Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says according to the available records, you do not meet all the required Medicare criteria for 
admission to an Inpatient Rehabilitation 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 the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: 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 reasonable 
and necessary. The Plan denied your request. The Plan says the requested procedure is considered 
experimental/investigational. 
 
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 68-year-old male being treated for spinal stenosis of the lumbar 
region with neurogenic claudication. They presented with low back and lower extremity pain. The pain is rated 
at 10/10. They have pain with standing and ambulation and is completely relieved with sitting. The exam 
reveals pain rising from a seated to a standing position that immediately causes his legs to start to tingle and 
have cramping pain. 
 
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. Food and Drug Administration (FDA) indications include implantation of the Superion 
device at one or two adjacent lumbar levels in patients with moderate spinal stenosis in whom operative 
treatment is indicated at no more than two levels, from L1 to L5. This enrollee has multiple degrees of spinal 
stenosis, many not at FDA indicated levels of moderate spinal stenosis (including the planned level of 
implantation L1-2 and L3-4.) FDA contraindications include spinal instability, scoliosis, obesity, and 
osteoporosis, and have not been adequately addressed in the medical records. Height is 68 inches, weight is 239 
pounds, and body mass index is 36.34 kg/m2. There is no discussion of scoliosis of the lumbar spine with no 
documentation of the Cobb angle. There is no discussion indicating that a DEXA scan has demonstrated the 
lack of significant osteoporosis in this patient. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
Vertiflex Superion interspinous device at L1-2 and L3-4, 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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Transthoracic Echocardiography (TTE). 
 You asked the Plan to pre-approve a Transthoracic Echocardiography (TTE). You say that a TTE is medically 
necessary. The Plan denied your request. The Plan says the requested TTE does not meet the Medicare 
coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 TTE. Our reviewer says that the 
requested TTE is not medically necessary. Our physician reviewer found that at issue is the medical necessity 
of a repeat TTE, in the absence of any apparent significant change in the enrollees clinical condition since the 
prior TTE. Clinical guidelines do not support repeating a TTE with no intervening change in clinical status or 
physical findings. In summary, there is no supportive evidence for the medical necessity of repeat TTE in this 
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 a TTE have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a Transthoracic Echocardiography (TTE).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 17, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you are appealing and have submitted a billing 
statement. The Plan denied your request. The Plan says you must receive your care from a 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 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 an office visit provided on June 17, 2022, by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar spine fusion surgery. 
 
You asked the Plan to pre-approve lumbar spine fusion surgery. You say that this procedure is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for lumbar spine 
fusion surgery 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 lumbar spine fusion surgery. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no documentation of spinal instability on imaging studies. There is 
no spinal fracture or lesion. There is no indication the fusion surgery is necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lumbar spine fusion surgery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve lumbar spine fusion surgery.
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 you are appealing the denial. The Plan denied your 
request. The Plan says the request is not medically necessary. 
 
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 daily skilled services are not required. There is no documentation that the 
enrollee requires services on an inpatient basis, only in a skilled nursing facility setting. Records support that 
services in the home with home health care or in a long-term care facility on a part time basis are more 
appropriate in this case. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical status does not require intensive physician and nursing oversight in an IRF. While the enrollee may 
benefit from additional multiple therapies, including physical and occupational therapy, the documentation 
does not reveal that she requires this therapy on an intensive IRF level. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMs Heart Failure system. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has recurrent congestive 
heart failure. The CardioMEMS device was approved by the Food and Drug Administration (FDA) in 2014. 
Nonetheless, 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 enrollee's 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a CardioMEMs Heart Failure system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 13, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the enrollee must receive care from a 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 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 an office visit provided on June 13, 2022, by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve panniculectomy services. 
 
You asked the Plan to pre-approve panniculectomy services. You say that this procedure is medically necessary 
for the enrollee's condition. The Plan denied your request. The Plan says the Medicare criteria for coverage 
have not been satisfied. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules say panniculectomy services when performed to alleviate such 
complicating factors as inability to walk normally, chronic pain, ulceration created by the abdominal skin fold, 
or intertrigal dermatitis, and the above symptoms have been present for at least three months and are refractory to usual standard medical therapy, such surgery may be considered reconstructive. 
 
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 panniculectomy services. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee has had significant weight loss and has a grade I 
pannus. The record provided does not document intertrigo unresponsive to conservative treatment or the 
presence of functional limitation. The elements of the coverage criteria are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of panniculectomy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve panniculectomy services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve segmental pneumatic appliance for use with pneumatic 
compressor, full leg (CPT code E0667) and pneumatic compressor, segmental home model with calibrated 
gradient pressure (E0652).  
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says Medicare requirements are not met because your swelling does not involve the trunk. 
The Plan states there's no mention from the provider that you had trunk or abdomen swelling. The Plan states 
there is no documentation that you failed a four-week trial of the basic leg pump device. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the DME. Our physician reviewer 
found the degree lymphedema in the records is not of a level of severity to meet the criteria of the device 
requested. The edema is just to the knees, and you have not failed your current therapy to the degree to make 
this device indicated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve segmental pneumatic appliance for use with pneumatic compressor, full leg (CPT code E0667) 
and pneumatic compressor, segmental home model with calibrated gradient pressure (E0652).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) scan of the cervical 
spine. 
 
You asked the Plan to pre-approve MRI scan services. You say that this procedure is medically necessary. The 
Plan denied your request. The Plan says the requested MRI scan is not medically reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI scan services. Our reviewer says 
that the requested MRI scan is not medically reasonable and necessary. Our physician reviewer found the 
enrollee has multiple sclerosis and had an MRI scan last year. No symptom changes or progression clinically is 
documented in the record. There is no medical need for the requested MRI scan. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MRI scan services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve magnetic resonance imaging (MRI) scan of the cervical spine.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 services are not medically necessary. Our physician reviewer found in this case, the record indicates 
that the enrollee has chronic respiratory failure from chronic obstructive pulmonary disease. The record does 
not indicate that continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) has 
been trialed and failed. 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 average volume-assured pressure support (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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a digital, binaural hearing aid (V5261) provided on May 23, 
2022. 
 
You asked the Plan to pay for a digital, binaural hearing aid (V5261). You say that a Plan representative told 
you that you would get $750 per ear reimbursement. The Plan denied your request. The Plan says you self-
referred to a non-participating provider. The services rendered by the non-participating provider were not 
authorized by the Plan. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan pays for 
hearing aids only when provided by an in-network provider. 
 
We looked at this file, and the Plan's rules. The rules say you may receive hearing services from any network 
hearing aid provider. The record shows you went out-of-network. Based on this information, we decided that 
the Plan's rules for coverage of a digital, binaural hearing aid (V5261) have been met. Therefore, we decided 
that the Plan does not have to pay for a digital, binaural hearing aid (V5261) provided on May 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a skilled nursing facility visit provided on May 26, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for a skilled nursing facility visit. You say that the physician provided medically 
necessary services to the member in good faith. You are requesting reconsideration of the denial and payment 
at the maximum allowed. The Plan denied your request. The Plan says the enrollee must receive care from a 
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 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 a skilled nursing facility visit provided on May 26, 
2022, by an out-of-network (OON) provider.