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

 
We decided that the Plan does not have to pre-approve Vertiflex Superion Interspinous device. 
 
You asked the Plan to pre-approve Vertiflex Superion Interspinous device. 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 Vertiflex Superion Interspinous device. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found you are diagnosed with lumbar spondylosis and spinal stenosis with 
intermittent neurogenic claudication. The Vertiflex device is experimental. More research is needed. Therefore, 
you do 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 Vertiflex Superion Interspinous device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Vertiflex Superion Interspinous device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve revision, open, of gastric restrictive procedure for 
morbid obesity, other than adjustable gastric restrictive device (separate procedure) (43848) and laparoscopy, 
surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; without implantation of mesh 
43281. 
 
You asked the Plan to pre-approve the surgical procedure. You say that it is your opinion that further delay of 
this scheduled surgery revision of previous bariatric surgery could create a larger health issue in the future. The 
Plan denied your request. The Plan says the request for inpatient hospital admission for hiatal hernia repair and 
revision of previous Roux-en-Y gastric bypass do not meet the requirements for approval. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this case the records indicates that the enrollee has had previous bariatric surgery.  
The records indicates that the enrollee has episodic reflux but is on no medication for this. The record does not 
demonstrate a complication from the previous bariatric procedure. The record provided does not establish the 
medical necessity and reasonableness, as defined by Medicare rules of the requested service. 
 
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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve revision, open, of gastric restrictive procedure for morbid obesity, other than 
adjustable gastric restrictive device (separate procedure) (43848) and laparoscopy, surgical, repair of 
paraesophageal hernia, includes fundoplasty, when performed; without implantation of mesh 43281.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is not stable to go home and has had 
eleven skilled nursing facilities deny them for entry. The Plan denied your request. The Plan says based on 
Medicare guidelines, the inpatient rehabilitation facility services you are requesting 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 most recent therapy notes indicate that the enrollee is able to ambulate with a 
walker and moderate assistance. There are no complex nursing or rehabilitation needs. While the enrollee has a 
need for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
 
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 IRF admission and services.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve transcranial magnetic stimulation (TMS) services (90869, 90867, 
90868). 
 
You asked the Plan to pre-approve TMS services. You say that the enrollee continues to have depressive 
symptoms and is looking for other treatment options for depression. The patient needs appropriate treatment to 
prevent worsening symptoms or hospitalization. The Plan denied your request. The Plan says that the enrollee 
does not meet the requirements for approval of the requested therapy. 
 
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 TMS services. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the records provided specifically requires the confirmed diagnosis to be Severe Major 
Depressive Disorder Single or recurrent as well as resistance the treatment with pharmacologic agents as 
evidenced by lack of clinical significant response to 4 trials of pharmacologic agents in the current depressive 
episode from at least two different agent classes along with concurrent documented psychotherapy. 
Documentation presented is not specified what medications the enrollee had been taking during the present 
episode of depression. She had been tried on a number of pharmacologic agents from different categories 
including Cymbalta, Wellbutrin, Prozac and Zoloft. She has undergone psychotherapy for one year. The 
enrollee did not show documentation of electroconvulsive treatment (ECT) or transcranial magnetic stimulation 
(TMS) in the past. The enrollee does meet the requirement for TMS. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TMS services have been met. Therefore, we decided that the Plan has to pre-
approve transcranial magnetic stimulation (TMS) services (90869, 90867, 90868).  
 
 
 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo. 
 
You asked the Plan to pre-approve Vabysmo. You say that the requested Vabysmo is medically necessary. The 
Plan denied your request. The Plan says the requested Vabysmo is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Vabysmo is not medically necessary. Our physician reviewer found the record indicates that the 
enrollee has a diagnosis of branch retinal vein occlusion with macular edema. The Food and Drug 
Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare 
approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's 
clinical situation. The elements of the coverage criteria are not satisfied. The requested service cannot be 
recommended. 
 
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 Vabysmo.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo (J3490). 
 
You asked the Plan to pre-approve Vabysmo. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drug, 
Avastin. 
 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 
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 drug, Avastin. The reviewer found that tThere is no 
documentation provided indicating that the plans required drug 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 Vabysmo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vabysmo (J3490).
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 will benefit from IRF and needs this 
level of rehabilitation in order to be able to return home. 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 member's nursing, medical and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
Our physician reviewer also found that the member does not require treatment by multiple therapies, including 
either physical therapy or occupational therapy, at an intensive rehabilitation therapy program. Our physician 
reviewer also found that the member can receive further services 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental sedation (D9239). 
 
You asked the Plan to pre-approve the dental sedation. You say that this service is medically necessary. The 
Plan denied your request. The Plan says the dental sedation services are not medically necessary for the 
enrollee's treatment. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the dental 
sedation when the services are medically necessary and reasonable.  
 
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 dental sedation. Our reviewer says 
that the requested sedation service is not medically necessary. Our physician reviewer found the records 
provided do not show that coverage rules are met. The records do not show that four or more teeth are being 
pulled on the same day, or a trial and failure of medications to help the patient relax during treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental sedation have not been met. Therefore, we decided that the Plan does 
not have to pre-approve dental sedation (D9239).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair, group 3 standard, multiple power 
option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (CPT code K0861) and u-
1 sealed lead acid battery (E2365). 
 
You asked the Plan to pre-approve the DME. You say that the enrollee's condition is getting worse, and the 
power wheelchair would help the enrollee's circulation and blood pressure. The Plan denied your request. The 
Plan says the DME is not necessary. 
 
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 DME. Our physician reviewer found criteria for a group 3 power wheelchair are not met as there is no indication the enrollee has had a 
specialty evaluation to assess their needs for a power wheelchair. Additionally, the documentation does not 
indicate that the enrollee has any pressure injuries or requires intermittent catheterization of the bladder that 
would necessitate power tilt or recline. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight 
capacity up to and including 300 pounds (CPT code K0861) and u-1 sealed lead acid battery (E2365).
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 a higher level of care is medically 
necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee can remain at the current acute care hospital until no acute services 
are required. The enrollee can then be transferred or discharged to a lower level of care for any ongoing needs. 
 
  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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor device (PCD.) 
 
You asked the Plan to pre-approve the PCD. You say that the pneumatic compression device is medically 
necessary, as your localized edema and other comorbidities are causing excruciating pain that is affecting your 
quality of life dramatically. The Plan denied your request. The Plan says the records do not show that you have 
failed a 6-month trial of conservative management.  
The Plan follows Medicare rules. Medicare rules say that PCDs are covered for certain 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 the PCD. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the provided documentation does not 
reveal clinically significant edema of the lower extremities, nor any direct evidence of edema causing or 
primarily contributing to your leg/knee pain. As there was insufficient objective evidence documented by your 
physician of you having lymphedema, nor any documentation of having tried conservative treatments for 
edema, this request for a pneumatic compression device will be considered not medically necessary at this 
time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the PCD have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compressor device (PCD.)
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires acute inpatient rehabilitation in 
effort to facilitate increased independence and return home to the community with improved quality of life. The 
Plan denied your request. The Plan says the enrollee's needs can be met at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not require the intensity of services provided at an IRF. The 
enrollees 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 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 does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, at an intensive rehabilitation therapy program. The enrollee continues 
to have a need for skilled therapy with ongoing safety concerns and a potential for functional improvement 
however, the documentation doesnt support that he would meet criteria for admission to an acute inpatient 
rehabilitation facility.  There is no indication that the enrollee would require skilled rehabilitation in an IRF, 
participating in rehab services 15 hours a week, under the supervision of a physician with at least 3 visits 
weekly to regain or maintain his functional status. He can receive further services 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.