Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a bioimpedance spectroscopy (BIS), extracellular fluid analysis for 
lymphedema assessment(s) (93702). 
 
You asked the Plan to pre-approve a bioimpedance spectroscopy. You say that you disagree with the denial and 
are requesting reconsideration. The Plan denied your request. The Plan says that a review of the current 
medical literature does not consider this service to be standard medical treatment for the diagnosis of 
lymphedema. In addition, this testing is less accurate than other testing modalities for lymphedema. Additional 
research and development are needed before the method can be accepted for routine clinical use. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 a bioimpedance spectroscopy. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found breast cancer-related lymphedema (BCRL) represents a significant concern for 
enrollees following breast cancer treatment, and assessment for BCRL represents a key component of 
survivorship efforts. Growing data has demonstrated the benefits of early detection and treatment of BCRL. 
Traditional diagnostic modalities are less able to detect reversible subclinical BCRL while newer techniques 
such as bioimpedance spectroscopy (BIS) have shown the ability to detect subclinical BCRL, allowing for 
early intervention and low rates of chronic BCRL with level I evidence. BIS is a standard of care, and the 
service is reasonable and 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 bioimpedance spectroscopy have been met. Therefore, we decided that the 
Plan has to pre-approve a bioimpedance spectroscopy (BIS), extracellular fluid analysis for lymphedema 
assessment(s) (93702).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve reverse left shoulder replacement (23472). 
 
You asked the Plan to pre-approve the surgical procedure. You say that the medical records provided support 
the necessity of the services in dispute. The Plan denied your request. The Plan says the reverse left shoulder 
replacement 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 surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found his 78-year-old female was being treated for left shoulder osteoarthritis. She 
presented with left shoulder pain which she notes is laterally and sometimes superiorly. The exam reveals a 
limited left shoulder range of motion which gets to about 110 degrees but with pain. She has crepitus. There is pain with external rotation testing. Strength is 4/5 with rotator cuff testing. There is tenderness to palpation 
over the anterior bicep. 
 
However, detailed documentation is not evident regarding a trial and failure of recent, reasonable, 
comprehensive less invasive conservative care measures. There is no documentation of a formal physical 
therapy course directed to the left shoulder. Moreover, the diagnostic imaging studies do not corroborate a 
rotator cuff tear of the left shoulder that is beyond repair. No compelling rationale is presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
reverse left shoulder replacement (CPT 23472), in this case, is not medically reasonable or 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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve reverse left shoulder replacement (23472).
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 you need additional therapy. The Plan denied your 
request. The Plan says under Medicare, the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 that 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 inpatient rehabilitation facility. 
You continue to have a need for skilled therapy with ongoing safety concerns and a potential for functional 
improvement however, the documentation doesnt support that you would meet criteria for admission to an 
IRF. There is no indication that you would require skilled rehabilitation in an IRF, participating in 
rehabilitation services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to 
regain or maintain her functional status. You can receive further services at a lower 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 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve twelve additional physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is 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 the therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. The requested additional visits are not medically reasonable or necessary. Our physician reviewer 
found that you have previously been treated with outpatient therapies and should be independent with a home 
exercise program. There is no documentation of a recent injury or decline in function. The additional therapy 
services are not an appropriate duration and frequency for treatment of your medical condition and therefore 
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 the therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve twelve additional physical therapy visits.
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. The Plan denied your request. The Plan says the 
enrollee does not need a doctor every day, medically necessary care may be provided safely in a lower level of 
care. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. 
 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 sclerotherapy (36471). 
 
You asked the Plan to pre-approve sclerotherapy. You say that the enrollee needs the surgery. You say that the 
enrollee's varicose veins busted in the legs four years ago. You also say that this caused the enrollee to be in 
pain for years. The Plan denied your request. The Plan says the requested sclerotherapy is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that liquid sclerotherapy is often used to treat cosmetic 
telangiectasias and reticular veins. 
 
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 sclerotherapy. Our reviewer says that 
the requested sclerotherapy procedure is not medically necessary. Our physician reviewer found there is no 
documentation that you are having significant symptoms and no documentation of recent varicose bleeding. 
The reviewer found that the documentation is far more consistent with the position that this procedure is 
cosmetic. Therefore, the reviewer found that the requested procedure is not medically reasonable or 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 sclerotherapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sclerotherapy (36471).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fixed bridge between tooth number 20 and 22  
(D6740 x 2 and D6245). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial. The Plan 
denied your request. The Plan says the request is not medically necessary. 
 
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. The Plan covers the dental 
services 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 dental services. Our reviewer says 
that the Plan's criteria for coverage have not been met. Our physician reviewer found that the Plan only allows 
fixed bridges where it can be shown a partial denture cannot be worn. There has been no documentation 
showing of a disability or disorder precluding use of a partial denture. 
 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 dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a fixed bridge between tooth number 20 and 22 (D6740 x 2 and D6245).
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 enrollee meets the IRF criteria and is reasonably 
expected to participate and benefit from 15 hours of therapy per week. The Plan denied your request. The Plan 
says the enrollee does not meet all the requirements, medically necessary care may be provided safely in a 
lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
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 the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a single photon emission computed tomograph (SPECT) scan with 
concurrently acquired computed tomography (CT) (78830). 
 
You asked the Plan to pre-approve a SPECT scan with concurrently acquired CT. The Plan denied your 
request. The Plan says that this request does not meet the Medicare or health plan coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that the SPECT acquires information on the concentration 
of radionuclides introduced into the patient's body, and is useful in the diagnosis of several clinical conditions. 
 
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 SPECT scan with concurrently 
acquired CT. Our reviewer says that the SPECT scan is medically reasonable and necessary for the enrollee. 
Our physician reviewer found the enrollee has symptoms suggestive of Parkinson's disease, but other 
extrapyramidal diseases are in the differential. Our reviewer also found that the requested SPECT Dopamine 
Transporter (DAT) scan is the best imaging tool to confirm or rule out Parkinson's disease, and should be 
approved. 
 
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 SPECT scan with concurrently acquired CT have been met. Therefore, we 
decided that the Plan has to pre-approve a single photon emission computed tomograph (SPECT) scan with 
concurrently acquired computed tomography (CT) (78830).  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Procrit. 
 
You asked the Plan to pre-approve Procrit. You say that Procrit is medically necessary. The Plan denied your 
request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Procrit is 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 Procrit. Our reviewer says that this drug is not medically necessary. Our physician reviewer found the record does not show that the enrollee's anemia is 
caused by one of the listed conditions for which this drug is covered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Procrit have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Procrit.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the spine. 
 
You asked the Plan to pre-approve the MRI. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the enrollee has not completed six weeks of provider directed treatments. 
 
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 reviewer says that the 
requested MRI is not considered medically reasonable and necessary. Our physician reviewer found there is not 
evidence of a recent six-week trial of physical therapy for back pain which would warrant this imaging. 
 
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 magnetic resonance imaging (MRI) of the spine.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repair or non-routine service for durable medical 
equipment other than oxygen equipment requiring the skill of a technician, labor component, per 15 minutes 
(K0739), a manual wheelchair accessory, solid (rubber/plastic) caster tire with integrated wheel (E2222), a 
wheelchair component or accessory, not otherwise specified (K0108), a manual wheelchair accessory, caster 
fork, any size, replacement only (E2226), a manual wheelchair accessory, wheel lock assembly, complete, replacement only (E2206), a replacement cover for wheelchair seat cushion or back cushion (E2619) and a 
manual wheelchair accessory, pneumatic propulsion tire, any size (E2211). 
 
You asked the Plan to pre-approve wheelchair repair and accessories. You say that the requested accessories 
and repair are medically necessary. The Plan denied your request. The Plan says the requested service is not 
medically necessary. The manual wheelchair has exceeded reasonable useful lifetime. The requested 
replacement parts do not meet necessity criteria. The enrollee and provider should submit a request for an 
appropriate new wheelchair and covered accessories to meet the enrollees needs that can be supported for 
medical necessity. 
 
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. The records show that the current wheelchair was purchased in July 
2017. The manual wheelchair has exceeded it RUL, it is greater than five years old. For this reason, the repair 
request is not covered. A request for a new wheelchair should be submitted. Based on this information, we 
decided that Medicare rules for coverage of wheelchair repair and accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve repair or non-routine service for durable medical equipment 
other than oxygen equipment requiring the skill of a technician, labor component, per 15 minutes (K0739), a 
manual wheelchair accessory, solid (rubber/plastic) caster tire with integrated wheel (E2222), a wheelchair 
component or accessory, not otherwise specified (K0108), a manual wheelchair accessory, caster fork, any size, 
replacement only (E2226), a manual wheelchair accessory, wheel lock assembly, complete, replacement only 
(E2206), a replacement cover for wheelchair seat cushion or back cushion (E2619) and a manual wheelchair 
accessory, pneumatic propulsion tire, any size (E2211).
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 the LTAC level of care is the most 
appropriate for the enrollee to achieve the best outcome due to complex medical needs. The Plan denied your 
request. The Plan says the LTACH is not medically necessary, and the enrollee's needs are being met at the 
current facility until the enrollee's condition is stable for transfer to an alternate level of care. 
 
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 enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the current acute care setting. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The health plan has approved ongoing care 
in the current acute care setting. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
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.