Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care provided. 
 
You asked the Plan to pre-approve acute inpatient hospital care. 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 inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care 
would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care provided.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (76705) provided on February 20, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76705 is a column II code to column I code 93976. This claim has 
not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for the services (76705) 
provided on February 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an InSpan device. 
 
You asked the Plan to pre-approve an InSpan device. You say that the requested InSpan device is medically 
necessary. The Plan denied your request. The Plan says the requested InSpan device 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 an InSpan device. Our reviewer says 
that the requested InSpan device is not medically necessary. Our physician reviewer found this is considered an 
experimental/investigational device. Two learned orthopedic societies have declined to endorse the use of 
interspinous or interlaminar spacers. Therefore, the request is deemed 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 an InSpan device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an InSpan device.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Supartz injections (J7321). 
 
You asked the Plan to pre-approve Supartz injections. You say that the enrollee needs hyalgan injections due to 
severe osteoarthritis for the knee joint. You also say that the injection is necessary for the enrollee to be able to 
perform daily activities. The Plan denied your request. The Plan says that the requested injection does not meet 
the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Supartz injections. Our reviewer says 
that Supartz injections meet the criteria for coverage. Our physician reviewer found the provided 
documentation indicates that the enrollee has not responded to simple pharmacologic interventions. The 
reviewer found that the Food and Drug Administration (FDA) has stated that the requested drug is indicated for 
the enrollee's condition. Therefore, the reviewer found that the elements of the coverage criteria are 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 Supartz injections have been met. Therefore, we decided that the Plan has to 
pre-approve Supartz injections (J7321).  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee received oral medications, had 
stable vital signs and was treated for a UTI. The enrollee does not require skilled nursing or therapy services on 
a daily basis. She does not meet severity of illness or intensity of service criteria for an inpatient basis in a 
skilled nursing facility 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 skilled nursing facility (SNF) care.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve basic life support ambulance transportation. 
 
You asked the Plan to pre-approve basic life support ambulance transportation. 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 non-emergency ambulance services 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 basic life support ambulance 
transportation. Our reviewer says that the services are not medically necessary. Our physician reviewer found it 
was noted that the enrollee was able to ambulate with a walker with assistance, use a wheelchair and was not 
bedbound. Therefore, the enrollee did not meet the LCD criteria for this ambulance service as they are not 
bedbound. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of basic life support ambulance transportation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve basic life support ambulance transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intermittent limb compression devices (E0651, E0667). 
 
You asked the Plan to pre-approve intermittent limb compression devices. You say that the requested items are 
a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for 
coverage of the requested items have not been met.  
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. The rules also say that a PCD coded E0650 or E0651 is covered when all of the 
requirements listed in the Medicare rules section have been 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 intermittent limb compression devices. 
Our reviewer says that the requested items are not medically reasonable and necessary in this case. Our 
physician reviewer found that the record documents stage II lymphedema. The record does not document the 
presence of marked hyperkeratosis with hyperplasia and hyperpigmentation, papillomatosis cutis 
lymphostatica, deformity of elephantiasis, or skin breakdown with persisting lymphorrhea. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intermittent limb compression devices have not been met. Therefore, we 
decided that the Plan does not have to pre-approve intermittent limb compression devices (E0651, E0667).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gocovri. 
 
You asked the Plan to pre-approve Gocovri. You say that this is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Gocovri.  
 
 Benefits for Gocovri may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro 2 Motion G orthotic device (L8702). 
 
You asked the Plan to pre-approve a MyoPro orthotic device. The Plan denied your request. The Plan says the 
clinical value and effectiveness of MyoPro orthotic device in the setting of chronic right-sided spasticity and 
weakness has not been demonstrated in the peer-reviewed literature. 
 
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 a MyoPro orthotic device. Our reviewer 
says that a MyoPro orthotic device is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the MyoPro is not known to be effective, based on scientific evidence, professional 
standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in 
widespread use based on scientific evidence. Our reviewer found that there is insufficient evidence in the 
literature that the MyoPro Orthosis will improve the long-term outcomes for you, improve hemiparetic arm 
function, or be safe for long term use. Our physician reviewer also found that there is insufficient evidence in 
the literature that this device will increase participation in bimanual activities. 
 
 
 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 MyoPro orthotic device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro 2 Motion G orthotic device (L8702).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that your father needs help with medical issues and 
is being denied. The Plan denied your request. The Plan says the SNF services you are requesting 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 services. Our reviewer says that 
the enrollee does not meet the Medicare criteria for SNF care. 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 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stage II lnterStim procedure. 
 
You asked the Plan to pre-approve stage II lnterStim procedure. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically 
necessary.  
The Plan follows Medicare rules. Medicare rules say that the enrollee must have had a successful test 
stimulation in order to support subsequent implantation. Before an enrollee is eligible for permanent 
implantation, he/she must demonstrate a 50% or greater improvement through test stimulation. The rules also 
say that improvement is measured through voiding diaries. 
 
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 stage II lnterStim procedure. Our 
reviewer says that the documentation does support that the requested services are medically reasonable and 
necessary. Our physician reviewer found the enrollee has refractory overactive bladder. The enrollee has failed 
prior treatments with medications and Percutaneous Tibial Nerve Stimulation. Stage I Interstim trial from April 
28, 2022 to May 3, 2022 showed greater than 50% symptomatic improvement based upon a voiding diary. This 
means the enrollee meets 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 stage II lnterStim procedure have been met. Therefore, we decided that the Plan 
does not have to pre-approve stage II lnterStim procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion device placement. 
 
You asked the Plan to pre-approve the Vertiflex Superion device placement. You say that the enrollee has 
suffered from this condition for too long and has failed conservative approaches to treatment. You say that you 
recommend this minimally invasive procedure when conservative treatment has failed and as a safer alternative 
to a laminectomy or spinal fusion procedure. The Plan denied your request. The Plan says Medicare does not 
cover experimental and investigational services. 
 
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 Vertiflex Superion device 
placement. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that the Vertiflex device is experimental and more 
research is needed. 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Vertiflex Superion device placement have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Vertiflex Superion device placement.
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 feel the enrollee meets Medicare criteria for 
Acute Inpatient Rehabilitation. You also say that the enrollee will benefit from an Acute Inpatient 
Rehabilitation that cannot be accomplished at a lower level of care. The Plan denied your request. The Plan 
says the enrollee does not meet the Medicare criteria for admission to an IRF. 
 
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 patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer 
found that the patient does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical 
and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. Our 
physician reviewer also found that 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: 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. The Plan denied your request. The Plan says the enrollee does not 
meet the Medicare criteria for admission to an IRF. 
 
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 patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer 
found that the patient does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical 
and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. Our 
physician reviewer also found that 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapy services provided on October 20, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage of services incident to the professional 
services of a physician or non-physician practitioner (NPP) is limited to situations in which there is direct 
supervision of auxiliary personnel.  
 
We looked at the file and Medicare rules. In this case, the services were provided by an occupational therapist 
without direct physician or NPP supervision. 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 pay for the 
therapy services provided on October 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (97010) provided on December 3, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this code is not 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 97010 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 97010 is not separately payable. 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 pay for the services 
(97010) provided on December 3, 2021.