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

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the genicular nerves. 
 
You asked the Plan to pre-approve the genicular nerve RFA procedure. You say that it is felt that this treatment 
would be beneficial in reducing the enrollee's pain. The Plan denied your request. The Plan says this procedure 
is currently considered experimental and cannot be covered. 
 
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 genicular nerve RFA procedure. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has knee pain due to arthritis. There has been a trial of rest, 
physical therapy, bracing, as well as steroid and viscosupplement injections. Recent diagnostic nerve blocks 
had good effect.  
 
The role of genicular nerve ablation in the treatment of knee osteoarthritis is still being evaluated. It is 
considered experimental/investigational at this time. Therefore, the request is considered not medically 
reasonable or necessary.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the genicular nerve RFA procedure have not been met. Therefore, we decided 
that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the genicular nerves.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS HF system. 
 
You asked the Plan to pre-approve a CardioMEMS HF system. You say that the requested CardioMEMS HF 
system is medically necessary. The Plan denied your request. The Plan says the requested CardioMEMS HF 
system 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 a CardioMEMS HF system. Our 
reviewer says that the requested CardioMEMS HF system is not medically necessary. Our physician reviewer 
found the CardioMEMS device was approved by the FDA in 2014 and consists of a sensor device placed in the 
pulmonary artery to allow measurement of pulmonary artery pressure in the management of patients with 
congestive heart failure (CHF). The clinical study on which FDA approval was based showed improved 
clinical outcomes and decreased hospitalizations in patients in whom the CardioMEMS system was implanted, 
reflecting a patient population with preserved ejection fraction and was somewhat limited in scope. Subsequent 
follow-up studies remain encouraging and suggest an improvement in heart failure symptoms with the use of 
the device. In addition, published expert opinion in the cardiology literature is supportive of the clinical usefulness of CardioMEMS.  Nonetheless, there remains a dearth of randomized, blinded clinical studies 
examining long-term clinical outcomes establishing the value of CardioMEMS in patient management. As a 
result, at this time the CardioMEMS system would not be considered medically appropriate and necessary in 
this enrollee's clinical management. 
 
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 CardioMEMS HF system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a CardioMEMS HF system.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transesophageal echocardiograph (93312). 
 
You asked the Plan to pre-approve the transesophageal echocardiograph. You say that the procedure is 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that coverage for transesophageal echocardiograph is 
considered medically reasonable and necessary when a transthoracic echocardiograph has not established the 
diagnosis, or in a patient where transthoracic echocardiograph is felt not to give adequate information. 
 
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 transesophageal echocardiograph. 
Our reviewer says that the requested procedure is not medically necessary. Our physician reviewer found the 
record indicates that the enrollee requires cardiac clearance for neurosurgical shunt placement. The record does 
not indicate that a transthoracic echocardiogram has been performed or would not be a satisfactory study for 
the enrollee's needs. 
 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 transesophageal echocardiograph have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a transesophageal echocardiograph (93312).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
You asked the Plan to pre-approve Aranesp. You say that Aranesp is medically necessary. The Plan denied 
your request. The Plan says the enrollee has not tried and failed the preferred step therapy drugs. The Plan says 
that there is no indication the preferred drugs would likely be less effective and/or cause adverse effects for the 
enrollee. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Aranesp. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the Plan requires a trial of drug Retcrit 
or Procrit before they will approve the requested drug. The case file does not contain documentation of trial and 
failure of Retcrit or Procrit. The documentation does not support that Retcrit or Procrit would likely be less 
effective, and/or would likely have adverse effects for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says a power 
wheelchair would not make you more independent. 
 
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.  
 
The records do not show that your condition can be improved by a walker, cane or manual wheelchair. Based 
on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power wheelchair.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Euflexxa. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has bilateral knee pain related to osteoarthritis, diagnosis confirmed with imaging studies. 
The enrollee has failed conservative treatment. The documentation does not support that the enrollee has tried 
and failed Orthovisc or Supartz FX. The documentation does not support that Orthovisc or Supartz FX would 
likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the enrollee does not meet 
criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an allograft procedure (20930). 
 
You asked the Plan to pre-approve the allograft procedure. You say that this service is medically necessary. 
The Plan denied your request. The Plan says the requested procedure is experimental and non-covered. 
 
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 allograft procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found Vivigen allograft is experimental. 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 allograft procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an allograft procedure (20930).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional rides. 
 
You asked the Plan to pre-approve additional rides. You say that you want to see if the member can get 
approved for more rides. You also say that it is very important for the member to continue his dialysis 
treatments. The Plan denied your request. The Plan says your request for rides in addition to the 24 one-way 
rides the member is covered for exceeds the benefit limit. 
 
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 Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 24 one-way rider per year to approved locations trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional rides.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abiraterone tablets. 
 
You asked the Plan to pre-approve self-administered drug. You say that you are appealing this denial. The Plan 
denied your request. The Plan says this drug is not covered by Medicare Part B and the Plan does not 
administer the enrollee's Medicare Part D prescription drug benefits. 
 
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 abiraterone tablets.  
 
Benefits for self-administered drug 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 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve these services. You say that you have neuropathy and finger-stick testing 
causes more pain. The Plan denied your request. The Plan says the criteria for coverage are not met. 
 
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 documentation indicates that you do not treat with insulin three 
or more times per day or use an insulin pump. 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 continuous glucose monitor (CGM).
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 enrollee needs IRF care. The Plan denied your 
request. The Plan says based on the clinical information reviewed, the requested IRF services do not meet 
criteria for coverage because the enrollee is unable to participate in at least 3 hours of therapy per day for 5 
days a week. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the enrollee is medically stable and does not need physical medicine and 
rehabilitation physician's close supervision 3 times per week (at a minimum) for the ongoing management of 
any active or acute exacerbations of chronic medical conditions. There are no acute nursing needs identified or 
documented. The enrollee does not need 3 hours a day for 5 days a week of therapies with multidisciplinary 
approach in an IRF. The documentation does not support medical necessity due to lack of medical complexity 
and nursing needs for admission to an IRF. While the enrollee would benefit from physical therapy and 
occupational therapy, the enrollee's needs can be safely provided in an alternate and lower intensity 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous stabilization device. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says this 
device is considered investigational. 
 
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 requested services. Our physician 
reviewer found that the device is experimental. More research is needed to show safety and efficacy. Therefore, 
the request 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an interspinous stabilization device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuous glucose monitor supplies. 
 
You asked the Plan to pre-approve continuous glucose monitor supplies. You say that it hurts to check your 
blood sugars five times a day. The Plan denied your request. The Plan says you do not meet criteria for the 
requested supplies. 
 
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 documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of continuous 
glucose monitor supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve 
continuous glucose monitor supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that this item is necessary for your 
condition. The Plan denied your request. The Plan says this equipment is not covered by Medicare or the Plan. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat. 
 
You asked the Plan to pre-approve a raised toilet seat. You say that this device is necessary for your condition. 
The Plan denied your request. The Plan says this device is not covered under Medicare rules. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic treatment. 
 
You asked the Plan to pre-approve chiropractic treatment. You say that chiropractic treatment is medically 
necessary. The Plan denied your request. The Plan says the requested chiropractic care does not meet the Plan's 
Medical Policy. Throughout the entire care plan, the provider recommends a treatment frequency of 2x/month. 
This would support maintenance care rather than active care. There is also no documentation of any type of re-
examination performed. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
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 chiropractic treatment. Our reviewer 
says that chiropractic treatment is not medically necessary. Our physician reviewer found that once an 
enrollee's clinical status has remained stable for a given condition, as in this case, without the expectation of 
additional objective clinical improvements, further manipulative treatment is considered maintenance therapy 
and is not covered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of chiropractic treatment have not been met. Therefore, we decided that the Plan 
does not have to pre-approve chiropractic treatment.
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 enrollee's chance to return home and maintain 
living at home will be significantly reduced if IRF care is denied. The Plan denied your request. The Plan says 
based on Medicare guidelines, the requested IRF services 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 that the enrollee is medically stable and does not need physical medicine and rehabilitation physician's close supervision 3 times per week (at a minimum) for the ongoing management of 
any active or acute exacerbations of chronic medical conditions. There are no acute nursing needs identified or 
documented. At the current functional level, the enrollee does not need 3 hours a day for 5 days a week of 
therapies with multidisciplinary approach in an IRF. The documentation does not support medical necessity 
due to lack of medical complexity, current functional level, and nursing needs for admission to an IRF. While 
the enrollee would benefit from physical therapy and occupational therapy, the enrollee's needs can be safely 
provided in an alternate and lower intensity 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 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.