Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve new lenses. 
 
You asked the Plan to pre-approve new lenses. You say that you cannot use the glasses you received, and you 
feel you should be able to be reimbursed for the lenses. The Plan denied your request. The Plan says you used 
your eyewear benefit on August 2, 2022, and you are not eligible for new eyewear until August 2, 2023. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services on a rolling calendar year since your last date of service. 
 
We looked at the file and the Plan's rules. The record shows that you received eyewear on August 2, 2022, and 
your eyewear benefit has been exhausted through August 2, 2023. Based on this information, we decided that 
the Plan's rules for coverage of new lenses have not been met. Therefore, we decided that the Plan does not 
have to pre-approve new lenses.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition, endoskeletal system, below knee, alignable 
system (L5910) and an addition to lower limb prosthesis, vacuum pump, residual limb volume management 
and moisture evacuation system (L5781). 
 
You asked the Plan to pre-approve an alignable system and a vacuum pump. You say that the requested items 
are medically necessary. The Plan denied your request. The Plan says a replacement alignable system exceeds 
the enrollee's need and is not reasonable and necessary for the approved replacement socket. 
 
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 alignable system and a vacuum 
pump. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the documentation does not indicate that the alignable 
system is damaged beyond repair and cannot be re-used for approved socket. The literature reviewed indicates 
that further research is needed with clinical trials that recruit larger sample sizes and report long-term outcome 
data for the requested elevated vacuum suspension system. 
 
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 alignable system and a vacuum pump have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an addition, endoskeletal system, below knee, alignable 
system (L5910) and an addition to lower limb prosthesis, vacuum pump, residual limb volume management 
and moisture evacuation system (L5781).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve the requested ESI. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is no evidence that the prior ESI provided relief lasting at least three months. 
 
The Plan follows Medicare rules. Medicare rules say that repeat ESI when the first injection directly and 
significantly provided improvement of the condition being treated may be considered medically reasonable and 
necessary when the medical record documents at least 50% of sustained improvement in pain relief and/or 
improvement in function measured from baseline using SAME scale for at least three months. 
 
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 ESI. Our reviewer says 
that the documentation does not support that the ESI criteria have been met. Our physician reviewer found the 
enrollee underwent an ESI on April 26, 2022, and reported 95% pain relief on June 11, 2022. The records 
provided do not include evidence that this pain relief lasted at least 3 months as required by the 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 the requested ESI have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a repeat epidural steroid injection (ESI).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an OON provider. 
 
You asked the Plan to pre-approve an office visit. The Plan denied your request. The Plan says the treatment 
can be safely rendered in-network. An office visit with an in-network provider has been approved. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an OON provider.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a revascularization procedure (37228, 37721, 37229, 37220). 
 
You asked the Plan to pre-approve the revascularization procedure. You say that this procedure 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 Percutaneous Transluminal Angioplasty (PTA) is 
covered when used for the treatment of Atherosclerotic Obstructive Lesions in the lower extremities, i.e., the 
iliac, femoral, and popliteal arteries, or in the upper extremities, i.e., the innominate, subclavian, axillary, and 
brachial arteries. 
 
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 revascularization procedure. Our 
reviewer says that the requested procedure is medically necessary. Our physician reviewer found the 
documentation supports that the enrollee has symptomatic atherosclerotic obstruction in his left lower 
extremity for which imaging and potential revascularization would be considered 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 revascularization procedure have been met. Therefore, we decided that the 
Plan has to pre-approve a revascularization procedure (37228, 37721, 37229, 37220).  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires the daily treatment 
that only an LTACH can provide. The Plan denied your request. The Plan says the enrollee does not meet the 
Medicare guidelines for LTACH admission, and they can safely receive the care they need in a hospital setting. 
 
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 that 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 the LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve the requested injections. You say that the enrollee would benefit from these 
injections. The Plan denied your request. The Plan says the LCD criteria are not met. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint interventions may be covered when the 
enrollee has an absence of radicular symptoms and no non-facet pathology that could be causing the symptoms. 
 
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 injections. Our reviewer 
says that the requested injections are not shown to be medically reasonable and necessary. Our physician 
reviewer found the physical examination on June 17, 2022, revealed a positive straight leg raise test which suggests lumbar radiculopathy. There are also no objective imaging studies of the lumbar spine indicating that 
there is an absence of non-facet pathology that could explain the patient's pain. This treatment is not medically 
necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intracept procedure. 
 
You asked the Plan to pre-approve Intracept procedure. You say that you disagree with the Plan's 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 Intracept procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a history of low back pain. The Intracept procedure is experimental. 
More research is needed. 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 Intracept procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Intracept procedure.
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 have a small window in which you can do 
rehabilitation before you require another round of chemotherapy. You feel that this is medically necessary. The 
Plan denied your request. The Plan says the documentation does not support that you have the endurance to 
tolerate three hours of daily 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 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 enrollee is at a level of function which does not require intensive rehabilitation 
but can improve with repetitive exercise. He has limited capacity for intensive therapy sessions. He can access 
appropriate rehabilitation services without admission to 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: 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 you are deconditioned and do not require intensive specialized or complex 
rehabilitation services. You do not require frequent physiatry oversight and have decreased endurance limiting 
your response to intensive therapy. 
 
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: 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 you are appealing this denial. The Plan denied your 
request. The Plan says the enrollee does not meet the Medicare criteria for SNF care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
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. 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 you believe this is medically necessary. The Plan 
denied your request. The Plan says you do not meet criteria for IRF 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 enrollee has dementia and recurrent subdural hematomas. He requires extensive 
queuing in therapy with multiple rest breaks. He is at minimal assistance for transfers and ambulation and moderate assistance for toiler transfer. The enrollee has significant cognitive loss impeding the ability to 
participate and benefit from intensive therapy. He has a persistent recurrent acute brain injury in setting of 
chronic brain injury. 
 
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 backup diabetic shoes with a metal brace. 
 
You asked the Plan to pre-approve backup diabetic shoes with a metal brace. You say that you would like the 
Plan to reconsider their denial. The Plan denied your request. The Plan says duplicative equipment is 
considered not medically necessary and may include, but not be limited to, equipment that is intended as a 
backup in addition to the main piece of equipment. Additionally, only one pair of diabetic shoes is covered per 
year. 
 The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a pair of diabetic shoes with a metal brace and that you are asking for a second 
pair to use for backup purposes. The diabetic shoes with a metal brace that you already have, serves the same 
purpose as backup diabetic shoes with a metal brace. Therefore, we decided that the Plan does not have to pre-
approve backup diabetic shoes with a metal brace.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wedge pillow. 
 
You asked the Plan to pre-approve the wedge pillow. You say that the pillow is medically necessary. The Plan 
denied your request. The Plan says this is not considered medical equipment and is not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a wedge pillow.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis, open, sacroiliac joint, including obtaining 
bone graft, including instrumentation, when performed (27280). 
 
You asked the Plan to pre-approve sacroiliac joint fusion. You say that additional clinicals have been submitted 
to show medical necessity. The Plan denied your request. The Plan says the open SI joint fusion requested does 
not meet the requirements for approval. 
 
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 sacroiliac joint fusion. 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 documented SI joint instability, fracture, or lesion. The enrollee's records 
do not show provocative exam or injections confirming the SI joints as the source of her pain. 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sacroiliac joint fusion have not been met. Therefore, we decided that the Plan 
does not have to pre-approve arthrodesis, open, sacroiliac joint, including obtaining bone graft, including 
instrumentation, when performed (27280).
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 enrollee is stable enough to transfer 
to an LTACH and an LTACH is the place where the enrollee can receive the appropriate level of care. LTACH 
level of care is also medically necessary for the enrollee, and they do meet LTACH admission criteria. The 
Plan denied your request. The Plan says the request is not medically necessary, when the enrollee is ready to 
leave the hospital, they can safely receive this care in another setting. 
 
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 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 LTACH services.