Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the additional PT visits. You say that the enrollee still requires skilled PT 
for training on using the velcro wraps and education on long term maintenance of their progressive 
lymphedema. The Plan denied your request. The Plan says based on the clinical notes received, the swelling in 
the enrollee's legs has improved and they can order leg wraps to manage swelling going forward. The Plan also 
says detail is lacking in the skills that require further treatment of the enrollee's condition by a physical 
therapist, and this request cannot be authorized at this time. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional PT visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found the enrollee has previously been treated with outpatient 
therapies and should be independent with a home exercise program. There is no documentation of a recent 
injury or decline in function. Our reviewer also found that the additional therapy services are not an appropriate 
duration and frequency for treatment of the enrollees medical condition and therefore are 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 additional PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 10 additional physical therapy (PT) visits.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Plaquenil/Hydroxychloroquine Sulfate tablets. 
 
You asked the Plan to pre-approve Plaquenil/Hydroxychloroquine Sulfate tablets. The Plan denied your 
request. The Plan says the enrollee does not meet the Medicare criteria for Plaquenil/Hydroxychloroquine 
Sulfate tablets to be covered under their Part B 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 
Plaquenil/Hydroxychloroquine Sulfate tablets.  
 
Benefits for Plaquenil/Hydroxychloroquine Sulfate tablets 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 an addition, endoskeletal knee-shin system, single axis, 
fluid swing and stance phase control (L5828), an addition, endoskeletal, knee-shin system, stance flexion 
feature (L5845), an addition to endoskeletal knee-shin system, fluid stance extension (L5848), an addition to 
lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance 
phase (L5856), All endoskeletal lower extremity prosthesis, axial rotation unit (L5984) and All lower extremity 
prosthesis, shank foot system with vertical loading pylon  (L5987). 
 
You asked the Plan to pre-approve a microprocessor knee and K3 foot. You say that the enrollee has been 
struggling with an ill-fitting socket, a malfunctioning MPK knee, and a degraded foot. The enrollee is eager 
and motivated to regain his independence and ability to walk safely in the community and at home where he 
maintains his hilly yard, especially with winter approaching. The Plan denied your request. The Plan says the 
request for a microprocessor knee and advanced foot does not meet Medicare criteria as reasonable and 
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 microprocessor knee and K3 foot. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee is using two crutches to ambulate outside the home and uses a 
manual wheelchair at home. The enrollee has a 29-degree hip flexion contraction. This is not consistent with 
K3 ambulation. The documentation also does not support that the enrollee's functional needs require a 
microprocessor knee over a mechanical knee. The criteria have not been met per Local Coverage 
Determination (LCD) L33787 for the K3 level foot and microprocessor knee. 
 
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 microprocessor knee and K3 foot have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an addition, endoskeletal knee-shin system, single axis, fluid swing 
and stance phase control (L5828), an addition, endoskeletal, knee-shin system, stance flexion feature (L5845), 
an addition to endoskeletal knee-shin system, fluid stance extension (L5848), an addition to lower extremity 
prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase (L5856), All 
endoskeletal lower extremity prosthesis, axial rotation unit (L5984) and All lower extremity prosthesis, shank 
foot system with vertical loading pylon  (L5987).
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 Medicare guidelines, the requested IRF services do not meet criteria for 
coverage. 
 
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 complexity of the enrollees nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process 
stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed (22869), insertion of interlaminar/interspinous process stabilization/distraction device, without open 
decompression or fusion, including image guidance when performed, lumbar; second level (22870) and 
interspinous process distraction device (implantable) (C1821). 
 
You asked the Plan to pre-approve a Vertiflex Superion device. You say that the enrollee was previously 
approved for the Vertiflex procedure. It was valid until November 18, 2022. However, the enrollee was not 
able to reschedule this until after the authorization expired. This treatment is considered safe and effective, as 
supported by its clinical benefits to enrollees, continued medical professional adoption, and strong clinical 
evidence with numerous peer-reviewed studies. The Plan denied your request. The Plan says unproven and not 
medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy. A 
Vertiflex Superion device does not meet accepted standards of medical practice. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Vertiflex Superion device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the vertiflex device is experimental and unproven. More research is needed 
due to insufficient evidence of 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 a Vertiflex Superion device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction 
device, without open decompression or fusion, including image guidance when performed (22869), insertion of 
interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, 
including image guidance when performed, lumbar; second level (22870) and interspinous process distraction 
device (implantable) (C1821).
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 requires intensive therapy to return to 
his home post treatment. The Plan denied your request. The Plan says criteria for admission to the IRF setting 
have not been met. The enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of 
care. 
 
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 complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH is medically necessary, and 
the enrollee is medically stable and ready for transfer to the next level of care. The Plan denied your request. 
The Plan says the LTACH services are not medically necessary, and the enrollee's needs can be met in a lower 
level of care such as an acute rehabilitation, skilled nursing facility, nursing facility, outpatient setting, or home 
care. 
 
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 was admitted to the acute care hospital with a cerebrovascular accident 
(CVA), acute respiratory failure, seizures requiring anti-seizure medication, mechanical ventilation support, 
and nutrition management. The enrollee appears to be more stable and with improving respiratory status and 
should only require short-term additional acute care hospital services that can safely be administered at the 
current facility until more appropriate for a lower 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the Intracept procedure and not just 
the device received its initial FDA clearance in 2016. That clearance means the procedure is safe and effective. 
The Plan denied your request. The Plan says there are not enough studies on Intracept to show it is safe and 
effective. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the Intracept procedure (64628).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement rollator. 
 
You asked the Plan to pre-approve the rollator. You say that a new rollator is medically necessary. The Plan 
denied your request. The Plan says a rollator was already provided to the enrollee. Records do not show this 
rollator is damaged beyond repair or otherwise unusable. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a rollator that was provided on September 26, 2022. The requested replacement 
rollator serves the same purpose as the existing one. Therefore, we decided that the Plan does not have to pre-
approve a replacement rollator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/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 an Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the Intracept procedure is experimental. More research is needed to demonstrate 
the procedure's safety and effectiveness. 
 
 
  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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628, 64629).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hemoglobinopathy gene testing. 
 
You asked the Plan to pre-approve hemoglobinopathy gene testing. You say that the requested 
hemoglobinopathy gene testing is medically necessary. The Plan denied your request. The Plan says the 
requested hemoglobinopathy gene testing 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 hemoglobinopathy gene testing. Our 
reviewer says that the requested hemoglobinopathy gene testing is not medically necessary. Our physician 
reviewer found the enrollee is with a diagnosis of mild anemia. Evaluation, including colonoscopy, EGD, 
removal of hemorrhoids, iron panel, Vitamin B12, folate, and kappa/lambda light chain ratio has not found a 
cause for the anemia. On October 6, 2022, the enrollee's hemoglobin was 12.3 (L). The enrollee was feeling 
well, with "mild fatigue which is not unusual." The available documentation does not support that the result of 
the requested testing will directly impact the enrollee's management and is medically reasonable and necessary 
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 hemoglobinopathy gene testing have not been met. Therefore, we decided that 
the Plan does not have to pre-approve hemoglobinopathy gene testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a FreeStyle Libre CGM. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested device. 
 
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 the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
FreeStyle Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
FreeStyle Libre continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that given the previously submitted 
history, physical examination, and the radiologic findings, the Intracept Procedure is medically necessary and 
supported by strong science. The Plan denied your request. The Plan says there are not enough studies on 
Intracept to show it is safe and effective. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the Intracept procedure (64628, 64629).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the radiofrequency ablation (RFA), nerves innervating 
the sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography) (64625). 
 
You asked the Plan to pre-approve the surgical procedure. You say that the information you have provided 
above justifies a right S1-2-3 RFA for the enrollee substantiating that is medically appropriate and necessary. 
The Plan denied your request. The Plan says this procedure is considered experimental, investigational or 
unproven. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the surgical procedure have not been met. Therefore, we decided that the Plan does not have to pre-
approve the radiofrequency ablation (RFA), nerves innervating the sacroiliac joint, with image guidance (ie, 
fluoroscopy or computed tomography) (64625).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
July 21, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service July 21, 2022.