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

We decided that the Plan does not have to pre-approve intraosseous destruction of the basivertebral nerve 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 this procedure is not an accepted standard of medical practice.
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 intraosseous destruction of the basivertebral nerve (Intracept Procedure) is experimental for low back pain. More research is needed to show safety and efficacy.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve intraosseous destruction of the basivertebral nerve for the enrollee
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bioimpedance spectroscopy.
You asked the Plan to pre-approve bioimpedance spectroscopy. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve bioimpedance spectroscopy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has a history of breast cancer and is seeking coverage of a bioimpedance device for the detection of lymphedema. There is no scientific research that documents bioimpedance's long-term effectiveness and improvement on outcomes for the treatment of breast cancer. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bioimpedance spectroscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve bioimpedance spectroscopy.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI of the lumbar spine for the enrollee.
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says there is lack of clinical documentation showing failure to improve after six or more weeks of non-operative treatment.
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 the MRI. Our reviewer says that the requested MRI is not medically reasonable or necessary. Our physician reviewer found that in this case, the record indicates that the enrollee has low back pain and radicular sings of pain and numbness in the right lateral calf and lateral foot that started after knee replacement in May 2021. An electromyography performed October 2021 shows no electrodiagnostic evidence of nerve impairment. The record does not indicate the occurrence of acute injury. The record indicates that the enrollee is currently in therapy. The requested service is not medically necessary and reasonable for the diagnosis and treatment for the enrollee's clinical condition at this time. The elements of the coverage criteria are not satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI of the lumbar spine for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 dental extractions and an evaluation to be performed by an oral surgeon.
You asked the Plan to pre-approve 6 dental extractions and an evaluation to be performed by an oral surgeon. 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 generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan says covered services must be performed by a participating general dentist. We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of 6 dental extractions and an evaluation to be performed by an oral surgeon have not been met. Therefore, we decided that the Plan does not have to pre-approve 6 dental extractions and an evaluation to be performed by an oral surgeon.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Atezolizumab and Cabozantinib combination therapy.

You asked the Plan to pre-approve Atezolizumab and Cabozantinib. You say that this chemotherapy
combination is medically necessary. The Plan denied your request. The Plan says this treatment is
investigational and non-covered.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
drugs if they are medically accepted as safe and effective or appropriate for the particular use.

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 Atezolizumab and Cabozantinib. Our
reviewer says that this therapy combination is not medically necessary. Our physician reviewer found
Atezolizumab and Cabozantinib combination therapy is still in clinical trials and is not yet approved for the
enrollee's condition or supported in the literature.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Atezolizumab and Cabozantinib have not been met. Therefore, we decided that
the Plan does not have to pre-approve Atezolizumab and Cabozantinib combination therapy.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve radiation therapy.
You asked the Plan to pre-approve the radiation therapy treatment. You say that the radiation therapy treatment is medically necessary. The Plan denied your request. The Plan says that coverage criteria has 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 the radiation therapy treatment. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found given National Comprehensive Cancer Network guideline's recognition of hippocampal sparing intensity modulated radiation therapy (IMRT) as a consideration in the setting of prophylactic brain radiation, and at least on randomized trial demonstrating a benefit, the requested radiation therapy is within the standards 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 the radiation therapy treatment have been met. Therefore, we decided that the Plan has to pre-approve radiation therapy.
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: 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 the LTACH services are medically
necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
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 record indicates that the enrollee still has an endotracheal tube present and is
receiving critical care services. The enrollee's needs are met in the current acute care setting.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional transportation trips (A0100).
You asked the Plan to pre-approve the additional trips. You say that the additional trips are medically necessary
to facilitate a surgery. The Plan denied your request. The Plan says the benefit has been exhausted.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers a maximum of 20 trips per year.
We looked at your request, the records in the case file, and the rules. The record shows you have used 19 of 20
trips. Based on this information, we decided that with the use of the last trip, you will exhaust your
transportation benefit. Therefore, we decided that the Plan does not have to pre-approve additional
transportation trips (A0100).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a 12-month rental of a home ventilator,
You asked the Plan to pre-approve a 12-month rental of a home ventilator. 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 ventilators (E0465, E0466, and E0467) are covered under specific 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 a 12-month rental of a home ventilator. Our reviewer says that the services are not medically necessary. Our physician reviewer found there is no evidence that the enrollee has neuromuscular disease or thoracic restrictive disease. There is no evidence that the enrollee has compliantly used standard treatments resulting in treatment failure. As such, the requested home ventilator is not shown to be medically necessary or reasonable. 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 12-month rental of a home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a 12-month rental of a home ventilator
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 services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
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 not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator.
You asked the Plan to pre-approve a portable ventilator. 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 ventilators (E0465, E0466, and E0467) are 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 a portable ventilator. Our reviewer says that the services are not medically necessary. Our physician reviewer found there is no evidence that the enrollee has neuromuscular disease or thoracic restrictive disease. There is no evidence that the enrollee has compliantly used standard treatments resulting in treatment failure. As such, the requested home ventilator is not shown to be medically necessary or reasonable. 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 portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system and electronic connection.
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 covered.
The Plan must follow Medicare rules. The 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, adht electronic connection is also non-covered. We looked at the file and Medicare rules. The services at issue are a power seat elevation feature and electronic connection. These services are not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system and electronic connection.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hymovis.
You asked the Plan to pre-approve Hymovis. 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 viscosupplementation therapy for the knee via intra-articular injections of hyaluronic preparations 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 Hymovis. Our reviewer says that the services are not medically necessary. Our physician reviewer found in this case, there is no documentation of failure of at least three months of conservative therapy or failure of intra-articular corticosteroid injection therapy. The review has determined that the enrollee does not meet the coverage criteria detailed in the LCD. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Hymovis have not been met. Therefore, we decided that the Plan does not have to pre-approve Hymovis.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve therapeutic facet joint injections.
You asked the Plan to pre-approve therapeutic facet joint injections. 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 facet joint procedures are 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 therapeutic facet joint injections. Our
reviewer says that the services are not medically necessary. Our physician reviewer found in this case, you
have not had a previous diagnostic facet joint procedure. The review has determined that you do not meet the
coverage criteria detailed in the LCD.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of therapeutic facet joint injections have not been met. Therefore, we decided that
the Plan does not have to pre-approve therapeutic facet joint injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 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 the enrollee does not require an intensive, complex, multidisciplinary approach to daily therapy. While the enrollee may benefit from physical therapy and occupational therapy, her rehab needs can be safely met in an alternate and low intensity setting such as in a skilled nursing facility or in-home with therapies. 
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility services.

You asked the Plan to pre-approve the skilled nursing facility services. You say that the SNF services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

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 the skilled nursing facility services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary does not require skilled nursing or therapy services on a daily 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 skilled nursing facility services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a height adjustable joystick mount hardware (K0108), expandable controller (E2377), harness upgrade (E2313), and electronic connection between wheelchair controller and two or more power seating system motors (E2311).
You asked the Plan to pre-approve a height adjustable joystick mount hardware, expandable controller, harness upgrade, and electronic connection between wheelchair controller and two or more power seating system motors. 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 wheelchair accessories are 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 height adjustable joystick mount hardware, expandable controller, harness upgrade, and electronic connection between wheelchair controller and two or more power seating system motors. Our reviewer says that the items are not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that you meet the coverage criteria detailed in the Local Coverage Determination for the requested power wheelchair accessories. Records report you have 4+/5 right upper extremity strength, and you are modified independent status with dressing thus indicating you have adequate upper extremity strength and function to operate the wheelchair's power options with their own switches.
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 height adjustable joystick mount hardware, expandable controller, harness upgrade, and electronic connection between wheelchair controller and two or more power seating system motors have not been met. Therefore, we decided that the Plan does not have to pre-approve a height adjustable joystick mount hardware (K0108), expandable controller (E2377), harness upgrade (E2313), and electronic connection between wheelchair controller and two or more power seating system motors (E2311).