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

 
We decided that the Plan does not have to pre-approve a total knee replacement from an out-of-network 
provider. 
 
You asked the Plan to pre-approve these services. You say that the enrollee would like to proceed with surgery. 
The Plan denied your request. The Plan says the services are available from network providers. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a total knee replacement from an out-of-network provider.
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 this is medically necessary. The Plan 
denied your request. The Plan says an LTACH admission is not medically necessary, and the enrollee can 
safely receive the care they need in another setting. 
 
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 in this case, the documentation does not support that the enrollee has need for 
complex medical treatment in a LTACH(e.g., multiple and prolonged intravenous therapies, monitoring of 
significantly medically active conditions requiring clinical assessment 6 or more times a day, multiple and 
frequent intervention of at least 6 or more times a day, like ventilator management, cardiac monitoring, 
complex wound care for multiple wounds stages 3 and above, the need for specialized high-tech equipment like 
cardiac monitors, on-site dialysis, or surgical suites). The enrollee does not require services at the LTACH that 
are not available at the acute care hospital or the skilled nursing facility. The requested treatments are not 
medically necessary at the LTACH level of care. The enrollee has improved medically and can receive further care at the current acute care hospital or a lower level of care when deemed appropriate. 
 
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 injection of VIA Disc Allograft. 
 
You asked the Plan to pre-approve injection of VIA Disc Allograft. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested services are 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 injection of VIA Disc Allograft. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has chronic low back pain. The enrollee has tried non-steroidal 
anti-inflammatory drugs, steroids, and opiates. The enrollee has had physical therapy and a home exercise 
program. as well as behavioral therapy. Imaging shows degenerative changes at L2-L3 disc. This procedure is 
considered experimental/ investigational. Therefore, the enrollee does not meet criteria for the requested 
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 injection of VIA Disc Allograft have not been met. Therefore, we decided that 
the Plan does not have to pre-approve injection of VIA Disc Allograft.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the full electric Joerns hospital bed (E1399) and Joerns 
mattress (E1399). 
 
You asked the Plan to pre-approve the hospital bed and mattress. You say that you need the back of your head 
to go up higher. Your current bed does not go high enough, and you request reconsideration. The Plan denied 
your request. The Plan says the documentation submitted does not support the medical necessity of the 
requested hospital bed. The records do not show that the enrollee has failed standard alternative hospital beds 
and mattresses. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve the full electric Joerns 
hospital bed (E1399) and Joerns mattress (E1399).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of Axonics sacral nerve stimulator (SNS) and 
implantation of a new Axonics SNS. 
 
You asked the Plan to pre-approve the procedures. You say that this is medically necessary. The Plan denied 
your request. The Plan says medical necessity is not established to warrant a replacement at this time. 
 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 procedures. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the records submitted show a functioning and intact device. There is no clear 
documentation that urinary symptoms have returned to pre-device levels. 
 
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 procedures have not been met. Therefore, we decided that the Plan does not 
have to pre-approve removal of Axonics sacral nerve stimulator (SNS) and implantation of a new Axonics 
SNS.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the medical records provided support the 
need for the requested LTACH admission. The Plan denied your request. The Plan says based on Medicare 
guidelines and the information we have about the enrollee's condition they do not meet all the requirements for 
admission. 
 
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 appears to be improving and should only require short-term additional 
acute care services that can safely be provided at the current facility until more appropriate for a lower level of 
care soon. The enrollee does not require services at the LTACH that are not available and covered at the current 
facility. 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 the LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tracheostomy mask. 
 
You asked the Plan to pre-approve tracheostomy mask. You say that you need this item to breath. The Plan 
denied your request. The Plan says the requested item is not separately covered. 
 
The Plan must follow Medicare rules. Medicare rules say that tracheostomy masks are not separately 
reimbursed. This item should be included with the rental of the concentrator that was approved by the Plan. 
 
We looked at the file and Medicare rules. Tracheostomy masks are not separately reimbursed. This item should 
be included with the rental of the concentrator that was approved by the Plan. Based on this information, we 
decided that Medicare rules for coverage of tracheostomy mask have not been met. Therefore, we decided that 
the Plan does not have to pre-approve tracheostomy mask.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an iTind procedure. 
 
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 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 services are not medically necessary. Our physician reviewer found the enrollee has benign prostatic 
hyperplasia (BPH) with lower urinary tract symptoms (LUTS) and nocturia. The American Urological 
Association (AUA) revised guideline summary for effective evidence based surgical management of males 
with LUTS secondary to BPH does not include the use of the iTind procedure. The services are considered 
experimental/investigational in nature and 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an iTind procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator, any type, used with non-invasive 
interface, (e.g., mask, chest shell) (E0466). 
 
You asked the Plan to pre-approve the ventilator. You say that the records provided support the necessity of the 
service in dispute. The Plan denied your request. The Plan says this request is not medically necessary. 
 
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 ventilator. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this enrollee was recently hospitalized with hypoglycemia, heart failure with preserved ejection 
fraction, and possible aspiration pneumonia. The enrollee has severe obesity and presumed obesity 
hypoventilation syndrome. There is no diagnosis of severe chronic obstructive pulmonary disease, thoracic restrictive disease, or neuromuscular disease.  Arterial blood gas (ABG) during the hospitalization showed 
compensated carbon dioxide (CO2) retention, which improved with nocturnal bilevel positive airway pressure 
(BiPAP). There is no ABG done while stable as an outpatient to confirm chronic CO2 retention. If the patient 
does have chronic CO2 retention, may benefit from CPAP or BiPAP during sleep as an outpatient. Medicare 
does not cover a home ventilator when used as BiPAP, or for the diagnosis of obesity hypoventilation 
syndrome. A home ventilator is 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 ventilator have been met. Therefore, we decided that the Plan does not have 
to pre-approve a home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell) (E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right diagnostic genicular knee block. 
 
You asked the Plan to pre-approve right diagnostic genicular knee block. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the requested services are 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 right diagnostic genicular knee block. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee has osteoarthritis of the knee. There is insufficient 
literature to support the medical necessity of the requested service for the enrollee's condition. Therefore, the 
enrollee does not meet criteria for the requested 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 right diagnostic genicular knee block have not been met. Therefore, we decided 
that the Plan does not have to pre-approve right diagnostic genicular knee block.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyewear purchased on September 20, 2022. 
 
You asked the Plan to pay for the eyewear. You say that you feel that this should be covered. The Plan denied 
your request. The Plan says your benefit was exhausted for routine eyewear. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers frames/lenses or contacts up to $100 every two years.  
 
We looked at the file and the Plan's rules. The Plan has provided documentation that you used this benefit in 
June 2021. The benefit was exhausted at the time of this purchase. Based on this information, we decided that the Plan's rules for coverage of the eyewear have not been met. Therefore, we decided that the Plan does not 
have to pay for the eyewear purchased on September 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CTA, neck, with contrast material(s), including 
noncontrast images, if performed, and image postprocessing (70498) provided on November 9, 2022. 
 
You asked the Plan to pay for the CTA. You say that the CTA is necessary. The Plan denied your request. The 
Plan says the services denied correctly as they do not meet the clinical requirements to be approved. 
 
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 pay for the CTA. Our physician reviewer found the 
record indicates that you have neck pain. The record does not indicate the presence any cerebrovascular disease 
or stroke. The provided records do not indicate the medical necessity or reasonableness, as defined by 
Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The requested 
service cannot be 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 CTA have not been met. Therefore, we decided that the Plan does not have 
to pay for the CTA, neck, with contrast material(s), including noncontrast images, if performed, and image 
postprocessing (70498) provided on November 9, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve five additional home health speech therapy visits. 
 
You asked the Plan to pre-approve home health services. You say that due to the enrollee's medical complexity, 
five additional speech therapy sessions would be beneficial. 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 after the 36 
speech therapy treatments already provided, records do not support that the complexity of the patient's 
conditions are such that the skills of a professional therapist are required to achieve further improvement in the 
patient's symptoms or functional status. Additional speech therapy treatments 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve five additional home health speech therapy visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the AVISE CTD test panel provided on September 21, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was medically reasonable and 
necessary. The Plan denied your request. The Plan says these tests were 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 pay for the laboratory services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found AVISE testing has not been clinically validated to be more accurate and clinically 
useful compared to the above testing already performed on the patient and wound have added no improvement 
in treatment or outcome. Therefore, without sufficient support provided, this request for AVISE testing will be 
considered 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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the AVISE CTD test panel provided on September 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets Medicare LTACH 
admission criteria and the ongoing medical care warrants this level of care to achieve a safe and sustainable 
discharge. The Plan denied your request. The Plan says based on Medicare guidelines the long term acute care 
hospital services you are requesting do not meet the requirements for approval. 
 
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 appears to be improving on current treatment and should only require 
short-term additional acute care services that can safely be provided at the current facility until more 
appropriate for a lower level of care soon. The enrollee does not require services at the LTACH that are not 
available and covered at the current facility. 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 long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power mobility device (PMD). 
 
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 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 these services. Our reviewer says that 
the criteria for coverage are not met. Our physician reviewer found the records show that you have disease of 
the heart muscle (cardiomyopathy). You are able to walk, use the toilet, and shower with supervision. The 
records do not support that you require a PMD to perform mobility-related activities of daily living 
(MRADLs). The services are therefore not reasonable or medically necessary at this time. 
 
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 power mobility device (PMD).