Persius/hicric huggingface dataset:
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 you are a new tracheotomy patient and 
still have low oxygen saturation. The Plan denied your request. The Plan says you do not meet Medicare 
criteria for coverage. 
 
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 medical record does not show that you require services beyond what you are 
already receiving and that a transfer to an LTACH facility is 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 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 facet joint injections. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint injections are covered for the indications 
established in the applicable LCD. 
 
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 joint injections. Our reviewer says 
that the requested facet joint injections are not medically necessary.  Our physician reviewer found that the documentation does not show or support previous (2nd) injection. There 
is no description of pain relief and duration of relief. There is no baseline measurement for pain or record of 
other therapeutic injections and their success or failure. There is no documentation or assessment on why the 
enrollee is not a candidate of RFA in the medical records. The documentation submitted does not give any of 
the information required to meet LCD guidelines. It is not medically reasonable or necessary for the enrollee to 
have the requested procedure. 
 
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 joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home mechanical (portable) ventilator for the enrollee. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says that the request for a home mechanical ventilator with settings that could be 
delivered by BiPAP with AVAPS for this member with COPD/ILD overlap is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found the Life2000 
System is not medically necessary. This system is not a true ventilator, because it is not capable of providing 
full ventilatory support. It is meant to be used during activity, and provides positive pressure oxygen via a nasal 
interface. There is inadequate evidence that this device provides benefit in the treatment of chronic lung disease. The 
enrollee also does not meet Medicare criteria for a home ventilator. There is no diagnosis of chronic obstructive 
pulmonary disease, neuromuscular disease, or thoracic restrictive disease. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home mechanical (portable) ventilator for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PrimaGen allograft for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of the PrimaGen Allograft in the setting of an 
anterior lumbar spine fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the requested PrimaGen Allograft in the setting of an anterior lumbar spine fusion surgery, in this case, is 
not medically reasonable or necessary. However, there is limited published, large-scale, long-term peer-
reviewed literature that shows this request to be an effective and/or safe treatment for the noted pathology. 
There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception to guidelines. Therefore, the request for PrimaGen Allograft in the setting of an 
anterior lumbar spine fusion surgery 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve PrimaGen allograft for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit (99213) to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a specialist office visit. You say that the patient has seen this provider since 
2016. You also say that the patient does not want to see the in-network doctor and wants to stay with this 
provider. The Plan denied your request. The Plan says the records received do not indicate that there is an 
emergent/urgent medical condition or are in need of specialized services that are not available in the network. 
The Plan also says that there are in-network provider(s) within a reasonable distance of the enrollee's location 
that can provide this service or item. 
 
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 
a specialist office visit (99213) 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need IRF care to improve your function and 
regain independence. The Plan denied your request. The Plan says you do not meet the Medicare criteria for 
admission to an IRF. 
 
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 based on the documentation provided, you do not require the intensity of 
services provided at an IRF.  Specifically, you are not shown to require fifteen hours per week of rehabilitative 
services and regular physician evaluation. Your care needs can be met 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: 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's medical status does not require intensive physician and nursing 
oversight in an IRF. While the enrollee may benefit from additional multiple therapies, including physical and 
occupational therapy, the documentation does not reveal that the enrollee requires this therapy on an intensive 
IRF level or can tolerate an intensive therapy program given documentation of poor endurance and activity 
tolerance. 
 
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 Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for the psychotherapy services provided on July 27, 2021, via telehealth. 
 
You asked the Plan to pay for the telehealth psychotherapy services. You say that the services are shown to be 
medically necessary. The Plan denied your request. The Plan says that there is no documented consultation 
with a primary care physician in the record. A referring provider on the claim does not satisfy this criterion. 
 
The Plan must follow Medicare rules. Medicare rules say that CPs are required to document consultation with 
an enrollee's primary care physician, unless the enrollee was referred by the primary physician. 
 
We looked at the file and Medicare rules. We find that both the claim and the progress note document that the 
enrollee was referred for this psychological care by a primary care provider. The rules clearly state that in this 
situation, documentation of a consultation is not required. Based on this information, we decided that Medicare 
rules for coverage of the telehealth psychotherapy services have been met. Therefore, we decided that the Plan 
has to pay for the psychotherapy services provided on July 27, 2021, via telehealth.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the computed tomography (CT) guidance for the placement of radiation 
therapy fields (77014) provided on May 10, 2021, through June 16, 2021. 
 
You asked the Plan to pay for the CT guidance for the placement of radiation therapy fields. You say that you 
would like reconsideration because these services are payable as they were not for planning purposes. The Plan 
denied your request. The Plan says that Medicare expects that CT guidance for radiation therapy fields will not 
be separately billed during the duration of the IMRT treatment when code 77301 (Intensity modulated 
radiotherapy plan, including dose volume histograms for target and critical structure partial tolerance 
specifications) is billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has failed to forward an applicable Medicare citation to 
indicate that these services may not be paid. Of note, these services are physician services and not being billed 
by the facility. APC payment rules are not applicable in this case. Additionally, there is no evidence to support 
that these services were provided prior to or as part of the image guided radiation therapy planning. It is the 
burden of the Health Plan to substantiate their denial with evidence. In this case, the Plan's denial has not been 
substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for the computed 
tomography (CT) guidance for the placement of radiation therapy fields (77014) provided on May 10, 2021, 
through June 16, 2021.  
 
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: Favorable

 
We decided that the Plan has to pre-approve the percutaneous implantation of neurostimulator electrode. 
 
You asked the Plan to pre-approve the percutaneous implantation of neurostimulator electrode. The Plan denied 
your request. The Plan says that the request is not medically necessary because your records show you do not 
have chronic intractable pain but osteoarthritis and inflammation of the hip joint. 
 
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 the percutaneous implantation of 
neurostimulator electrode. Our reviewer says that the requested items/services are considered medically 
reasonable and necessary in this case. Our physician reviewer found that the documentation supports that you 
have chronic intractable pain and would be a candidate for implantation of a neurostimulator electrode. 
 
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 percutaneous implantation of neurostimulator electrode. have been met. 
Therefore, we decided that the Plan has to pre-approve the percutaneous implantation of neurostimulator 
electrode.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tie down kit for the enrollee. 
 
You asked the Plan to pre-approve the kit. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is used to secure the wheelchair during transportation. 
 
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 tie down kit for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that this is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says this device is not medically reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the requested home ventilator is not medically reasonable and necessary. Our physician reviewer found a 
home ventilator is not medically necessary. This patient has severe chronic obstructive pulmonary disease 
(COPD) with hypoxemic respiratory failure. The records do not document CO2 retention with an arterial blood 
gas (ABG) test done while awake and stable. Bilevel positive airway pressure (BiPAP) has not been tried. 
Medicare does not cover a home ventilator when used as BiPAP. The denial is upheld. 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacral nerve stimulation for urinary incontinence. 
 
You asked the Plan to pre-approve the requested sacral nerve stimulation. You say that it is felt that this 
treatment is necessary to alleviate the enrollee's symptoms. The Plan denied your request. The Plan says 
coverage criteria for this treatment have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that sacral nerve stimulation is covered for the treatment 
of urinary urge incontinence, urgency-frequency syndrome, and urinary retention when the patient is refractory 
to conventional treatments and does not have stress incontinence, urinary obstruction, and specific neurologic 
diseases which are associated with secondary manifestations of these three 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 the requested sacral nerve stimulation. 
Our reviewer says that the requested sacral nerve stimulation is not shown to be reasonable and necessary in 
this case. Our physician reviewer found the enrollee is a female with mixed urinary incontinence, frequency, 
and incomplete bladder emptying. She performs Crede maneuver to initiate voiding. She underwent pubovaginal sling in 2016. Co-morbidities include diabetes, sarcoidosis, peripheral neuropathy, 
morbid obesity and hyperlipidemia. 
 
The enrollee does not meet criteria for the requested sacral nerve stimulator. Specifically, the records do not 
indicate that she is refractory to conventional therapy. The records also show that she has stress incontinence, 
urinary obstruction, and specific neurologic disease (e.g., diabetes with peripheral nerve involvement) that 
exclude coverage for a sacral nerve stimulator. 
 
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 sacral nerve stimulation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve sacral nerve stimulation for urinary incontinence.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre CGM sensor. You say that this is medically necessary. 
The Plan denied your request. The Plan says that you do not meet criteria for coverage. 
 
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 you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre CGM sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre continuous glucose monitor (CGM) sensor.