Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to preapprove 10 extra physical therapy sessions. 
 
You asked the Plan to preapprove 10 extra physical therapy sessions. You say that the member needs to 
continue physical therapy. You also say that the member is currently still having right hip and knee pain 
accompanied by stiffness that limits daily mobility and function. The Plan denied your request. The Plan says 
the requested services are not reasonable and necessary, and the health plan has no contractual obligation to 
cover services that are not covered by Medicare. 
 
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 preapprove 10 extra physical therapy sessions. 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 in this case, the member has previously been treated 
with outpatient therapies and should be independent with a home exercise program. Our physician reviewer 
also found that there is no documentation of a recent injury or decline in function. Our physician reviewer also 
found that the additional therapy services are not an appropriate duration and frequency for the member's 
medical condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 10 extra physical therapy sessions have not been met. Therefore, we decided 
that the Plan does not have to preapprove 10 extra physical therapy sessions.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar surgery. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee has not tried and failed conservative management. 
 
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 requested services. Our physician 
reviewer found that there is no documentation of a 6 week trial of conservative measures, such as physical 
therapy. Therefore, the request is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve lumbar surgery.
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 are appealing with supporting records. The Plan 
denied your request. The Plan says based on Medicare guidelines and the information they have about the 
enrollee's condition; the enrollee does not meet the requirements 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve an electroencephalogram (EEG) and a visual evoked potential 
(VEP) test. 
 
You asked the Plan to pre-approve the tests. You say that the medical documentation provided supports the 
need for the tests which remain in dispute. The Plan denied your request. The Plan says that the documentation 
provided does not support the need for the EEG and the VEP tests. 
 
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 tests. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the documentation supports that an EEG and VEP testing are/were medically reasonable and 
necessary for the enrollee in this case to help rule in or rule out the diagnostic possibilities. The enrollee 
presented to the neurologist with symptoms which included numbness, fatigue, generalized weakness, 
intermittent slurring of speech, decreased balance, poor coordination, and intermittent blurred vision and 
double vision. The exam was notable for decreased grip strength and decremental loss of sensation in the 
extremities. Diagnostic possibilities included seizures, multiple sclerosis, myopathy, polyneuropathy, 
radiculopathy, carpal tunnel syndrome, diabetes, and hypothyroidism. 
 
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 tests have been met. Therefore, we decided that the Plan has to pre-approve 
an electroencephalogram (EEG) and a visual evoked potential (VEP) test.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued home health skilled nursing visits beyond 
September 22, 2022. 
 
You asked the Plan to pre-approve the continued home health care. You say that it is felt that this care remains 
necessary. The Plan denied your request. The Plan says the enrollee's needs do not require the skills of a 
licensed nurse. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 continued home health care. Our 
reviewer says that the requested home health services are not considered medically reasonable and necessary. 
Our physician reviewer found the enrollee does not have documented skilled nursing needs. There is no clear 
documentation as to why the enrollee, or the people he lives with, are unable/unwilling to provide the minor 
wound care required.  As such, the requested, ongoing, home health skilled nursing services are not medically 
necessary or reasonable 
 
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 continued home health care have not been met. Therefore, we decided that 
the Plan does not have to pre-approve continued home health skilled nursing visits beyond September 22, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have pre-approve continued SNF care. 
 
You asked the Plan pre-approve continued SNF care. You say that you are appealing on the enrollee's behalf of 
a continued stay in a SNF. The Plan denied your request. The Plan says the SNF coverage is exhausted. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 120 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 120 days of SNF care during the benefit period from March 4, 2022, 
to July 1, 2022. The Plan has covered 120 days of SNF care.  
 
 
 Although the enrollee may still need skilled care, the Plan is not required to pay for more than 120 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have pre-approve continued SNF care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that there is sufficient science published 
showing that the requested procedure improves the quality of life of patients suffering from vertebrogenic low 
back pain. You say that the procedure is safe and effective. The Plan denied your request. The Plan says the 
requested procedure is considered 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 the Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the Intracept procedure is considered 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 the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis Tab 5mg. 
 
You asked the Plan to pre-approve Eliquis. You say that the requested medication is medically necessary. The 
Plan denied your request. The Plan says the requested medication does not fall under Part B coverage. The 
enrollee does not have pharmacy (drug) benefits administered by the Plan. The enrollee does have NOKIA 
which provides its own pharmacy benefits. 
 
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 Eliquis Tab 5mg.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve secondary power scooter repair. 
 
You asked the Plan to pre-approve secondary power scooter repair. You say that you fell in the hospital and 
hurt your back. Unfortunately, the manual wheelchair isn't enough mobility for you to get around. The 
wheelchair will only go as far as your arms can go but the scooter can take you up to 10 miles. You are not 
asking for a new scooter, just for the battery to be repaired on your current scooter so you can get around. The 
Plan denied your request. The Plan says repairs to a secondary or back-up power mobility equipment is not 
covered. 
 
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 receive a primary manual wheelchair on May 12, 2022. Repairs to a secondary or back-
up power mobility equipment is not covered. Therefore, we decided that the Plan does not have to pre-approve 
secondary power scooter repair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power 
options represented by code K0861and related accessories. 
 You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not have a medical need for multiple power options included with 
the requested group 3 power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 wheelchair. Our reviewer says that 
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found that based on 
the medical records provided there is no documentation that the group 3 power wheelchair with multiple power 
options represented by code K0861and related accessories (power tilt and recline) at issue in this case meet 
Medicare criteria for medically reasonable and necessary. Provided records do not support that the enrollee is 
high risk for skin breakdown, has a history of pressure ulcer(s) or has had skin flap surgery. Records do not 
document the enrollee performs bladder self-catheterization and is unable to transfer independently or that the 
enrollee has increased muscle tone or spasticity, thus she does not meet criteria for the power tilt and recline or 
the requested multiple power options feature. These rules can be found in Local Coverage Determination 
(LCD): Wheelchair Options/Accessories - L33792. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 3 power wheelchair with multiple power options represented by code K0861and 
related accessories.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home health aide or certified nurse assistant, 
providing care in the home; per hour (S9122). 
 
You asked the Plan to pre-approve the home health services. You say that that the enrollee requires 24 hours 
care/observation as well as help with direction with personal hygiene and management of feeding tubes. 
 The Plan denied your request. The Plan says the requested services appear to be custodial care and is not 
reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 home health services. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found Based on the medical records provided, the medical records provided there is no documentation that the services meet the definition of home health aide services as per Sections A, B, C, D & E 
of Section 50.2. There is no documentation that the home health aide services reasonable and necessary to the 
treatment of the patient's illness or injury by the skilled professional staff. Provided records do not document 
any acute or unstable medical conditions or changes in medication or treatment which would necessitate skilled 
nursing or therapy visits. As no skilled nursing or therapy services meet criteria for coverage, then skilled home 
health aide services do not meet criteria for coverage. Care through a private home care agency for custodial 
services appears needed in this case. 
 
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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the home health aide or certified nurse assistant, providing care in the home; per 
hour (S9122).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BioDFence Dryflex (Q4138) 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 this treatment is not considered approved under the policies and is considered 
investigatory (or still being studied). 
 
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 that the plan has determined that application of an amniotic membrane graft to the corneal surface of the 
right eye is medically reasonable and appropriate. 
However, there is insufficient evidence to support that the use of BioDFence Dryflex is medically reasonable 
and necessary for this 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve BioDFence Dryflex (Q4138) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CardioMEMS pulmonary pressure sensor implantation. 
 
You asked the Plan to pre-approve CardioMEMS pulmonary pressure sensor implantation. 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 CardioMEMS pulmonary pressure 
sensor implantation. 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 recurrent congestive heart 
failure. The CardioMEMS device was approved by the FDA in 2014 and consists of a sensor device placed in 
the pulmonary artery to allow measurement of pulmonary artery pressure in the management of patients with 
CHF. The clinical study on which FDA approval was based showed improved clinical outcomes and decreased 
hospitalizations in patients in whom the CardioMEMS system was implanted, reflecting a patient population 
with preserved ejection fraction and was somewhat limited in scope. Subsequent follow-up studies remain 
encouraging and suggest an improvement in heart failure symptoms with the use of the device. In addition, published expert opinion in the cardiology literature is supportive of the clinical usefulness of CardioMEMS.  
Nonetheless, there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this enrollees clinical 
management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CardioMEMS pulmonary pressure sensor implantation have not been met. 
Therefore, we decided that the Plan does not have to pre-approve CardioMEMS pulmonary pressure sensor 
implantation.
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. You say that this can help relieve pain and assist the 
enrollee getting back to normal mobility and lifestyle. The Plan denied your request. The Plan says the records 
do not show a physical evaluation to determine if there is any non-facet pathology that could explain the source 
of the enrollee's pain. 
 
The Plan follows Medicare rules. Medicare rules state that facet joint interventions are only covered if certain 
criteria are met. 
 
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 enrollee does not meet the Medicare criteria for the requested facet joint injections. Our physician 
reviewer found there is no documentation indicating that there has been failure to respond to non-
invasive/conservative care management and that there is no non-facet pathology per clinical assessment or 
radiology studies that could explain the source of the enrollee's 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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.