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

 
We decided that the Plan does not have to pre-approve the lumbar interspinous decompression device (22869). 
 
You asked the Plan to pre-approve the Vertiflex device. You say that per the enrollee's treating physician, the 
enrollee meets the medical necessity outlined in the criteria. The Plan denied your request. The Plan says more 
studies are needed to show Vertiflex is safe and effective to treat back pain. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at this the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the lumbar interspinous decompression device (22869).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prochlorperazine. 
 
You asked the Plan to pre-approve Prochlorperazine. The Plan denied your request. The Plan says the enrollee's 
plan does not include Part B medication coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Prochlorperazine.  
 
Benefits for Prochlorperazine may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient treatment to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve outpatient treatment. You say that you specialize in treating patients with 
lymphedema. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because this provider is out-of-network with the Plan and authorization was not obtained. 
 
 
 
 
 
 
 
 
 
 
 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 
outpatient treatment to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric care. 
 
You asked the Plan to pre-approve inpatient psychiatric care. You say that the enrollee continues to display 
psychotic symptoms and discharge would be unsafe. The Plan denied your request. The Plan says the denial of 
authorization for continued inpatient hospital care is correct, because this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care. Our reviewer says that the enrollee does not meet the Medicare criteria for continued inpatient psychiatric care. Our 
physician reviewer found it is not expected that the enrollee would improve in a reasonable period of time with 
continued care because the enrollee does not have suicidal thoughts, homicidal ideation, or auditory or visual 
hallucinations. The enrollee was compliant with treatment while not showing any acute threats to safety. It does 
not appear medically necessary to have continued care provided at the inpatient hospital level of care rather 
than 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 inpatient psychiatric care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continued inpatient psychiatric care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walk-in shower/bath. 
 
You asked the Plan to pre-approve a walk-in shower/bath. You say that a walk-in shower/bath is medically 
necessary. The Plan denied your request. The Plan says walk in showers or installed bath equipment is not 
covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. Commercial bath or shower installations 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 walk-in shower/bath.
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 do not need intensive therapies, consisting of at least 3 hours of therapy per day 
at least 5 days per week with multidisciplinary approach to daily therapy in an IRF. While you may benefit 
from physical therapy, and occupational therapy, your rehab can be safely provided at a lower intensity and 
alternate setting such as in a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Supartz. 
 
You asked the Plan to pre-approve Supartz. You say that the records provided support the need for the 
requested drug. The Plan denied your request. The Plan says the enrollee's doctor did not document that the 
enrollee has tried one of the preferred drugs. 
 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 Supartz. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the enrollee has not trialed two of the 
viscosupplemental treatments such as Orthovisc and Synvisc or Synvisc-One.  Step therapy, as outlined by the 
plan, requires that 2 of these be trialed first. The documentation does not outline contraindications or reasons 
these medications were not considered or that the Plan's required drugs would likely be less effective and/or 
likely have adverse effects for the 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 Supartz have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Supartz.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a standing table system (E0637). 
 
You asked the Plan to pre-approve a standing table system. You say that this item is medically reasonable and 
necessary. The Plan denied your request. The Plan says this item is not covered by Medicare or the Plan. 
 
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 standing table system (E0637).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor and supplies. 
 
You asked the Plan to pre-approve a continuous glucose monitor and supplies. You say that a continuous 
glucose monitors and supplies are necessary because you have tremors. The Plan denied your request. The Plan 
says there are not exceptions for a continuous glucose monitor and supplies if you do not meet the required 
criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on the 
medical records, you do not meet all the required criteria for coverage. Therefore, we decided that the Plan 
does not have to pre-approve a continuous glucose monitor and supplies.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive urine drug testing (UDT) provided on 
September 29, 2021. 
 
You asked the Plan to pay for the definitive UDT. You say that this was ordered by the treating physician and 
should be considered medically necessary. The Plan denied your request. The Plan says the criteria for this 
testing on 22 or more drug classes are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that definitive UDT may be reasonable and necessary 
based on patient specific indications, including historical use, medication response, and clinical assessment, 
when accurate results are necessary to make clinical decisions. 
 
We looked at the file and Medicare rules. The provider did not submit progress notes from the ordering 
physician to support that this testing was ordered based on patient-specific indications. Based on this 
information, we decided that Medicare rules for coverage of the definitive UDT have not been met. Therefore, we decided that the Plan does not have to pay for the definitive urine drug testing (UDT) provided on 
September 29, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional twelve (12) physical therapy (PT) visits. 
 
You asked the Plan to pre-approve additional PT visits. You say that physical therapy helps you a lot and you 
would like to continue these services. The Plan denied your request. The Plan says the requested physical 
therapy services are not medically necessary in this case. 
 
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 additional PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of your 
condition. Our physician reviewer found that the additional requested therapy generally is not accepted as 
specific and effective therapy for your condition beyond what was approved by the plan. You have had prior 
therapy and the documentation does not reveal that you require the unique skills of a professional therapist to 
safely and effectively provide treatment, or that the services can only be safely and effectively performed only 
by a therapist, or by or under the supervision of a therapist. You are compliant in a home exercise program. The 
requested services are not part of a maintenance program, and the specialized skill, knowledge and judgment of 
a qualified therapist is not required to establish, design and/or deliver a program to maintain your current 
condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an additional twelve (12) physical therapy (PT) visits.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve assistant surgeon services with an out of network (OON) provider. 
 
You asked the Plan to pre-approve the OON assistant surgeon services. You say that the network provider the 
Plan has referred the enrollee to cannot perform the pre-approved surgery at the network hospital because she 
does not have privileges at that hospital. You say that the main surgeon was approved to perform the surgery at 
the network hospital and requested this provider as his co-surgeon The Plan denied your request. The Plan says 
that there are network providers who can provide the service within a reasonable time and distance. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
We looked at the file and Medicare rules. The Plan did not show that they have an in-network assistant surgeon 
who could perform at the hospital where they approved the surgery to take place. Based on this information, we 
decided that Medicare rules for coverage of the OON assistant surgeon services have been met. Therefore, we 
decided that the Plan has to pre-approve assistant surgeon services with an out of network (OON) provider.  
 
 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 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 the enrollee does not need intensive therapies, consisting of at least 3 hours of 
therapy per day at least 5 days per week with multidisciplinary approach to daily therapy in an IRF. While the 
enrollee may benefit from PT, and OT, the enrollee's rehab can be safely provided at a lower intensity and 
alternate setting such as in a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 enrollee would benefit from intensive inpatient 
rehabilitation hospitalization as the enrollee needs intensive therapies, daily physician visits, and around the 
clock nursing care in order for the enrollee to perform her activities of daily living properly. The Plan denied 
your request. The Plan says the enrollee does not require an intensive level of therapy requiring physician 
oversight. 
 
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 the complexity of the enrollees nursing, medical and 
rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While 
the documentation does support a need for physical and/or occupational therapy, there is no documented need 
for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that the 
enrollee 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tradjenta. 
 
You asked the Plan to pre-approve Tradjenta. The Plan denied your request. The Plan says Tradjenta to be 
administered at home is not covered under the Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tradjenta.  
 
 
 Benefits for Tradjenta may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oxygen concentrator. 
 
You asked the Plan to pre-approve an oxygen concentrator. You say that the requested oxygen concentrator is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for an 
oxygen concentrator. 
 
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 oxygen concentrator. Our reviewer 
says that the enrollee does not meet criteria for an oxygen concentrator. Our physician reviewer found coverage 
criteria for home oxygen are not met at this time, therefore the oxygen concentrator is not medically necessary. 
This enrollee has asthma/chronic obstructive pulmonary disease (COPD) with frequent exacerbations, and 
complex obstructive sleep apnea (OSA). The enrollee failed CPAP and BiPAP titrations because of emergent 
central events and hypoventilation.  On average volume-assured pressure support (AVAPS) titration, need for 
supplemental oxygen was not clearly demonstrated because there appeared to be adequate O2 saturations while 
on the optimal AVAPS setting.  Suggest overnight oximetry while on current AVAPS settings and room air 
(RA), as well as AVAPS interrogation to determine residual Apnea Hypopnea Index (AHI). 
 
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 oxygen concentrator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an oxygen concentrator.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that the records provided support the need for Botox. The 
Plan denied your request. The Plan says there is no evidence of the medication being used for a diagnosis 
supported in the Medicare rules for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that the injection of Botox is only covered for specifically 
listed medical indications.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Botox. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the record indicates that the enrollee has 
gastroesophageal reflux in the setting of esophagogastrectomy and pyloric stenosis.  The record does not 
indicate the presence of achalasia or any of the other covered indications. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.