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

 
We decided that the Plan does not have to pre-approve contractility modulation therapy (0408T). 
 
You asked the Plan to pre-approve contractility modulation therapy. You say that the requested therapy is 
medically necessary for the enrollee. The Plan denied your request. The Plan says the requested therapy 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 Contractility Modulation Therapy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found several randomized clinical trials of CCM versus control have also been 
reported, along with meta-analysis pooling the data from multiple studies, with CCM providing meaningful 
improvement in quality-of-life scores and objective functional capacity. While the clinical studies led to FDA 
approval in 2019, CCM remains the subject of multiple studies examining long-term efficacy, as well as 
randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such statistically rigorous 
studies are completed, it is premature to presume clinical outcomes and benefit. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Contractility Modulation Therapy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve contractility modulation therapy (0408T).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services provided to the enrollee on December 
24, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 99291 (1 Unit) remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical record does not 
include documentation of a critical care evaluation and management of a critically ill or injured patient, 
including the time that the service was performed. Therefore, this procedure cannot be verified. 
 
We looked at this coder'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 pay for critical care services provided to the enrollee on December 24, 2021.
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 member is in need of a transfer of care from the  
long-term acute care hospital (LTACH) to IRF. You also say that the member is needing physical therapy, 
occupational therapy and speech therapy. The Plan denied your request. The Plan says based on Medicare 
guidelines, the Inpatient Rehabilitation Facility (IRF) services requested do not meet the requirements for 
approval. 
 
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 member's medical status does not require intensive physician and nursing 
oversight in an IRF. Our physician reviewer also found that while the patient may benefit from additional 
multiple therapies, including physical and occupational therapy, the documentation does not clearly reveal that 
the patient requires this therapy or can tolerate this therapy on an intensive IRF level. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar or sacral epidural injection. 
 
You asked the Plan to pre-approve a lumbar or sacral epidural injection. You say that the purpose of this 
injection is to assist with surgical planning. The Plan denied your request. The Plan says a lumbar or sacral 
epidural injection is not medically necessary. 
 
The Plan follows Medicare rules.  
 
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 lumbar or sacral epidural injection. 
Our reviewer says that a lumbar or sacral epidural injection is not medically necessary. Our physician reviewer 
found that in this case, there is no documentation that there was at least 50% improvement of pain or improved 
function for at least three months from the last injection. If the first injection did not help the pain, a different 
approach or medication must be used for the next one, and it should be at least 14 days since the first injection.  
There is no documentation of the substance to be injected (such as, a local anesthetic, steroid medication, 
and/or a contrast dye). 
 
 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 lumbar or sacral epidural injection have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a lumbar or sacral epidural injection.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Qutenza (J7336). 
 
You asked the Plan to pre-approve Qutenza. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the enrollee has not tried and failed one drug from the serotonin and 
norepinephrine reuptake inhibitor (SNRI) class (duloxetine, venlafaxine), and one tricyclic antidepressant 
(nortriptyline or desipramine). 
 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 Qutenza. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has tried and failed the preferred drugs. The reviewer found that there is no indication 
that the plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 
Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Qutenza have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Qutenza (J7336).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgery (33266) to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the surgery. You say that this service is medically necessary and can only be 
obtained out-of-network. The Plan denied your request. The Plan says there is a network facility that can 
provide the procedure at issue. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve surgery 
(33266) to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulation device 
(TENS) (E0720, E0730). 
 
You asked the Plan to pre-approve a TENS device. You say that you are in need of the Next Wave Tens Unit 
due to your severe back pain that radiates from your neck to your toes and down the arms. The Plan denied 
your request. The Plan says you do not meet the medical criteria for coverage. 
 
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 a TENS device. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found a TENS unit is covered for acute post-operative pain. A Tens unit for spine and extremity nerve 
pain use remains experimental. More research is needed to show safety and efficacy. 
 
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 TENS device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a transcutaneous electrical nerve stimulation device (TENS) (E0720, E0730).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show that you have primary 
osteoarthritis of both knees. You have not tried and failed the Plan's required drugs, Synvisc or Synvisc-One. 
The records do not show that the required drugs would have adverse effects or be less effective; therefore, the 
Gel-One is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Gel-One.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with proton-beam radiation therapy. 
 
You asked the Plan to pre-approve proton-beam radiation therapy. You say that the requested services are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says medical-necessity rules have 
not been met because the requested services are experimental/investigational. 
 
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 proton-beam radiation therapy. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that a medically necessary therapy must be at least as beneficial as an existing 
and available medically appropriate alternative. The medical literature is inconclusive as to whether proton-
beam radiation therapy is at least as beneficial as other forms of definitive radiation 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 proton-beam radiation therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve treatment with proton-beam radiation therapy.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left total knee arthroplasty. 
 
You asked the Plan to pre-approve left total knee arthroplasty. 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 left total knee arthroplasty. 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 knee pain with grinding, nighttime discomfort and limping. 
Imaging shows severe breakdown of knee cartilage. There is no documentation of a recent 6 to 12 week trial of 
physical therapy for knee pain. 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 left total knee arthroplasty have not been met. Therefore, we decided that the 
Plan does not have to pre-approve left total knee arthroplasty.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a behind the ear binaural hearing aid (V5140) and a 
binaural dispensing fee (V5160) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a behind the ear binaural hearing aid (V5140) and a binaural dispensing fee 
(V5160). You say that this is medically necessary. The Plan denied your request. The Plan says the requested 
service with a non-contracted provider is not deemed medically necessary. The Plan also says that the member 
has available contracted providers in the area that can provide the services needed. 
 
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 behind the ear binaural hearing aid (V5140) and a binaural dispensing fee (V5160) to be provided by an out-
of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that you have balance deficiencies and muscle 
weakness. The Plan denied your request. The Plan says you do not need daily skilled nursing or rehabilitation 
services on an inpatient basis. 
 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 services. Our physician reviewer 
found that you presented to the acute hospital with difficulty speaking. Your condition has stabilized. Imaging 
showed no evidence of a stroke. You are walking 70 feet with a single point cane and 150 feet with a rolling 
walker with contact guard assistance. You are at a close supervision assist level for transfers and are at 
supervision to minimum assist for activities of daily living. There are no skilled nursing service needs. 
Although there are skilled therapy service needs, you do not require services on a daily basis in a 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies provided on 
January 14, 2022. 
 
You asked the Plan to pay for the CGM supplies. You say that all necessary documents have been submitted. 
The Plan denied your request. The Plan says the documentation does not support payment for this claim. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery or relevant medical records which support medical 
necessity for the supplies provided in this case. There is no progress note from the ordering physician showing that criteria are met. In addition, although a delivery ticket was submitted, no proof of delivery was provided. 
The tracking number on the ticket could not be verified. The record shows that the Plan made several attempts 
to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to 
pay for the continuous glucose monitor (CGM) supplies provided on January 14, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Vabysmo (C9097). 
 
You asked the Plan to pre-approve Vabysmo. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step-therapy rules for coverage of the requested drug 
have not been met. 
 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 Vabysmo. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of Lucentis before they will approve the requested drug. The requested medication is a new 
start. The provided records do not indicate that the enrollee has tried and failed the Plan's preferred step-one 
alternative. The record does not indicate that the enrollee has a contraindication to or would have an adverse 
effect from the Plan's preferred step-one alternative. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vabysmo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Vabysmo (C9097).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services 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 enrollee is not able to complete the physical therapy assessment due to a history of 
dementia with significant cognitive deficits. 
 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 services. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has very advanced dementia and does not engage. The 
enrollee is incoherent in speech, and there is no evidence that they can follow directions. Per Medicare rules, 
the enrollee needs to be able to participate in therapy. The enrollee lacks the capacity to participate in 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve physical therapy services for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve physical therapy. You say that you are having pain in both hips, specifically 
the surgical hip. You also say you have having lumbar issues. The Plan denied your request. The Plan says the 
request to be seen by an out-of-network provider is not medically necessary since they have a Plan contracted 
provider that can provide the service or item requested. 
 
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 
physical therapy to be provided by an out-of-network (OON) provider.