
package. 
 
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 
periodontal maintenance (D4910).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endodontic therapy (D3310). 
 
You asked the Plan to pre-approve the endodontic therapy. You say that the enrollee is in periodic pain, and 
excavation of decay invaded pulp chamber. You also say that a root canal is necessary to prevent acute 
infection. The Plan denied your request. The Plan says this service is not covered under the enrollee's benefit 
plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 
endodontic therapy (D3310).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide automatic grasp addition (L6881), proportional control 
(L7499), waterproof feature (L7499), user positional thumb (L7499) or variable grip (L7499) as separate line 
items. 
 
You asked the Plan to provide automatic grasp addition (L6881), proportional control (L7499), waterproof 
feature (L7499), user positional thumb (L7499) or variable grip (L7499). You say that because of injury you 
need an electric hand and additions. The Plan denied your request. The Plan says you meet criteria for the 
prostheses but the additions are considered unbundled. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes 
automatic grasp addition (L6881), proportional control (L7499), waterproof feature (L7499), user positional 
thumb (L7499) or variable grip (L7499) has a bundled relationship with code L6880 and cannot be paid if 
billed. These codes cannot be paid as separate line items. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to provide; automatic grasp 
addition (L6881), proportional control (L7499), waterproof feature (L7499), user positional thumb (L7499) or 
variable grip (L7499), separately, to avoid duplication of services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy visits. 
 
You asked the Plan to pre-approve 10 additional physical therapy visits. You say that you would like to stay 
out of a wheelchair and be able to walk. You say that this can happen with physical therapy. The Plan denied 
your request. The Plan says additional visits 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 10 additional physical therapy 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 that you have had prior therapy and 
have been educated on your condition, safety and therapeutic exercises. Our reviewer says that the unique skills 
of a professional therapist are not required to safely and effectively provide ongoing treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 10 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 10 additional physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve knee orthoses. 
 
You asked the Plan to pre-approve knee orthoses. You say that these are medically necessary. The Plan denied 
your request. The Plan says that your records do not demonstrate recent injury or surgery or that instability of 
your knee was found on physical exam. 
 
The Plan must follow Medicare rules. Medicare rules say that a knee orthosis is covered if the above criteria is 
met. 
 
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 knee orthoses. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. The knee 
orthoses are not medically necessary as you have not had recent injury to or a surgical procedure on the 
knee(s). You are noted to be ambulatory. The documentation does not reveal instability on an objective 
physical exam of the knees. Our physician reviewer found that your condition does not meet Medicare criteria 
for the knee orthoses. 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of knee orthoses have not been met. Therefore, we decided that the Plan does not 
have to pre-approve knee orthoses.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walker with a seat. 
 
You asked the Plan to pre-approve the walker. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee was already provided with a standard wheelchair in 2018. 
 
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 walker. Our reviewer says that the 
requested walker is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation does not reveal physician or medical practitioner objective progress notes indicating 
there is a significant mobility limitation that limits participation in MRADLs, that you would safely be able to 
use a walker, and that any mobility deficit would be solved by a walker. 
 
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 walker have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a walker with a seat.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve brachioplasty surgery. 
 
You asked the Plan to pre-approve brachioplasty. You say that you are in pain and this surgery would help. The 
Plan denied your request. The Plan says the denial of authorization for this service is correct, because this 
surgery would be purely cosmetic in nature. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 brachioplasty. Our reviewer says that 
you do not meet the Medicare criteria for brachioplasty. Our reviewer found your plastic surgery consultation 
documented that you had massive weight loss 2 years ago and now have excess skin in your underarms and get 
irritated skin. Physical examination revealed excess skin with moisture present underneath arms. Your treating 
physician documents that brachioplasty would be purely cosmetic in nature which is not covered by Medicare. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of brachioplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve brachioplasty surgery.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services can be safely received in other settings, for example: a skilled nursing 
facility, home with home health services, or home with outpatient therapy. 
 
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 enrollee does not require the intensity of services provided at an IRF.  
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR). 
 
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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MRI, brain (including brain stem); without contrast 
material (CPT Code 70551). 
 
You asked the Plan to pre-approve the MRI. You say that the reason for the request is to monitor the patient's 
arachnoid cyst, and subdural hygroma before the patient comes in for their next appointment. The Plan denied 
your request. The Plan says the requested imaging is not supported for the evaluation of a primary headache 
disorder in the absence of focal neurological deficits. The Plan states the clinical information provided does not 
describe a condition other than a primary headache disorder and, therefore, the request is not indicated at this 
time. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI. Our physician reviewer found 
the enrollee has a known arachnoid cyst in the right frontal area. This has been imaged previously and noted 
stable by computed tomography (CT) and MRI studies starting in 2016. A CT study dated September 19, 2020, 
notes a stable cyst without hemorrhage or parenchymal mass. A clinical impression, differential diagnosis, or 
assessment and plan are likewise not included for review. Without this documentation, the request for an MRI 
cannot be evaluated for coverage according to the NCD guidelines. The request is determined not medically 
reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve MRI, brain (including brain stem); without contrast material (CPT Code 70551).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Continuous Glucose Monitor (CGM) (K0553). 
 
You asked the Plan to pre-approve the CGM. You say that the CGM is medically necessary. The Plan denied 
your request. The Plan says that coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that CGM's are covered when medically necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CGM. Our reviewer says that the 
CGM is medically necessary. Our physician reviewer found the records show that the enrollee has been advised 
by his physician to increase how often he tests and that insulin injections will be adjusted accordingly. The 
CGM will allow the enrollee to test more frequently as the physician has requested. 
 
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 CGM have been met. Therefore, we decided that the Plan has to pre-
approve a Continuous Glucose Monitor (CGM) (K0553).  
 
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.