Persius/hicric huggingface dataset:
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 the enrollee's pain is of long-term 
duration and has failed non-operative treatment. You say that the Intracept procedure is medically necessary 
and the most effective treatment at this time. The Plan denied your request. The Plan says medical studies 
haven't proven this service is helpful for the treatment of the enrollee's health problem. 
 
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 the documentation is lacking regarding reasonably detailed or evidenced findings 
supporting the spinal vertebral bodies as being the overwhelming primary generators of the enrollees chronic 
persistent pain. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. 
 
  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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 10 physical therapy (PT) visits (97164). 
 
You asked the Plan to pre-approve an additional 10 PT visits. You say that the services are medically 
necessary. The Plan denied your request. The Plan says the services are not medically necessary. 
 
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 an additional 10 PT visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of your 
condition. Our physician reviewer found the records do not demonstrate that the unique skills of a professional 
therapist are required to safely and effectively provide treatment, that the services can be safely and effectively 
performed only by a therapist, or for physical therapy, by or under the supervision of a therapist. The requested 
services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a 
qualified therapist is not required to establish, design and/or deliver a program to maintain your current 
condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an additional 10 PT visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an additional 10 physical therapy (PT) visits (97164).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Radiesse injections rendered on April 25, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were 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 pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the current peer-reviewed medical 
literature and Medicare-approved major drug compendia do not support the use of Radiesse injections for your 
diagnosis of excessive saliva flow (sialorrhea). The services were 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 pay for the Radiesse injections rendered on April 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intercostal nerve block (CPT code 64421) to be 
provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the services are necessary. The 
Plan denied your request. The Plan says there is an in-network provider that can perform the services you need. 
 
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 intercostal 
nerve block (CPT code 64421) 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 home mechanical ventilator. 
 
You asked the Plan to pre-approve a home mechanical ventilator. You say that without the requested device, 
the enrollee is at high risk for hospital readmission and potentially life-threatening exacerbations. The Plan 
denied your request. The Plan says a home mechanical ventilator set in average volume assured pressure 
support (AVAPS) mode with Auto-EPAP that could be delivered by bilevel positive airway pressure (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 mechanical ventilator. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found a home ventilator 
is not medically necessary. The enrollee has a diagnosis of chronic obstructive pulmonary disease (COPD) and was recently hospitalized with pneumonia.  Arterial Blood Gas (ABG) was consistent with mild acute on 
chronic carbon dioxide (CO2) retention.  There are no pulmonary function tests to assess the severity of the 
COPD, and no ABG done while stable as an outpatient to confirm chronic CO2 retention. 
 
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 mechanical ventilator have been met. Therefore, we decided that the 
Plan does not have to pre-approve a home mechanical ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro orthotic device. 
 
You asked the Plan to pre-approve a MyoPro orthotic device. You say that the records provided support the 
need for the requested device. The Plan denied your request. The Plan says the clinical value and effectiveness 
of a MyoPro orthotic device in the setting of left hemiplegia due to a Cerebral Vascular Accident (CVA) 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 a MyoPro orthotic device. Our reviewer 
says that a MyoPro orthotic device is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the MyoPro is not known to be effective, based on scientific evidence, professional 
standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in 
widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro 
Orthosis will improve the long-term outcomes for this patient, improve hemiparetic arm function, or be safe for 
long term use. There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities.  
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 MyoPro orthotic device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro orthotic device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous epidural implantation of neurostimulator 
electrode array, epidural (63650) and implantable neurostimulator electrode, each (L8680).  
You asked the Plan to pre-approve the spinal cord stimulator implant trial. You say that the medical records 
provided support the necessity of the requested service. The Plan denied your request. The Plan says enrollee 
does 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 spinal cord stimulator implant trial. 
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 neck pain which radiates to the arms. The enrollee is 
status post cervical discectomy and fusion and takes Naproxen, Amitriptyline, Baclofen, Lidoderm patches as 
well as Oxycodone and Percocet for pain. The enrollee was evaluated by a psychologist and cleared for a SCS 
trial. The enrollee's last cervical MRI was in 2016 and there is no recent documentation or consultation by a 
surgeon. The request does not meet the criteria of the NCD and is deemed not medically reasonable or 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the spinal cord stimulator implant trial have not been met. Therefore, we 
decided that the Plan does not have to pre-approve percutaneous epidural implantation of neurostimulator 
electrode array, epidural (63650) and implantable neurostimulator electrode, each (L8680).
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve 10 additional visits for re-evaluation of a physical therapy 
established plan of care (97164). 
 
You asked the Plan to pre-approve these services. You say that the requested services are medically necessary 
for the enrollee. The Plan denied your request. The Plan says that the requested services are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that services that do not require the professional skills of a 
therapist to perform or supervise are not medically necessary, even if they are performed or supervised by a 
therapist, physician or non-physician practitioner (NPP). 
 
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 requested services are medically necessary. Our physician reviewer found that the enrollee has a medical 
history of weakness, osteoporosis and impaired mobility and gait. The enrollee has had 30 visits of physical 
therapy. A clinical progress note dated September 8, 2022, indicated that the enrollee required contact guard 
assistance for transfers and for ambulating 50 feet with a front wheel walker as of August 29, 2022. As of 
September 8,  2022, the enrollee required stand by assistance for ambulating 150 feet with a front wheel walker 
and contact guard assistance for transfers. 
 
The most recent documentation dated September 8, 2022, indicated that the enrollee has improved in terms of 
her ability to independently ambulate for longer distances with a walker. While the enrollees progress has been 
gradual, her function has improved, and she continues to have functional deficits with mobility and increased 
risk for a fall. Therefore, additional therapy and the skills of a physical therapist would be appropriate to 
continue to meet these goals and transition to a home exercise program to ensure independence and minimize 
fall risk. Therefore, the 10 visits of additional therapy can be considered 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 been met. Therefore, we decided that the Plan has to pre-
approve 10 additional visits for re-evaluation of a physical therapy established plan of care (97164).  
 
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: 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 the enrollee can benefit from continued therapy 
services such as physical therapy, occupational therapy, and speech therapy. A discharge home is not an 
appropriate level of care for enrollee as they need more skilled care. Enrollee is on a ventilator and family is 
not able to provide care for them at this level. The Plan denied your request. The Plan says the enrollee is medically stable with no further vent wean goals. Any skilled nursing, PT/OT, speech therapy needs can be 
provided at a lower level of care. The enrollee is dependent for all care currently. 
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient care to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve outpatient care. You say that you have family that can take care of you in 
Arizona so are relocating. The Plan denied your request. The Plan says this provider is out-of-network with the 
Plan and you can be treated by an in-network provider. 
 
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 
outpatient care to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from admission to an IRF. 
The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
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 treatment by multiple therapies, including either 
physical therapy or occupational therapy, at an intensive rehabilitation therapy program. The enrollee 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission is medically necessary. 
The Plan denied your request. The Plan says the LTACH admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided documentation indicates that the enrollee does not require services at the 
LTACH that are not already available at the current facility. The reviewer found that there are no services at the 
LTACH that the patient requires that are not already available and covered at the current facility. Therefore, the 
reviewer found that transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implantable loop recorder (33285). 
 
You asked the Plan to pre-approve the implantable loop recorder. You say that the medical records provided 
support the necessity of the requested service. The Plan denied your request. The Plan says a loop recorder is 
not medically necessary for the enrollee at this time. 
 
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 implantable loop recorder. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found while the enrollee has a history of atrial fibrillation/flutter, there is no documentation provided to suggest a history of unexplained syncope or any other apparent indication for an 
implantable loop recorder. In summary, there is insufficient documentation to support the medical necessity for 
insertion of an implantable loop recorder 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 the implantable loop recorder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the implantable loop recorder (33285).