Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Reblozyl. 
 
You asked the Plan to pre-approve Reblozyl. The Plan denied your request. The Plan says that this drug must 
be used for a medically accepted indication. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 Reblozyl. Our reviewer says that the 
use of Reblozyl is FDA approved and supported by the compendia. Our physician reviewer found that the 
enrollee is symptomatic and has failed erythropoiesis-stimulating agents. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Reblozyl have been met. Therefore, we decided that the Plan has to pre-approve 
Reblozyl.  
 
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 CardioMEMS device. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
device has not been proven to improve the management of chronic heart failure. 
 
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 the enrollee has recurrent congestive heart failure. There remains a dearth of randomized, 
blinded clinical studies examining long-term clinical outcomes establishing the value of CardioMEMS in 
patient management. As a result, at this time the CardioMEMS system would not be considered medically 
appropriate and necessary in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services for an office visit and scanning 
computerized ophthalmic diagnostic imaging provided on May 11, 2022. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says prior 
authorization is required. 
 
The Plan contract covers physicians services. The Plan says physicians services require prior authorization. 
 
We looked at the file and the Plans rules. The file shows that there was not a prior authorization for these 
services. Based on this information, we decided that Medicare rules for coverage of physician's services have 
not been met. Therefore, we decided that the Plan does not have to pay for physician's services for an office 
visit and scanning computerized ophthalmic diagnostic imaging provided on May 11, 2022.
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 the enrollee is suitable for transfer to an 
LTACH. You also say that the enrollee cannot be adequately cared for in her current condition at a skilled 
nursing facility or at home with home health services. The Plan denied your request. The Plan says the LTACH 
services you requested do not meet the requirements for approval. 
 
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 enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The Plan has approved ongoing care in the current acute 
care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found documentation does not support actual formal surgical ablation of pre-designated 
basivertebral nerves as being medically necessary and/or reasonable at this time. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the requested Intracept intraosseous basivertebral nerve ablation at the L5-S1 vertebral 
body, 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 an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services rendered on March 4, 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 are not covered. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the services were not performed by a physician, PA, 
or NP/CNS or under the direct supervision of one. Therefore, we decided that the Plan does not have to pay for 
the acupuncture services rendered on March 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the transport chair and related sales tax 
purchased on June 19, 2022. 
 
You asked the Plan to provide reimbursement for the transport chair and sales tax. You say that you required 
this chair because you are no longer mobile and cannot use a walker. The medical need for this item is 
documented by the treating physician. The Plan denied your request. The Plan says this was not purchased 
from a Medicare-certified provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to provide reimbursement for the transport chair 
and related sales tax purchased on June 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0651, E0667). 
 
You asked the Plan to pre-approve the device. You say that the plan providers do not supply this device. The 
Plan denied your request. The Plan says there are in-network providers within a reasonable distance. 
 
The Plan must follow Medicare rules. Medicare rules say that contract suppliers are not required to furnish a 
specific brand name item or mode of delivery to a beneficiary unless prescribed by a physician or treating 
practitioner to avoid an adverse medical outcome. 
 
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 device. Our reviewer says that the 
requested device is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that based on the medical records provided there is no documentation that there is anything specific 
about the requested device/brand that would make it specifically medically necessary over devices that might 
be in the plan's network. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device (E0651, E0667).
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 the enrollee would benefit from long-
term acute care due to medical complexity. The Plan denied your request. The Plan says the enrollee can safely 
receive services in another setting. 
 
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 does not require services at the LTACH that are not available at the 
acute care hospital or skilled nursing facility. The enrollee has improved medically and can receive further care 
at the current acute care hospital or a lower level of care when deemed appropriate. 
 
 
  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 an external upper limb tremor stimulator of the 
peripheral nerves of the wrist for the enrollee. 
 
You asked the Plan to pre-approve the stimulator. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is a lack of evidence to support this device over traditional treatment for 
essential tremor. 
 
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 stimulator. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the documentation does not support that the requested external upper limb tremor 
stimulator of the peripheral nerves of the wrist is medically reasonable and necessary for the enrollee in this 
case. Rather, the device would be considered experimental and investigational 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 stimulator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an external upper limb tremor stimulator of the peripheral nerves of the wrist for the 
enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you feel that you need a higher level of care. The 
Plan denied your request. The Plan says you do not meet 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 the enrollee was admitted due to a fall resulting in a right hip fracture. She was 
treated surgically and remained medically stable. She was discharged home with home health services. The most recent therapy notes indicate that the enrollee is able to ambulate household distances with a walker with 
contact guard assistance. 
 
In this case, the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute 
rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, at an 
intensive rehabilitation therapy program. 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 her functional status.  
 
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 five (5) office visits (99214) with a gastroenterology to 
be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve office visits. You say that the enrollee was referred for a rectal mass that is 
complex to perform and other locations do not perform the procedure. The Plan denied your request. The Plan 
says the enrollee must use network providers to get her medical care and services. 
 
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 
five (5) office visits (99214) with a gastroenterology to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroplasty for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says the magnetic resonance imaging (MRI) showed that the fractures are stable and healing. 
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the medical records show that there is an L5 fracture which has retropulsion which is a 
contraindication to cement augmentation. Also, cement in the sacrum (sacroplasty) is experimental for 
osteoporotic fractures of the sacrum. More research is needed to show safety and efficacy of sacroplasty. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacroplasty for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an osteogenesis stimulator, electrical, noninvasive, other 
than spinal applications (E0747). 
 
You asked the Plan to pre-approve an osteogenesis stimulator. You say that you have a fracture and are in a lot 
of pain. You need the DME because it is necessary for you to recover. The Plan denied your request. The Plan 
says you do not meet criteria for approval of this device. 
 
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 an osteogenesis stimulator. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found you presented with right shoulder pain that is mildly improved. The pain is 
rated at 4/10 on the pain scale. The pain is worse with lifting and reaching. The exam reveals pain with limited 
motion. There is crepitation along the scapular spine. However, detailed documentation is not evident regarding 
serial diagnostic imaging studies to support the scapular fracture is in a nonunion state. The first imaging study 
provided for review was from 8/23/22, with a noted MRI dated 9/1/22. There has not been 90 days between the 
studies to support a scapular non-union. Moreover, current peer-reviewed literature indicates that further large, 
randomized, controlled trials are required to support the use of electrical bone growth stimulators in the 
treatment of long-bone non-unions. 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 an osteogenesis stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an osteogenesis stimulator, electrical, noninvasive, other than spinal 
applications (E0747).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed. 
 
You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your 
request. The Plan says based on the clinical information provided to us there is no documentation that a regular 
bed wound not meet your medical needs and there are no notes that give a clear reasoning as to if and why 
there is a need for frequent and urgent position changes. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or  
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 bed. Our reviewer says that the 
requested bed is not medically reasonable or necessary. Our physician reviewer found that your condition does 
not require positioning of the body in ways not feasible in an ordinary bed. Your condition does not require 
special attachments that cannot be fixed and used on an ordinary bed. Your condition does not require frequent 
change in body position and/or immediate or frequent need for a change in body position. 
 
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 bed have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a semi-electric hospital bed.