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

 
We decided that the Plan has to pre-approve an office visit to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve an office visit. You say that you sustained a head contusion and radial 
fracture from a fall and need a follow up office visit for that radial fracture. The Plan denied your request. The 
Plan says that the services have been requested out-of-network and have not been approved in advance. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide medical records or a clear attempt to obtain medical 
records from the provider. Without medical records, we cannot determine if the out of area services are 
urgently needed or not. Therefore, we decided that the Plan has to pre-approve an office visit to be provided by 
an out-of-network (OON) provider.  
 
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 portable ventilator (E0466). 
 
You asked the Plan to pre-approve a portable ventilator. You say that the requested ventilator is medically 
necessary. The Plan denied your request. The Plan says the requested ventilator does not meet criteria. 
 
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 portable ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee was recently hospitalized 
with pneumonia. There is no documentation of CO2 retention with an ABG, and the normal total CO2 in blood 
makes chronic CO2 retention less likely. There are no pulmonary function tests to assess the severity of COPD. 
The enrollee does not meet criteria for a ventilatory assistance device. 
 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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says IRF care is not medically necessary and your needs can be met at a lower level of 
care such as in a skilled nursing facility, at home with home health services or at home with outpatient therapy. 
 
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 while the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services an IRF would provide. 
 
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 a repeat bilateral medial branch blocks. 
 
You asked the Plan to pre-approve the repeat bilateral medial branch block. You say that the enrollee has a 
diagnosis of lumbar face arthrosis and responded with 80% pain relief from bilateral L4-L5 median branch 
nerve block injection services provided on August 13, 2021. The Plan denied your request. The Plan says the 
records show that the previous median branch blocks provided 50-60% improvement in symptoms. 
 
The Plan follows Medicare rules. Medicare rules say that repeat medical branch blocks are covered for certain 
clinical 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 repeat bilateral medial branch 
block. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has a history of bursitis right hip and a history of chronic low back pain due to lumbar facet arthrosis.  
He is status-post bilateral L4-L5 median branch block (MBB) injection services on August 13, 2021. A 
progress note from July 12, 2022 reported 80% relief of pain. However, other notes in the submitted records 
documented a 50-60% improvement in the enrollee's pain symptoms.  The provider is requesting a repeat/2nd 
bilateral L4-L5 MBB's. Radiofrequency ablation planned to be done if the enrollee responds favorably to the 
2nd MBB injections. As there is contradictory information from the records submitted, it is not possible to 
approve the requested 2nd MBB's. The review has determined that the requested MBB's are 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 repeat bilateral medial branch block have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a repeat bilateral medial branch blocks.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pain management injection to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve pain management injection. You say that the injection is medically 
necessary to help stop your pain until your injury has completely healed. The Plan denied your request. The 
Plan says the provider is out-of-network. 
 
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 pain management injection. We found no exception that would require the Plan 
to pre-approve the pain management injection. The records provided for review do not show that the pain 
management injection was urgent or emergent. 
Therefore, we decided that the Plan does not have to pre-approve the pain management injection to be provided 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that your condition requires foot orthotics. The Plan 
denied your request. The Plan says this item is not a covered benefit for your medical condition. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you suffered a stroke, 
and you need additional transportation to attend your rehabilitation therapy. The Plan denied your request. The 
Plan says you have exhausted the maximum benefit of 12 one-way trips per year. 
 
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 a maximum of 12 trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to a SNF 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 
enrollee meets the Medicare criteria for SNF care. Our physician reviewer found the enrollee does not have 
documented skilled nursing needs, though monitoring of her surgical wound and heart rate are reasonable.  The 
enrollee does have documented skilled therapy needs. The enrollee is walking 50, but with poor technique and 
upper extremity cautions. Ongoing technique and endurance training is reasonable. Daily skilled services are 
required to establish a maintenance program or to prevent deterioration of the enrollees condition. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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 facet joint injections. 
 
You asked the Plan to pre-approve these services. You say that your pain is getting worse and that you have 
numbness in your leg. The Plan denied your request. The Plan says that your records show you do not have an 
absence of non-facet pathology, nor do you have any documentation to show a numerical indicator of the relief 
gained from the first injection in this series. 
 
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 enrollee has had 
epidural steroid injections with success in reducing radicular symptoms and has had previous facet joint 
injections with good effect. There is evidence of spinal stenosis on the imaging reports. However, there is no 
numerical indication of the improvement in pain after the first injection of this series. The requested injections 
are not medically necessary because the records do not show an absence of non-facet pathology, nor any 
documentation to show a numerical indicator of the relief gained from the first injection of the series. 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 facet joint injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve portable oxygen. 
 
You asked the Plan to pre-approve these services. You say that you need the item in order to travel. The Plan 
denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve portable oxygen.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injection services. 
 
You asked the Plan to pre-approve epidural steroid injection services. You say that the medical records 
provided support the need for the requested injection services. The Plan denied your request. The Plan says the 
requested injection services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that repeat epidural steroid injections are covered for 
certain clinical 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 epidural steroid injection services. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has a 
history of Parkinson's disease and severe lumbar degenerative joint disease with lumbar radiculopathy. The 
enrollee had a prior L3-L4 transforaminal epidural steroid injection (TFESI) in January 2022, and did not have 
good pain relief reported (no specific documented percentage of pain relief, documented that it was not 
effective).  The enrollee did not have a documented relief of 50% or more or improvement in activity for at least 3 months 
and no clinical documentation to support that repeat ESI will be a different approach than prior TFESI. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural steroid injection services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve epidural steroid injection services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the brain without 
contrast (70551). 
 
You asked the Plan to pre-approve an MRI. You say that an MRI is medically necessary. The Plan denied your 
request. The Plan says the requested MRI is not medically necessary in this case. The record shows that the 
enrollee has had chronic headaches/migraines for many years. The enrollee has had previous studies over the 
years, and no abnormal findings have been found. It does not appear the cause is neurological in this case. 
 
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 an MRI. Our reviewer says that the 
requested imaging is not medically necessary in this case. Our physician reviewer found the enrollee has a 
longstanding history of headaches and have had at least three previous neuroimaging studies which returned 
unremarkable. According to current practice guidelines, there is no necessity to do neuroimaging in patients 
with headaches consistent with migraine who have a normal neurologic examination, and there are no atypical 
features or red flags present. The enrollee in this case had a non-focal neurological examination. They were not 
noted to have had any significant changes since the time of prior imaging. In as much, performance of an MRI 
would not be consistent with practice guidelines. As such, this request would not be 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 an MRI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve magnetic resonance imaging (MRI) of the brain without contrast (70551).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthopedic footwear, mens shoe, oxford (L3219). 
 
You asked the Plan to pre-approve foot orthotics. You say that you are appealing because these were 
authorized two years ago and at the moment they are broken. The Plan denied your request. The Plan says this 
item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve Orthopedic footwear, mens shoe, 
oxford (L3219).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve shoe lift, elevation, heel and sole, neoprene, (L3310). 
 
You asked the Plan to pre-approve foot orthotics. You say that they are making a brace for your left leg. The 
orthotic technician recommends a heel lift for the right foot to maintain balance and safety. The Plan denied 
your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve shoe lift, elevation, heel and sole, 
neoprene, (L3310).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard, power wheelchair and accessories 
(K0861, E2377, E2313, E2359, E1007, E2311, K0108, E1012, E0955, E1028, E0953, E2607) to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the enrollee has contacted 
several wheelchair companies, and no one would assist him with a wheelchair that was in-network. You also 
say the requested items are medically necessary. The Plan denied your request. The Plan says there are in-
network companies/providers that can provide care for the enrollee. 
 
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 
a group 3 standard, power wheelchair and accessories (K0861, E2377, E2313, E2359, E1007, E2311, K0108, 
E1012, E0955, E1028, E0953, E2607) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an animatronic support pet. 
 
You asked the Plan to pre-approve an animatronic support pet. You say that you would like this item due to 
loneliness. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an animatronic support pet.