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

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the right shoulder. 
 
You asked the Plan to pre-approve an MRI. You say that you are requesting reconsideration for the denial of an 
MRI. The Plan denied your request. The Plan says that the MRI requested is not covered based on corporate 
medical policy criteria. 
 
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 
enrollee qualifies for an MRI of the right shoulder. Our physician reviewer found the enrollee has right 
shoulder pain and a positive Hawkins test which is highly sensitive for rotator cuff pathology. The enrollee has 
also had a steroid injection in the subacromial space. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
magnetic resonance imaging (MRI) of the right shoulder.  
 
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 the Vertiflex procedure. 
 
You asked the Plan to pre-approve Vertiflex. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says this is 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 Vertiflex. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertiflex device is experimental, more research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex procedure.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Neupogen. 
 
You asked the Plan to pre-approve Neupogen. 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. 
 
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 Neupogen. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the medical records provided 
there is no indication that the enrollee has tried and failed the required drugs. There is no indication that the 
plan's required drugs would likely be less effective and/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 Neupogen have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Neupogen.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator trial. 
 
You asked the Plan to pre-approve spinal cord stimulator. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the enrollee does not meet criteria for this. 
 The Plan follows Medicare rules. Medicare rules state that spinal cord stimulators are only covered under 
certain circumstances. 
 
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 spinal cord stimulator. Our reviewer 
says that the enrollee does not meet criteria for a spinal cord stimulator. Our physician reviewer found there is 
questionable degree of pain relief documented with the trial. There is no documentation of the surgical consult 
treatment results for back pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spinal cord stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a spinal cord stimulator trial.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. 
 
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 there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Transfer to the LTACH is not medically necessary as it would not 
be clinically advantageous at this time. Completion of treatment at the current facility is 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Sprint peripheral nerve stimulator (PNS). 
 
You asked the Plan to pre-approve Sprint PNS procedure. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says studies have not proven this is helpful for the enrollee. 
 
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 Sprint PNS procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Sprint PNS device is experimental for degenerative neck conditions, more 
research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Sprint PNS procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Sprint peripheral nerve stimulator (PNS).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat radiofrequency ablations (RFAs). 
 
You asked the Plan to pre-approve RFAs. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the record does not show 50% pain relief from the previous RFA. 
 
The Plan follows Medicare rules. Medicare rules state that repeat radiofrequency ablation (RFA) is only 
covered if the enrollee had a minimum of consistent 50% pain improvement or ability to perform movements 
and activities of daily living for at least 6 months.  
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 RFAs. Our reviewer says that the 
enrollee does not meet criteria for this procedure. Our physician reviewer found the rules specifically require 
50% pain relief in order to repeat radiofrequency ablation (RFA). Since this was not achieved, the request is 
not medically reasonable and 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 RFAs have not been met. Therefore, we decided that the Plan does not have to 
pre-approve repeat radiofrequency ablations (RFAs).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the high-intensity focused ultrasound (HIFU) procedure 
rendered on July 29, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that HIFU 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 pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the records show that you have a 
diagnosis of prostate cancer with a baseline prostate specific antigen (PSA) of 5.6 ng/mL. Magnetic resonance 
imaging (MRI) and computed tomography (CT) scans were negative for metastases. The records do not show 
that you had recurrent cancer following radiation treatment; therefore, the criteria for coverage for HIFU were 
not met. The services were therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the high-intensity focused ultrasound (HIFU) procedure rendered on July 29, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve Eustachian tube dilation. 
 
You asked the Plan to pre-approve Eustachian tube dilation. You say that the services are necessary. The Plan 
denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 Eustachian tube dilation. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found Eustachian tube balloon dilation has been shown to be associated with improvement 
in subjective and objective treatment outcome measures. Patients with eustachian tube dysfunction are likely to 
benefit from balloon dilation, particularly those with medication-refractory disease. Randomized controlled 
trials have demonstrated that Eustachian tube balloon dilation provides superior clinical outcomes over medical 
management, and that benefit is maintained over 12 months. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eustachian tube dilation have been met. Therefore, we decided that the Plan has 
to pre-approve Eustachian tube dilation.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 home health physical therapy visits. 
 
You asked the Plan to pre-approve home health services. You say that the enrollee needs guidance from a 
physical therapist to perform appropriate exercises and address problems. The Plan denied your request. The 
Plan says the services are not medically necessary. 
 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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the 
documentation does not support that the enrollee requires additional skilled rehabilitation services to provide 
treatment that is medically necessary. The enrollee has been medically stable without any recent exacerbations 
of chronic medical problems or hospitalizations. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 10 home health physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee needs the ventilator to help 
breathe at night. He is recovering from pneumonia and needs this device. The Plan denied your request. The 
Plan says the request for a home mechanical ventilator set in iVAPS mode with Auto-EPAP (AE) that could be 
delivered by 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 a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
chronic respiratory failure consequent to chronic obstructive pulmonary. Provided records document that the 
home ventilator is being requested for use in intelligent volume assured pressure support (IVAPS) mode with 
auto-titration (AE) which could be provided by a BiPAP device with average volume assured pressure support 
(AVAPS) and a back-up rate.  As stated in the Local Coverage Determination (L33800): "Claims for 
ventilators used to provide CPAP or bi-level CPAP therapy for conditions described in this RAD policy will be 
denied as not reasonable and 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on October 4, 2021. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the claim 
was not received within the 12-month timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the physician's services was not filed until October 7, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on October 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism. 
 
You asked the Plan to pre-approve a seat lift mechanism. The Plan denied your request. The Plan says this is 
not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section 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 seat lift mechanism. Our reviewer 
says that a seat lift mechanism is not medically reasonable and necessary in this case. Our physician reviewer 
found that the records do not document the enrollee has severe arthritis of the hip or a neuromuscular disease. 
Bilateral knee osteoarthritis is documented. Although a certificate of medical necessity reports a need for the 
device, the provided medical records in this case do not document a seat lift is included in the treating 
practitioner's course of treatment. The records do not clearly document a seat lift is likely to: (a) effect improvement in the enrollee's condition; or (b) arrest or retard deterioration in the enrollee's condition. The 
records do not document that the enrollee is completely incapable of standing from a chair in the home. 
Physical therapy notes of January 3, 2023, indicate she is able to transfer sit to stand with stand-by assistance. 
The records also document that the enrollee has the ability to ambulate. 
 
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 seat lift mechanism have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a seat lift mechanism.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy evaluation and treatment to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve physical therapy evaluation and treatment to be provided by an OON 
provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-
network providers that are able to provide these services. Therefore, coverage criteria have not been met. 
 
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 
physical therapy evaluation and treatment to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 
You asked the Plan to pre-approve Evenity. The Plan denied your request. The Plan says the step therapy 
criteria have not been met. 
 
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 Evenity. Our reviewer says that Evenity 
is not medically reasonable and necessary in this case. Our physician reviewer found that there is no indication 
that the enrollee has tried and failed the required drug(s). There is no indication that either zoledronic acid or 
Prolia would likely be less effective and/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 Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF 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 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not qualify for SNF coverage. The enrollee does not have 
documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee 
is not shown to have a significant decline in function or to be able to participate in daily skilled therapy. Daily 
skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollees 
condition. The enrollees care needs, custodial and intermittent, can, as a practical matter, be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.