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

 
We decided that the Plan has to pre-approve a nasal/sinus endoscopy with balloon dilation with dilation of the 
sphenoid sinus ostium. 
 
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 that the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has severe allergic rhinitis and 
chronic sinusitis. Treatment with a prednisone taper and budesonide flushes have failed. A sinus computed 
tomography (CT) scan showed moderate maxillary and frontal inflammation bilaterally and mild ethmoid and 
sphenoid edema. When medical treatment does not result in sufficient improvement of sinus symptoms, 
endoscopic sinus surgery, including balloon dilation, is medically reasonable and necessary. The billing of 
sphenoid balloon sinuplasty is appropriate in this case, as balloon sinuplasty is the only procedure planned for 
the sphenoid sinus. More extensive sinus surgery is not planned for the sphenoid sinus. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve a nasal/sinus endoscopy with balloon dilation with dilation of the sphenoid sinus ostium.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with power tilt and 
recline, power elevating leg rests, and a power seat elevator. 
 
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 a Group 3 PWC 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 you have left-sided weakness and 
spasticity. A power mobility evaluation indicates that you require assistance and set up for activities of daily 
living. You are non-ambulatory and have no history of skin breakdown. You are independent for transfers. The 
records do not support that the Group 3 PWC with requested power accessories are 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 Group 3 power wheelchair (PWC) with power tilt and recline, power elevating leg rests, 
and a power seat elevator.
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 a LTACH admission is medically 
necessary. The Plan denied your request. The Plan says the medical criteria for a LTACH admission 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 requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient 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 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: 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 requested LTACH admission is 
medically necessary. The Plan denied your request. The Plan says the requested LTACH admission 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 admission is not medically necessary. Our physician reviewer found the enrollee 
does not require services at the LTACH that are not available at the acute care hospital where he is currently 
receiving care. All medically necessary care is being provided in the current acute care setting. There are no 
services available at the LTACH that the enrollee requires that are not available at the health care setting being 
offered by the health plan. The health plan has approved ongoing care in the current acute care setting. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee. 
 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: 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 a LTACH admission is medically 
necessary. The Plan denied your request. The Plan says the medical criteria for a LTACH admission 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 all medically necessary care is being provided 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: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) care after August 26, 
2022. 
 
You asked the Plan to pre-approve SNF care. You say that the continued admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says that the continued admission to a SNF is not medically 
necessary. 
 
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 
continued SNF care is medically necessary. Our physician reviewer found the documentation shows that not all 
skilled therapy goals have been met and the enrollee is making good progress with daily skilled therapy. The 
enrollee continues to require skilled nursing for assessment and treatment thus continued daily skilled therapy 
on an inpatient basis in a skilled nursing facility is 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve continued 
skilled nursing facility (SNF) care after August 26, 2022.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee is not enrolled in a Medicare-approved clinical study looking at the benefits 
of spacer devices in lumbar spinal stenosis. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the device 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex Superion device for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve venous angioplasty and stent placement (36005, 36011, 
36012, 37252, 37253, 37248, 37249, 37238, 37239, 76937, 75825, and 75820). 
 
You asked the Plan to pre-approve venous angioplasty and stent placement. You say that the requested venous 
angioplasty and stent placement is medically necessary. The Plan denied your request. The Plan says the 
requested venous angioplasty and stent placement 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 venous angioplasty and stent 
placement. Our reviewer says that the requested venous angioplasty and stent placement is not medically 
necessary. Our physician reviewer found it is not possible to attribute leg pain in a patient with hypertension 
and hypercholesterolemia to venous disease without an assessment of arterial perfusion.  Additionally, there is 
no documentation of whole leg swelling and no documentation of iliac vein disease on non-invasive imaging.  
There has not been a concerted effort to treat the enrollee conservatively. The documentation does not support 
the medical necessity of the treatments in question. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of venous angioplasty and stent placement have not been met. Therefore, we 
decided that the Plan does not have to pre-approve venous angioplasty and stent placement (36005, 36011, 
36012, 37252, 37253, 37248, 37249, 37238, 37239, 76937, 75825, and 75820).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat sacroiliac (SI) joint radiofrequency ablation 
(RFA). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show that you have right 
sacroilitis. The requested SI joint RFA is considered experimental/investigational in nature due to the wide 
variation in effectiveness in medical literature. 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 repeat sacroiliac (SI) joint radiofrequency ablation (RFA).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator (SCS). 
 
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 an SCS trial 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 the enrollee has a functioning SCS in 
place. The request is to change the generator/battery to a model compatible with magnetic resonance imaging 
(MRI). The progress notes state she is not currently using the device because it does not provide enough pain 
relief. It is not clear how the requested change would improve her pain relief. There is no documentation that 
the device is not functioning. 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 a spinal cord stimulator (SCS).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Bemer physical vascular device. 
 
You asked the Plan to pre-approve Bemer device. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of authorization for this device is correct, because this 
device is not Food & Drug Administration (FDA) approved and the literature says this device is not superior to 
other treatment options. 
 
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 Bemer device. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the records do not document a benefit of the device over standard treatments for chronic low 
back pain including exercise. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Bemer device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Bemer physical vascular device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator (SCS) trial. 
 
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 a spinal cord stimulator trial can be covered only for 
patients who have undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to 
implantation. Such screening must include a psychological evaluation.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has had six back surgeries 
and chronic pain. She had an SCS that worked well but was removed due to infection. The request is to re-
implant the SCS. A psychological evaluation from June 15, 2022 states she is a poor candidate for the SCS. 
She does not have psychological clearance. The services are therefore not reasonable or medically necessary. 
 
The file does not show that a psychological evaluation has been conducted in conjunction with this request for 
a spinal cord stimulator trial. Therefore, we decided that the Plan does not have to pre-approve a spinal cord 
stimulator (SCS) trial.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the GeneSight Psychotropic testing. 
 
You asked the Plan to pre-approve the GeneSight Psychotropic testing. You say that you would like GeneSight 
testing approved due to medical necessity. The Plan denied your request. The Plan says the request is not 
medically necessary because the records do not document that a specific plan for medication change is being 
considered, and therefore, does not show that the agent(s) are known to have gene-drug interactions. 
 
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 GeneSight Psychotropic testing. 
Our physician reviewer found the testing is not considered reasonable and necessary merely on the basis of a 
patient having a particular diagnosis. Unless the record reflects that the treating clinician has already 
considered non-genetic factors to make a preliminary drug selection, PGx testing is not considered reasonable 
and necessary. The medical records provided do not meet the requirements listed in the LCD for Medicare 
coverage. 
 
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 GeneSight Psychotropic testing have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the GeneSight Psychotropic testing.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of carboplatin and pemetrexed. 
 
You asked the Plan to pre-approve carboplatin and pemetrexed. You say that this is the medically necessary 
treatment of optimal therapeutic benefit. The Plan denied your request. The Plan says the denial of 
authorization for these drugs is correct, because this is not medically necessary. 
 
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 carboplatin and pemetrexed. Our 
reviewer says that the enrollee does not meet the Medicare criteria for carboplatin and pemetrexed. Our 
physician reviewer found the combination of carboplatin and pemetrexed is not Food & Drug Administration 
(FDA) approved for the enrollee's early-stage disease diagnosis. The requested use of these drugs is not 
supported by one of the major drug compendia or by clinical research appearing a Medicare-approved medical 
journal. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of carboplatin and pemetrexed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve use of carboplatin and pemetrexed.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility admission. 
 
You asked the Plan to pre-approve a skilled nursing facility admission. You say that a SNF admission is 
medically necessary. The Plan denied your request. The Plan says the medical criteria for a SNF admission 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 a skilled nursing facility admission. Our 
reviewer says that the requested skilled nursing facility care is not medically necessary. Our physician reviewer 
found the enrollee may require assistance and supervision but has not had a significant decline in function and 
does not require the intensity of therapy services provided in the 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 a skilled nursing facility admission have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a skilled nursing facility admission.