Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat diagnostic block injections. 
 
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 repeat facet injections 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that the enrollee has chronic low back 
pain and sacroilitis that is not associated with radiculopathy or neurogenic claudication. There is no non-facet 
pathology to explain the pain. She had previous radiofrequency ablation (RFA) on April 25, 2022 that resulted in 85 percent pain relief. Given that she has had successful RFA, the repeat diagnostic blocks are 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 pre-approve repeat diagnostic block injections.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee's health is in jeopardy as a major stroke 
has left the enrollee debilitated. You say the enrollee is not able to function on their own, needs assistance with 
daily living, and needs physical and occupational therapy. The Plan denied your request. The Plan says the 
SNF services requested do not meet the requirements for approval. 
 
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 daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Ottobock Kenevo microprocessor knee and advanced 
K3 foot. 
 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 prosthetic additions 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that the submitted records do not 
support the need for a microprofessor knee over a mechanical knee. Your use of a wheelchair and other 
diagnoses do not support that you require a K3 level foot. 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 an Ottobock Kenevo microprocessor knee and advanced K3 foot.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve irreversible electroporation with NanoKnife. 
 
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 that the enrollee has locally-advanced 
pancreatic head carcinoma. There is insufficient literature to support the safety and efficacy of the requested 
services. The services are not reasonable or medically necessary for the enrollee 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 irreversible electroporation with NanoKnife.
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 you are requesting an expedited 
reconsideration for the denial of an LTACH admission based on medical necessity. The Plan denied your 
request. The Plan says the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer 
says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The Plan has approved ongoing care 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 LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ipilimumab and Nivolumab. 
 
You asked the Plan to pre-approve Ipilimumab and Nivolumab. 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 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 Ipilimumab and Nivolumab. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the requested drugs 
are not supported by compendia-based literature or FDA approved.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ipilimumab and Nivolumab have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Ipilimumab and Nivolumab.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spine surgery (20930, 20936, 63052, 22853, 22633, 
63053). 
 
You asked the Plan to pre-approve spine surgery. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
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 spine surgery. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the medical records do not show a recent decline in physical function. They do not show classic 
symptoms of spinal stenosis. There is no instability on imaging documented.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spine surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve spine surgery (20930, 20936, 63052, 22853, 22633, 63053).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on November 8, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the domiciliary or rest home visit. You say that the enrollee is in a nursing home 
and the admission authorization should cover these services. The Plan denied your request. The Plan says 
unauthorized, out-of-network care is not covered. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a domiciliary or rest home visit provided on 
November 8, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that the enrollee has a diagnosis of chronic respiratory failure consequent to chronic obstructive pulmonary disease (COPD). However, the 
provided records indicate the enrollee's most recent arterial blood gas (ABG) shows normal oxygen and carbon 
dioxide levels on room air. The home ventilator is being requested for use in average volume assured pressure 
support (AVAPS) mode with auto-EPAP (AE) which could be provided by a BiPAP device with AVAPS and a 
back-up rate. Provided records do not document trial and failure of a BiPAP device with AVAPS and a back-up 
rate. Medicare does not cover a home ventilator for this indication and the services are 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 pre-approve a home ventilator.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan with 
concurrently acquired computed tomography (CT) scan. 
 
You asked the Plan to pre-approve the PET/CT scan. You say that you are requesting reconsideration for the 
denial of a PET/CT scan. The Plan denied your request. The Plan says the request does not meet Medicare or 
the Plan's coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the PET/CT scan. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has no history of 
malignancy, and there are no indications for this examination in the submitted records. 
 
 
 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 PET/CT scan have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a positron emission tomography (PET) scan with concurrently acquired computed 
tomography (CT) scan.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
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 Botox is covered when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that a gastric emptying study 
demonstrated delayed gastric emptying and Botox is now being requested to test during an upper endoscopy. 
This is not an indication for which Botox is covered by the Medicare rules. The services are 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 pre-approve Botox.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you are unable to walk and cannot do one step and 
pivot. You also say your home is not suitable, you are very afraid of falling and require SNF services. The Plan 
denied your request. The Plan says the criteria for approval of an admission to a SNF have 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 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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound guided radiation therapy (US-IGRT). 
 
You asked the Plan to pre-approve ultrasound guided radiation therapy (US-IGRT). You say that the requested 
ultrasound guided radiation therapy (US-IGRT) is medically necessary. The Plan denied your request. The Plan 
says the requested ultrasound guided radiation therapy (US-IGRT) 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 ultrasound guided radiation therapy 
(US-IGRT). Our reviewer says that the requested ultrasound guided radiation therapy (US-IGRT) is not 
medically necessary. Our physician reviewer found radiation is a standard approach to the treatment of skin 
cancer and is often preferred over surgery when resection is likely to result in unacceptable morbidity or 
cosmesis. Image guided radiotherapy (IGRT) is a means to improve set-up accuracy. IGRT uses daily image guidance to help localize the target so as to minimize normal tissue dosing. Specifically, IGRT allows accuracy 
of treatment delivery, so when generating a planning target margin, the margins can be reduced, and thus allow 
reduction in the volume of normal tissues exposed to radiation. Usually, IGRT is used when critical structures 
are abutting or in close proximity to the target that is being treated to high doses. This situation does not apply 
to this enrollee for which the target lesion can be seen on the skin to assist in daily set up. When treating skin 
cancers, there is generally not a need for IGRT unless deep structures are being treated. 
 
Certainly using ultrasound on a daily basis is not unreasonable to offer but not necessary. The device itself is 
Food and Drug Administration (FDA) approved for use with ultrasound though that in and of itself does not 
mean that daily imaging is necessary but simply that the device was designed to incorporate this functionality. 
Therefore, to bill for daily simple simulations (77280- also requested in this case) and/or IGRT for a 
technology for which need has not been established by published data or supported by consensus guidelines 
(many of which recommend against treatment with these devices in general) is not 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 ultrasound guided radiation therapy (US-IGRT) have not been met. Therefore, 
we decided that the Plan does not have to pre-approve ultrasound guided radiation therapy (US-IGRT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Onetouch Verio test strips, 120 strips per 30 days. 
 
You asked the Plan to pre-approve Onetouch Verio test strips. You say that you disagree with the denial and 
request reconsideration. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
approval of the test strips. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 We looked at the file and Medicare rules. The records show that the limit for test strips is 100 strips per 30 
days. Coverage for the requested quantity requires the provider to attest to giving the enrollee sufficient 
training, the provider attests there is a prescription for the appropriate supplies and frequency, or the enrollee is 
treated with insulin. The file does not include any documentation from the enrollees physician documenting 
why she requires this specific brand of test strips. The file does include documentation stating that the enrollee 
is not on insulin. Without this, medical necessity cannot be established. Based on this information, we decided 
that Medicare rules for coverage of Onetouch Verio test strips have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Onetouch Verio test strips, 120 strips per 30 days.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting an expedited reconsideration 
stating the enrollee is an excellent candidate for acute inpatient rehabilitation. The Plan denied your request. 
The Plan says the IRF services requested do not meet the requirements for approval. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.