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

 
We decided that the Plan does not have to pre-approve endovenous ablation therapy (ERFA) of incompetent 
vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein 
treated (36745), and subsequent vein(s) treated in a single extremity (36746). 
 
You asked the Plan to pre-approve ERFA. You say that the enrollee has been wearing compression stockings 
for over 6 months. You say that they have tried conservative treatments with no improvements in symptoms. 
You also say that this vein was previously approved and treated. The Plan denied your request. The Plan says 
the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that ERFA and laser ablation are covered only for the 
treatment of symptomatic varicosities. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ERFA have not been met. Specifically, the file indicates that ERFA is being requested for a 
perforator vein. Therefore, we decided that the Plan does not have to pre-approve endovenous ablation therapy 
(ERFA) of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, 
radiofrequency; first vein treated (36745), and subsequent vein(s) treated in a single extremity (36746).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation mileage. 
 
You asked the Plan to pre-approve additional routine transportation mileage. You say that the services are 
necessary. The Plan denied your request. The Plan says your benefit does not cover transportation over sixty 
(60) miles to non-approved locations. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case.  
 
We looked at your request, the records in the case file, and the rules. Review of the file shows that the provider 
you are trying to see is more than sixty (60) miles from your home. Your 2022 EOC states a maximum trip distance of sixty (60) miles per one-way trip applies. Therefore, your request exceeds your benefit limit. 
Therefore, we decided that the Plan does not have to pre-approve additional routine transportation mileage.
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 it is medically necessary for the enrollee to receive 
IRF care. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for IRF 
admission. 
 
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 have clinical comorbidities and recent complications that may 
benefit from close medical supervision on an inpatient basis however the enrollee is bed bound (difficulty with 
bed mobility and unable to participate in some transfers) with home health therapies thus there is no 
documentation or comment from current evaluating clinician/therapist that the enrollee would be able to 
tolerate 3 hours of therapy per day or 15 hours of therapy spread over 7 days thus the IRF criteria has 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia (D9222 and D9223) provided by Patrick Nolan, D.D.S., on 
June 10, 2022. 
 
You asked the Plan to pay for anesthesia. You say that this is covered and should be overturned. The Plan 
denied your request. The Plan says that the rendered dental service is not a covered benefit. 
 
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 anesthesia 
when the services are medically necessary and reasonable. 
 
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 anesthesia have been met. Therefore, we decided that the Plan has to pay for 
anesthesia (D9222 and D9223) provided by a participating provider on June 10, 2022.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intraosseous basivertebral nerve ablation (Intracept). 
 
You asked the Plan to pre-approve Intracept procedure. You say that this procedure fills a treatment gap for 
patients that do not receive adequate relief from traditional conservative methods and do not have instability to 
indicate fusion is appropriate. The Plan denied your request. The Plan says there is little evidence in the 
medical literature to suggest that this is an appropriate 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 Intracept procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is an experimental/investigational procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve intraosseous basivertebral nerve ablation (Intracept).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency transportation (T2003). 
 
You asked the Plan to pre-approve non-emergency transportation. You say that the enrollee needs assistance 
getting to and from doctor's appointments and hospital visits. The Plan denied your request. The Plan says the 
enrollee must have both high blood sugar (diabetes) and a problem with the way the heart pumps the blood 
(congestive heart failure) to get these rides. The Plan also says that the information provided by the enrollee's 
provider shows that they have diabetes, but does not have congestive heart failure. 
 
 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when you are diagnosed with both diabetes and congestive heart 
failure (CHF).  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve non-emergency transportation (T2003).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular neurolytic ablation (64624). 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that is considered experimental and/or unproven. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The role of genicular 
nerve blocks and radiofrequency ablation after total knee replacement is still being investigated. It is 
considered experimental at this time. Our physician reviewer found that your condition does not meet criteria 
for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genicular neurolytic ablation (64624).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an alternating pressure mattress. 
 You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says 
coverage criteria have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that pressure support surfaces are only covered under 
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 requested services. Our physician 
reviewer found the records do not document that you have multiple stage 2 pressure ulcers located on the trunk 
or pelvis. You do not have a large or multiple stage 3 or 4 pressure ulcer(s) on the trunk or pelvis. You have not 
had a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the past 60 days as 
required by the coverage criteria. 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 an alternating pressure mattress.
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 chronic respiratory failure. The Plan denied your request. The Plan says the request for a home mechanical 
ventilator set in iVAPS mode with Auto-EPAP (AE) 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 provided clinical records 
document diagnoses of congestive heart failure, pulmonary edema, blindness, morbid obesity, obstructive sleep 
apnea, obesity hypoventilation syndrome, asthma and chronic respiratory failure with hypercarbia but do not 
document neuromuscular disease, thoracic restrictive disease, or chronic respiratory failure consequent to 
chronic obstructive pulmonary disease. Provided records document that the home ventilator is being requested 
for use in intelligent volume assured pressure support (IVAPS) mode with auto-titration which could be 
provided by a BiPAP device with AVAPS and a back-up rate.  As stated in the Local Coverage Determination 
(L33800): "Claims for ventilators used to provide CPAP or bi-level CPAP therapy for conditions described in 
this RAD policy will be denied as not reasonable and 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 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the computed tomography (CT) scan of the abdomen 
and pelvis with and without contrast. 
 
You asked the Plan to pre-approve the CT scan. You say that it is medically necessary for you to get the CT 
scan done. The Plan denied your request. The Plan says the CT scan is not reasonable and medically necessary 
according to Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 CT scan. Our reviewer says that the 
CT scan of the abdomen and pelvis is not medically reasonable and necessary. Our physician reviewer found 
that according to the AUA/ASTRO guidelines clinicians should not routinely perform abdominal-pelvic CT 
scans or bone scans in asymptomatic patients with low or intermediate risk of prostate cancer. The records 
show that this enrollee has favorable intermediate prostate cancer. 
 
  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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the computed tomography (CT) scan of the abdomen and pelvis with and without contrast.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that by the time the ambulance arrived you had 
regained consciousness, all your vital signs were fine, and you did not require medical attention so you 
discharged the ambulance team as there was no need for transport. The Plan denied your request. The Plan says 
these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on January 30, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a segmented pneumatic compression device and related 
supplies. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says there is 
no evidence of truncal edema. The Plan follows Medicare rules. Medicare rules say that pneumatic compression devices are only covered 
under 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 requested services. Our physician 
reviewer found that the enrollee has a history of lower extremity lymphedema. The records do not document 
trial and failure of at least four weeks of regular, daily, multiple-hour home usage of a non-segmented pump 
(E0650 or E0651) after careful, in-person fitting, training and supervision by a technician who is skilled in and 
who regularly and successfully uses the appliance provided as required. Based on the medical records, there is 
no documentation that the segmented pneumatic compression device at issue in this case meets all Medicare 
criteria for medically reasonable and necessary for the patient. 
 
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 a segmented pneumatic compression device and related supplies.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be 
provided 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. The 
complexity of the enrollees nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical repair of a 
hip fracture after a fall. The enrollees medical problems are stable. There are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition 
does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a posterior cervical foraminotomy at right-sided C4-5 
and C5-6. 
 
You asked the Plan to pre-approve the requested services. You say that you have tried physical therapy which 
makes the pain worse. The Plan denied your request. The Plan says the documentation does not support the 
need for surgery. 
 
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 you are being treated for ankylosing spondylitis of the thoracic spine and cervical 
radiculopathy. You presented with neck and right arm pain and numbness. You previously had cervical 
foraminotomies on the back around 2013. You started developing a burning pain that goes down your right arm 
to your first and second fingers. Detailed documentation is not evident regarding trial and failure of recent, 
reasonable, and comprehensive less invasive conservative care measures. Detailed evidence of severe and/or 
progressive neurological abnormalities has not been documented. There are limited large-scale, long-term 
references showing the safety and efficacy of the requested surgery in this clinical setting.  There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception. Therefore, the requested cervical foraminotomy at right-sided C4-5 and C5-6, in 
this case, is 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a posterior cervical foraminotomy at right-sided C4-5 and C5-6.
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. The Plan denied your request. The Plan says the SNF services 
requested are not supported based on the records received.  
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 continued 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 based on the documentation provided you do not qualify for SNF 
coverage. Daily skilled services are not shown to be required to establish a maintenance program or to prevent 
deterioration of your condition. You do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. Our reviewer also 
found that you do 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.