Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a neck magnetic resonance angiography (MRA) 
(70547). 
 
You asked the Plan to pre-approve neck MRA. You say that the enrollee has a balance disorder that started 3 
years ago. You say that it is progressive. You say that the enrollee has memory decline. You also say that the 
enrollee had visual changes in 2015. The Plan denied your request. The Plan says the requested neck MRA is 
not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that MRA is performed on patients with conditions of the 
head and neck for which surgery is anticipated and may be found to be appropriate based on the MRA. 
 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 neck MRA. Our reviewer says that the 
requested neck MRA is not medically necessary. Our physician reviewer found the provided documentation did 
not otherwise demonstrate that the enrollee has a condition of the head or neck for which surgery is anticipated 
and may be found to be appropriate. The reviewer found that the enrollee did not otherwise demonstrate any 
signs or symptoms that localize to the vasculature of the neck. Therefore, the reviewer found that the requested 
neck MRA 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 neck MRA have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a neck magnetic resonance angiography (MRA) (70547).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve LTACH services. You say that LTACH admission is medically necessary. 
The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient care at the current 
hospital and can remain there until ready for discharge to a lower level of care such as in a skilled nursing 
facility. 
 
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 medical record does not indicate that the enrollee requires services that he is 
not currently receiving but that would be available at the LTACH facility. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that unproven and not medically necessary procedures are not covered 
by Medicare due to insufficient evidence of efficacy. 
 
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 Intracept 
procedure is experimental. More research is needed to show safety and efficacy. Our physician reviewer found 
that the enrollee's 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 the Intracept procedure for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a third level for a facet joint injection for the enrollee. 
 
You asked the Plan to pre-approve the extra level. You say that this is medically necessary. The Plan denied 
your request. The Plan says no more than two levels can be done during a session. 
 
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 extra level. Our reviewer says that 
the requested third level is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the provider is requesting bilateral 3-level medial branch blocks. The review has 
determined that the enrollee does not have a covered indication for the requested 3-level facet joint blocks. 
 
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 extra level have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a third level for a facet joint injection for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have 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 the requested admission to a SNF does not meet 
criteria. 
 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 
service is not medically necessary. Our physician reviewer found records do not document the need for 
intravenous medications, new tube feeding, ostomy care or daily complex wound care. The enrollee is walking 
household distances with a front-wheeled walker with stand-by assistance and is stand-by assist for transfers. 
Provided records do not document a significant decline in the enrollee's functional status to necessitate daily 
inpatient skilled therapy services. The enrollee does not require the services on an inpatient basis, only in a 
skilled nursing facility setting. Records do not document that services in the home with home health care or in 
a long-term care facility on a part time basis are not 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 skilled nursing facility (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 IRF care is medically necessary. The Plan denied 
your request. The Plan says IRF care is not medically necessary and your ongoing skilled therapy and nursing 
needs can be met at a lower level of care such as in a skilled nursing facility, at home with home health services 
or in a long-term care setting. 
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan. 
 
You asked the Plan to pre-approve Hyalgan. The Plan denied your request. The Plan says the enrollee has not 
tried and failed Monovisc, Orthovisc, Synvisc, and Synvisc One. 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Hyalgan. Our physician reviewer found 
that the enrollee has bilateral knee pain due to osteoarthritis. The Plan requires a trial of Monovisc, Orthovisc, 
Synvisc, and Synvisc One before they will approve the requested drug. In this case, the enrollee has not tried 
and failed the required drugs. There is no documentation provided indicating that the Plans required drugs 
would likely be less effective or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hyalgan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC). 
 
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 a Group 3 PWC is covered when specific criteria 
are met. 
 
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 criteria for coverage are not met. Our physician reviewer found the enrollee has a mobility limitation that 
impairs participating in mobility-related activities of daily living (MRADLs) in the home. She is unable to use 
a cane, walker, or manual wheelchair due to pain, weakness, and lack of coordination. The documentation is 
not clear that the mobility limitation is from the brain injury, but rather from the progressive peripheral 
neuropathy that is not considered a Group 3 diagnosis. The records indicate she can safely use a power 
wheelchair but the requested Group 3 PWC exceeds her medical needs. 
 
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 Group 3 power wheelchair (PWC).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a epidural steroid injection. 
 
You asked the Plan to pre-approve a epidural steroid injection. 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 follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when specific criteria are met. 
 
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 epidural steroid injection. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the physical exam 
was negative for straight leg raising and there is no clear documentation of lumbar radiculopathy. The request 
does not meet the criteria of the LCD and 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 a epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a epidural steroid injection.
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF 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 there is no indication that the member would require skilled rehabilitation in an IRF, 
participating in rehabilitation services fifteen (15) hours a week, under the supervision of a physician with at 
least three (3) visits weekly to regain or maintain her functional status. The member can receive further 
services at a lower 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting admission to LTACH 
because you are not stable and need rehabilitation to regain strength. The Plan denied your request. The Plan 
says the enrollee does not meet all the Medicare guidelines and care can be provided at the current inpatient 
hospital level. 
 
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 he/she is currently receiving care. All medically necessary care is being provided in the 
current acute care setting.  
 
  There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the health plan. The health plan has approved ongoing care in the current acute care 
setting.  
 
The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the thorax; 
without contrast (71250). 
 
You asked the Plan to pre-approve a CT scan of the thorax. You say that the requested CT scan is medically 
necessary. The Plan denied your request. The Plan says the requested CT scan does not meet criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CT scan of the thorax. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found at issue is the medical 
appropriateness and necessity of a chest CT scan in the clinical evaluation of this patient. Clinical guidelines 
for the use of chest CT scan have not been met based on review of the submitted clinical documentation. 
 
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 CT scan of the thorax have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a computed tomography (CT) scan of the thorax; without contrast (71250).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the home ventilator is necessary. The Plan 
denied your request. The Plan says the request for a home mechanical ventilator set in average volume-assured 
pressure support (AVAPS) mode with Auto-EPAP (AE) that could be delivered by bilevel positive airway 
pressure (BiPAP) is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the home ventilator. Our physician 
reviewer found the documentation does not support that the ventilator at issue in this case is medically 
necessary and reasonable for the enrollee, as the documentation does not support that BiPAP with a backup rate 
and AVAPS was tried and failed. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tertiary oncology services. 
 
You asked the Plan to pre-approve the requested services. You say that you need treatment before your cancer 
spreads. The Plan denied your request. The Plan says a higher level of care 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 requested services. Our physician 
reviewer found that you have recurrent head and neck cancer. This diagnosis does not require an advanced 
level of care. Standard oncology services can adequately stage and treat your 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve tertiary oncology services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve a power seat elevation system. You say that the item is necessary. The Plan 
denied your request. The Plan says the item is not primarily in medical in nature. Therefore, coverage criteria 
has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that A power seat elevation feature (E2300) and 
power standing feature (E2301) are non-covered because they are not primarily medical in nature. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a power seat elevation system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power seat elevation system (E2300).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Percutaneous implantation of neurostimulator electrode 
array, epidural (63650). 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that your records show that this treatment is not being used as a late or 
last resort due to the lack of documentation of imaging and other pain procedures in your records. 
 
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 documentation 
does not reveal that the stimulator implant is being used as a last resort. There is no evidence that you have 
tried injections of any sort in the spine or that these injections are determined to be unsuitable or 
contraindicated for you. There is no evidence of objective lumbar imaging. 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 Percutaneous implantation of neurostimulator electrode array, epidural (63650).