Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device and leg sleeves 
(E0652, E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and leg sleeves. You say that the enrollee 
was not able to complete the trial with the basic pump due to pain over the foot therefore the requested 
pneumatic compression device pump was then tried, and the equipment did not cause the enrollee any pain. 
The Plan denied your request. The Plan says the requested equipment is not medically necessary because there 
is no indication of lymphedema extending to the trunk, abdomen, or chest and there is no documentation that a 
device without calibrated segmental pressure failed. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
and leg sleeves (E0652, E0667).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections at T11-T12 and T12-L1. 
 
You asked the Plan to pre-approve the requested facet joint injections. You say that this treatment is medically 
necessary. The Plan denied your request. The Plan says LCD criteria have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are covered for moderate to 
severe pain which has persisted despite conservative treatments when there is no non-facet joint pathology 
which could explain the pain symptoms. 
 
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 facet joint injections. Our 
reviewer says that the requested injections do not meet Medicare coverage criteria.  Our physician reviewer found the enrollee is a 66-year-old female with a history of chronic thoracic/lumbar 
back pain with radiculopathy to right lower extremity.  The enrollee had a fall in December 2021 with onset of 
lumbar back pain with right lower extremity pain that is intermittent and made worse withstanding and 
walking. She had an epidural steroid injection on September 1, 2022, which provided 60% relief for only 2-3 
days. There is imaging evidence of compression fracture/burst fracture. As there is a non-facet pathology that 
could explain the pain, the criteria for facet joint injections are not met. 
 
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 facet joint injections have not been met. Therefore, we decided 
that the Plan does not have to pre-approve facet joint injections at T11-T12 and T12-L1.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal fusion surgery. 
 
You asked the Plan to pre-approve spinal fusion surgery. You say that this is medically necessary. The Plan 
denied your request. The Plan says this procedure is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules state that lumbar spinal fusion may be considered medically 
necessary and covered for spondylolisthesis if certain 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 spinal fusion surgery.  Our reviewer says that the enrollee does not meet the Medicare criteria for the requested surgery. Our physician 
reviewer found detailed documentation is not evidence regarding any recent objective examination findings by 
the treating provider to corroborate any radiculopathy. There is no compelling rationale or extenuating 
circumstance noted to support the medical necessity of this request as an exception to guidelines. 
 
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 fusion surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve spinal fusion surgery.
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 you are going to need a lot of rehab. The Plan denied 
your request. The Plan says the enrollee's medical issues can be handled in a skilled nursing facility (SNF). 
 
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 the complexity of your nursing, medical and rehabilitation needs do not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  Your medical status does not require intensive physician and nursing oversight in an IRF. While you may 
benefit from additional multiple therapies, including physical and occupational therapy, the documentation 
does not reveal that you require this therapy on an intensive IRF level. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (ESI) (62323). 
 
You asked the Plan to pre-approve the repeat ESI. You say that the requested injection is medically necessary. 
You say that the enrollee last received a lumbar ESI 11 weeks ago. You also say that the enrollee is not a 
surgical candidate at this time. The Plan denied your request. The Plan says the requested injection is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat epidural steroid injection (ESI) when the first 
injection directly and significantly provided improvement of the condition being treated may be considered 
medically reasonable and necessary when the medical record documents at least 50% of sustained 
improvement in pain relief and/or improvement in function measured from baseline using same scale for at 
least three 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 the repeat ESI. Our reviewer says that 
the requested repeat ESI does not meet the criteria for coverage. Our physician reviewer found the provided 
documentation indicates the enrollee only had 4 weeks of relief from the previous injection. Therefore, the 
reviewer found that the criteria for coverage of a repeat injection have not been met. 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 ESI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat epidural steroid injection (ESI) (62323).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve FreeStyle Lite test strips. 
 
You asked the Plan to pre-approve FreeStyle Lite test strips. You say that you prefer this test strip brand 
because it uses less blood than other test strips. The Plan denied your request. The Plan says the Plan says that 
it was unable to be determined if you meet the criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of FreeStyle Lite test strips have not been met. Therefore, we decided that the Plan does not have to 
pre-approve FreeStyle Lite test strips.
Appeal type: Practitioner Services
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 the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says 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 the procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that in this case, there were/are multiple plausible pathologic sources of significant pain 
generation. The aching and throbbing back pain, pain is exacerbated by bending, along with the diminished 
painful spinal motion (in all directions) and intact neurologic exam were/are all non-specific to any pathologic 
entities. Overall, documentation was/is lacking regarding reasonably detailed and/or evidenced findings 
supportive of the spinal vertebral bodies as being the overwhelming primary generators of the enrollees 
chronic persistent pain. Documentation does not support actual formal surgical ablation of pre-designated 
basivertebral nerves as being medically necessary and/or reasonable at this time. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the requested Intracept intraosseous basivertebral nerve ablation at L2 and L3, in this 
case, is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex interspinous/interlaminar process spacer 
device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says is type of procedure is considered experimental and/or unproven. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that current evidence based medical guideline and peer reviewed literature do not fully support the spinal 
decompression device procedure over the gold standard of lumbar laminectomy. There is a lack of large 
volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees medical 
condition. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the requested Vertiflex Superion interspinous 
device at L2/3 and L3/4 is not medically reasonable or necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex interspinous/interlaminar process spacer device for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 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 Euflexxa. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has osteoarthritis of the knees. The documentation does not support that the enrollee has 
tried and failed Orthovisc OR Supartz FX. The documentation does not support that Orthovisc OR Supartz FX 
would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the enrollee does 
not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the high frequency chest wall oscillation system, 
includes all accessories and supplies, each) (E0483). 
 
You asked the Plan to pre-approve the HFCWOD. You say that the enrollee has had multiple asthma 
exacerbations requiring emergency room visits and hospital admission and as well as GERD and has mobility 
impairment. The Plan denied your request. The Plan says the records do not show that the enrollee has a 
diagnosis that meet medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that high frequency chest wall oscillation devices are 
covered only for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 
 
The record does not show that the enrollee has cystic fibrosis, bronchiectasis, or a covered neuromuscular disease. This means that the enrollee does not have a medical condition for which a high frequency chest wall 
oscillation device can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to 
pre-approve the high frequency chest wall oscillation system, includes all accessories and supplies, each) 
(E0483).
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 you are concerned that the enrollee is not receiving 
his physical therapy as he should be. You also say that the facility the enrollee is at has not given him physical 
therapy services for two weeks. The Plan denied your request. The Plan says the member does not meet the 
Center for Medicare and Medicaid Services medical necessity criteria. The Plan also says that it is feasible that 
to meet member's needs at a lower level of care. 
 
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 have documented skilled nursing needs. Our physician reviewer 
also found that the enrollee appears to be unable to participate in daily skilled therapy. Our physician reviewer 
also says that the enrollee's 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 standard power wheelchair with multiple 
accessories 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 wheelchair components and accessories are not approvable without base wheelchair 
approval. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested wheelchair is not medically reasonable or necessary. Our physician reviewer found that there is no 
documentation that the group 2 standard power wheelchair with multiple power options and power tilt/recline 
at issue in this case meets all Medicare criteria for medically reasonable and necessary for the patient.  Provided records do not support that the patient is high risk for skin breakdown, has a history of pressure 
ulcer(s) or has had skin flap surgery. Records do not document the patient performs bladder self-catheterization 
and is unable to transfer independently or that she has increased muscle tone or spasticity to meet criteria for 
the requested power tilt/recline and the multiple power options and accessories as required by the guidelines. 
 
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 a group 2 standard power wheelchair with multiple accessories for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home oxygen concentrator 12-month rental and 
portable oxygen 12-month rental. 
 
You asked the Plan to pre-approve a home oxygen concentrator 12-month rental and portable oxygen 12-month 
rental. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the 
requested items are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication. 
 
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 oxygen concentrator 12-month 
rental and portable oxygen 12-month rental. Our reviewer says that the requested items are not medically 
necessary. Our physician reviewer found the enrollee has a diagnosis of chronic obstructive pulmonary disease, 
unspecified. It is noted that the physician assistant related on September 9, 2022 that the enrollee is not using 
oxygen anymore. The case file contains a Detailed Written Order for oxygen dated 10/21/2020. The 
documentation does not contain current clinical documentation supporting that coverage criteria for home 
oxygen therapy have been met in this case. Therefore, the enrollee does not meet criteria for the requested 
items. 
 
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 oxygen concentrator 12-month rental and portable oxygen 12-month 
rental have not been met. Therefore, we decided that the Plan does not have to pre-approve a home oxygen 
concentrator 12-month rental and portable oxygen 12-month rental.
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 are appealing with supporting records. The Plan 
denied your request. The Plan says the enrollee's medical needs can be met by daily skilled nursing visits to 
give the enrollee the antibiotic. 
 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 have documented skilled nursing needs. Our physician reviewer 
also found that the enrollee appears to be functioning at/near his baseline. Our physician reviewer also says that 
the enrollee's care needs 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.