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

We decided that the Plan does not have to pre-approve the echocardiography to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the echocardiography. You say that the echocardiography should be done at the same facility because this is a follow-up to a cardioversion procedure. 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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. The records provided for review do not show that the service at issue is urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve the echocardiography to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 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 enrollee does 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
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an
interdisciplinary approach to rehabilitation care. The enrollee was admitted for hypertensive urgency, chest
pain, and pneumonia. 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, in an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or
occupational therapy, there is no documentation of a need for an intensive rehabilitation program.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter.
You asked the Plan to pre-approve a power scooter. You say that you disagree with the Plan's denial because your bones and feed hurt a lot. The Plan denied your request. The Plan says the requested item is not a covered benefit.
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 patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
In addition, the rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The file shows that your condition can be improved by a walker, cane or manual wheelchair. In addition, the power scooter at issue in this appeal is also being requested for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the exercise equipment (A9300).
You asked the Plan to pre-approve the exercise equipment. You say that you need this item. The Plan denied
your request. The Plan says this equipment is not primarily medical in nature.
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 the exercise equipment (A9300).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the spine surgery (22899) and destruction of intraosseous basivertebral nerve (C9752).

You asked the Plan to pre-approve the spine surgery (22899) and destruction of intraosseous basivertebral nerve (C9752). You say that this procedure fills a treatment gap for patients that do not receive adequate relief from traditional conservative methods. You say that the evidence clearly supports the use of this procedure as primary treatment for chronic low back pain and the procedure should be authorized. The Plan denied your request. The Plan says this 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 spine surgery (22899) and destruction of intraosseous basivertebral nerve (C9752). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the Intracept procedure is experimental. More research is needed to show safety and efficacy. 

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 spine surgery (22899) and destruction of intraosseous basivertebral nerve (C9752) have not been met. Therefore, we decided that the Plan does not have to pre-approve the spine surgery (22899) and destruction of intraosseous basivertebral nerve (C9752).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4 additional acupuncture visits (97810, 97811).
You asked the Plan to pre-approve additional acupuncture visits. You say that the medical records provided
will show proof of medical necessity. The Plan denied your request. The Plan says 8 additional acupuncture
visits have been approved however the remaining 4 visits are denied because they do not meet medical
necessity criteria.
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 Plan's rules apply in this case.
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 additional acupuncture visits. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found in this case, the record indicates that the enrollee has chronic low back pain
and received twelve treatments and another eight have been authorized. The additional treatments are being
provided in a new calendar year. The record indicates that the enrollee has not had twenty visits in 2022. The
elements of the coverage rule are not satisfied and the requested service is not 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 additional acupuncture visits have not been met. Therefore, we decided that the
Plan does not have to pre-approve 4 additional acupuncture visits (97810, 97811).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve anesthesia for pain injections.  You asked the Plan to pre-approve the anesthesia. The Plan denied your request. The Plan says this is 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 the anesthesia. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee does not meet the coverage criteria as initial pain relief must be reported at 75%-100% less. In addition, there was no documentation of ability to perform previously painful maneuvers. This review determined that the pain injections are not medically necessary, therefore, the request for anesthesia/monitored anesthesia care for the procedure is also 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 anesthesia have not been met. Therefore, we decided that the Plan does not have to pre-approve anesthesia for pain injections.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says the records do not support the need for a skilled nursing to make more visits.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 services. Our reviewer says that the
requested services are not medically reasonable or necessary. Our physician reviewer found that in this case,
the documentation doesn't support that the enrollee requires additional skilled nursing services to provide
treatment that is medically necessary. The enrollee does not require skilled nursing services to effectively
provide treatment, care, and/or services in order to improve the enrollee's condition, perform a maintenance
program to maintain the enrollee's condition and/or prevent deterioration. The enrollee has been medically
stable without any recent exacerbations of chronic medical problems or hospitalizations. The requested home
health services are 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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve home health services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve epidural steroid injection.
You asked the Plan to pre-approve epidural steroid injection. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically
necessary.
The Plan follows Medicare rules. Medicare rules say that epidural steroid injections are only covered for
certain 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. Our reviewer
says that the documentation does not support that the requested services are medically reasonable or necessary.
Our physician reviewer found the enrollee has chronic pain after laminectomy. The enrollee underwent a
transforminal epidural steroid injection. The results of which are not clearly documented as to degree and
duration of pain relief. has chronic pain after laminectomy. She underwent a transforminal epidural steroid
injection. The results of which are not clearly documented as to degree and duration of pain relief.
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 have not been met. Therefore, we decided that the
Plan does not have to pre-approve epidural steroid injection.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept Procedure.
You asked the Plan to pre-approve the Intracept Procedure. You say that you would like reconsideration
because the requested procedure is medically necessary. The Plan denied your request. The Plan says this
procedure remains unproven and is 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 the Intracept Procedure. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the record indicates that the enrollee has low back pain without radiculopathy. The
record includes an magnetic resonance imaging report that does not document the presence of Modic type
changes.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the Intracept Procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve the Intracept Procedure.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional OT visits.
You asked the Plan to pre-approve additional OT visits. You say that additional OT is medically necessary. The Plan denied your request. The Plan says additional OT is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve additional OT visits.
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent
deterioration of the enrollee's condition. Our physician reviewer found that the documentation does not support
and is not medically necessary for coverage for additional therapy visits. The requested therapy is not generally
accepted as specific and effective therapy for the patient's condition. The records do not demonstrate that the
unique skills of a professional therapist are required to provide treatment safely and effectively, that the
services can be safely and effectively performed only by a therapist, or for physical therapy and occupational
therapy, by or under the supervision of a therapist. The requested services are not part of a maintenance
program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design
and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of additional OT visits. have not been met. Therefore, we decided that the Plan
does not have to pre-approve additional OT visits.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a parathyroid scan (78070).
You asked the Plan to pre-approve a parathyroid scan. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says that the requested parathyroid scan is not reasonable or medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 a parathyroid scan. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the provided documentation and testing results suggest a very unlikely secondary cause of hypercalcemia as the PTH was elevated along with hypercalcemia which is almost always a sign of primary hyperparathyroidism. Secondary causes would cause a normal or low calcium level in the setting of an elevated PTH. The standard of care is to check a thyroid scan to evaluate for possible adenoma which was done here. Therefore, the thyroid scan will be considered medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a parathyroid scan have been met. Therefore, we decided that the Plan has to pre-approve a parathyroid scan (78070).
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xiidra drops.
You asked the Plan to pre-approve Xiidra drops. You say that you would like the Plan to reconsider their
denial. The Plan denied your request. The Plan says Xiidra drops are not covered under the enrollee's Medicare
Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xiidra drops.
Benefits for Xiidra drops may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Prolastin C.
You asked the Plan to pre-approve Prolastin C. You say that the requested drug is medically necessary. The
Plan denied your request. The Plan says that the requested drug is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and 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 Prolastin C. Our reviewer says that
Prolastin C is medically necessary. Our physician reviewer found the record indicates that the enrollee has a
diagnosis of alpha-1 antitrypsin deficiency. The reviewer found that the enrollee has a heterozygous genotype
and abnormal alpha -1 anti-trypsin level. The Food and Drug Administration (FDA) has stated that the
requested drug is indicated for the enrollee's condition. Therefore, the reviewer found that the elements of the
coverage criteria are 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 Prolastin C have been met. Specifically, the file shows that the requested drug is
indicate for the enrollee's condition. Therefore, we decided that the Plan has to pre-approve Prolastin C.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve extractions to be performed by an oral surgeon.
You asked the Plan to pre-approve extractions. You say that you need to have surgery. You say that you need to have your teeth extracted before you can have surgery. You say that you have been advised that you have 1 year to live unless you have this surgery. You also say that you feel this should be covered under your medical policy. The Plan denied your request. The Plan says you do not have a diagnosis of cancer or broken bones of the face or jaw.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth.
These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve extractions to be performed by an oral surgeon.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Esomepra 40mg tablets.
You asked the Plan to pre-approve Esomepra. You say that Esomepra is medically necessary. The Plan denied
your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Esomepra 40mg tablets.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650).
You asked the Plan to pay for the orthosis. You say that you're requesting an appeal for the lumbar support
brace. The Plan denied your request. The Plan says the requested clinical documentation (signed order) was not
received.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record does not contain a valid physician order, proof of delivery, or relevant medical records which
support medical necessity for the supplies provided in this case. Specifically, the signed physician order was
not received. The record shows that the Plan made several attempts to obtain the necessary documentation
without success. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650).