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

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the Medicare coverage criteria for SNF care.

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 care. Our reviewer says that the requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that based on the documentation provided, the enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is ambulating 100 feet and tending to activities of daily living with minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs can, as a practical matter, be provided at a lower level of care (ex. home, assisted living, long term 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is medically necessary 
for the enrollee's condition. The Plan denied your request. The Plan says there is insufficient evidence at this 
time to recommend the requested procedure. 
 
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 Vertiflex 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 enrollee is a 77-year-old male being treated for sacrococcygeal disorders, not 
elsewhere classified. He presented with low back pain. The exam reveals tenderness over the left sacroiliac and 
lumbosacral region.  
In this case, current evidence based medical guideline and peer reviewed literature do not fully support the 
spinal decompression device procedure over the gold standard of lumbar laminectomy. There is a lack of 
large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees 
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 the Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex procedure.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF rehabilitation to maximize 
their function so they can return home. The Plan denied your request. The Plan says that the Medicare 
guidelines for IRF admission were not met and the enrollee's needs can be met in a skilled nursing facility. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that the clinical documentation shows that the enrollee has many active comorbidities including 
Parkinson's disease (dysautonomia, urinary retention, tremors) and concern for cerebral vascular accident. 
Infectious disease consult specifically mentions that the enrollee must be closely monitored for progression of 
urinary tract infection symptoms for concern of C diff if treated with antibiotics thus the enrollee would be 
expected to require continued inpatient hospitalization for close medical monitoring during rehabilitation. 
Evaluating therapists list complex functional impairments with active parkinsonian tremors history of previous 
stroke, new right sided deficits and that the enrollee would be able to tolerate 3 hours of therapy thus IRF 
criteria has 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
IRF admission and services.  
  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 pay for skilled nursing, home health care and physical therapy 
services provided on July 21, 2022 to August 15, 2022, by an OON provider. 
 
You asked the Plan to pay for skilled nursing, home health care and physical therapy services. The Plan denied 
your request. The Plan says the out-of-network services were not authorized. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for skilled nursing, home health care and physical 
therapy services provided on July 21, 2022 to August 15, 2022, by an OON provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs (CPT code A9270) provided on 
March 17, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that you fell on ice and went to the 
emergency room (ER). You state they thought you said work related, but it is not work-related, and this 
happened before work. The Plan denied your request. The Plan says self-administered drugs are a non-covered 
item or service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
Medicare designates A9270 as "not paid by Medicare when submitted on outpatient claims (any outpatient bill 
type). Furthermore, the Plan contract says that covered drugs include: Drugs that usually aren't self-
administered by the patient and are injected or infused while you are getting physician, hospital outpatient, or 
ambulatory surgical center services. Therefore, the self-administered drugs you received in the ER are not 
covered. Therefore, we decided that the Plan does not have to pay for the self-administered drugs (CPT code 
A9270) provided on March 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the IRF setting is the most appropriate level of care for the enrollee. The Plan denied your request. The Plan says the Medicare guidelines for IRF admission were not met and the enrollee's needs can be met at a skilled nursing facility.

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 clinical documentation shows that the enrollee has functional impairment with some activities of daily living and active comorbidities (difficulty weaning supplemental O2 and labile heart rate), however there is no listed complex functional deficits that would require interdisciplinary team management or intense therapy. Additionally, evaluating therapists do not show that the enrollee would require or be able to tolerate 3 hours of therapy per day.

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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone marrow aspirate (CPT code 20939). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of the intracept procedure in the setting 
of bone marrow aspirate in the setting of spinal 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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found bone marrow aspirate is experimental. More research is needed to show safety and efficacy 
when used as bone graft material. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the bone marrow aspirate (CPT code 20939).
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve 15 in-home physical therapy (PT) visits (G0151). 
 
You asked the Plan to pre-approve 14 additional in-home PT visits. You say that the enrollee needs these 
services. The Plan denied your request. The Plan says that the additional in-home PT visits are not medically 
necessary. 
 
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 14 additional in-home PT visits. Our 
reviewer says that the requested 14 additional in-home PT visits are medically necessary. Our physician 
reviewer found the provided documentation indicates that the enrollee requires supervision for ambulating 200 
feet and stand by assistance for negotiating stairs. The documentation indicates that the enrollee has made 
progress with bed mobility, transfers, and ambulation. The reviewer found that the request for continued home 
health physical therapy therefore would be reasonable and necessary to continue with improved mobility as 
well as transition to an independent home program. Therefore, the reviewer found that the 14 additional visits 
are 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 14 additional in-home PT visits have been met. Therefore, we decided that the 
Plan has to pre-approve 15 in-home physical therapy (PT) visits (G0151).  
 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 home ventilator (E0466).

You asked the Plan to pre-approve a home ventilator. You say that the ventilator is to be used for the treatment of COPD. The Plan denied your request. The Plan says the request for a home mechanical ventilator set in PS with Safety Tidal Volume mode that could be delivered by BiPAP 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 a home ventilator. Our reviewer says that the service is not medically necessary. Our physician reviewer found the record indicates that the enrollee has chronic hypercarbic respiratory failure from chronic obstructive pulmonary disease. The provided primary source documentation does not contain sufficient detailed information in the medical record to justify the treatment selected. The enrollee could be treated with a BiPAP machine with AVAPS capability. The plan has indicated coverage for such a device is available upon request. 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electric patient lift (E0635).

You asked the Plan to pre-approve an electric patient lift. You say that the non-electric Hoyer lift was approved on August 15, 2022. Your daughter and staff cannot use the non-electric lift because you are too heavy and when they try, it jolts you all around and it is too painful. The Plan denied your request. The Plan says you have a lift that meets your needs. Further education by home health services for caregivers on use of hydraulic lift will be offered.
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 have a standard hydraulic lift. Medicare rules say that an electric lift is covered if the basic coverage criteria are met. A standard hydraulic lift serves the same purpose as an electric patient lift. The records show the Plan has offered further education for caregivers on use of the standard hydraulic lift. Therefore, we decided that the Plan does not have to pre-approve an electric patient lift (E0635).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has 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 that the requested admission to an IRF is not medically necessary.

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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer found the complexity of the enrollee's nursing medical and rehabilitation needs does require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee has had the onset of multiple new medical conditions, including atrial flutter and respiratory failure, which would benefit from the intensity of rehabilitation physician oversight and the interdisciplinary approach provided on acute inpatient rehabilitation.

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 been met. Therefore, we decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 

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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crown - porcelain/ceramic, tooth #1 (CPT code D2740) 
and core buildup, including any pins when required, tooth #1 (CPT code D2950). 
 
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied 
your request. The Plan says the services are not covered. 
 
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. D2950 is not listed in the 
enrollee's EOC as a covered benefit; therefore, it is not covered. Furthermore, crown - porcelain/ceramic, tooth 
#1 (CPT code D2740) is not covered because crowns on molar teeth are limited to metal materials. Therefore, 
we decided that the Plan does not have to pre-approve crown - porcelain/ceramic, tooth #1 (CPT code D2740) 
and core buildup, including any pins when required, tooth #1 (CPT code D2950).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the receiver (Monitor), dedicated, for use with 
therapeutic continuous glucose monitor system (K0554) and supply allowance used with a therapeutic CGM 
device (K0553). 
 
You asked the Plan to pre-approve the Dexcom G6 sensor. You say that the records provided support the 
necessity of the requested service. The Plan denied your request. The Plan says the enrollee does not meet the 
medical necessity criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan.  
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the Dexcom G6 sensor have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the receiver (Monitor), dedicated, for use 
with therapeutic continuous glucose monitor system (K0554) and supply allowance used with a therapeutic 
CGM device (K0553).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve i-FACTOR Peptide allograft (CPT code(s): 20930 and 
20931). 
 
You asked the Plan to pre-approve the allograft. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of i-Factor allograft in the setting of 
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 allograft. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the i-FACTOR Peptide allograft is experimental. More research is needed. 
 
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 allograft have not been met. Therefore, we decided that the Plan does not 
have to pre-approve i-FACTOR Peptide allograft (CPT code(s): 20930 and 20931).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device 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 experimental and investigational procedures are not covered by Medicare. 
 
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 this device is experimental. More research is needed. 
 
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 the Vertiflex device for the enrollee.