Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergent stretcher van transportation. 
 
You asked the Plan to pre-approve non-emergent stretcher van transportation. You say that you need to have 
planned transportation from a rehabilitation facility to a cancer institute twice a week. You say that you cannot 
go through the health plan's transportation coordinator for this transport because the rehabilitation facilities will 
only allow their transport to render this service. You state that your copayments for transportation should be 
waived as you are not able to use your transportation benefit. The Plan denied your request. The Plan says 
wheelchair (stretcher) van transportation or ambulette is not covered, except when ordered through the health 
plan's transportation coordinator. 
 
The Plan must follow Medicare rules. Non-emergent transportation such as wheelchair van, tai, stretcher van or 
ambulette is not covered except when ordered through the health plan's transportation coordinator. The 
transport must be scheduled through the health plan's transportation coordinator in order to use this benefit. 
Therefore, since this transportation will be scheduled and provided by a skilled nursing/ rehabilitation facility, 
we cannot provide coverage for non-emergent stretcher van transportation. Therefore, we decided that the Plan 
does not have to pre-approve non-emergent stretcher van transportation.
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 enrollee's needs are too complicated 
to be handled at a skilled nursing facility (SNF.) You say that the enrollee needs to be moved to the next level 
of care, which would be an LTACH. The Plan denied your request. The Plan says the guidelines for coverage 
have not been met. The Plan says that the services the enrollee needs could be provided in another setting. 
 
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 short-term acute care hospital can provide for all of the enrollees present 
inpatient care needs and the enrollee is receiving an appropriate level of care in the present setting. Continued 
care in the short-term acute care hospital is appropriate until the enrollee is stable to transfer to a lower level of 
care such as an inpatient rehabilitation facility, a sub-acute rehabilitation facility or a skilled nursing facility. 
 
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you broke your hip and are only getting physical 
therapy twice a week for 30 minutes each session, since April. You say that this hasn't resulted in enough 
progress to walk independently. You say that IRF care would greatly help your situation and allow you to walk 
without a walker. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not 
been met. The Plan says that the enrollee can safely receive the services needed in a less intensive setting 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted in April 2022, for hip replacement because of a hip fracture after a fall. She was discharged home 
with home health services and has left knee pain and trouble ambulating despite physical therapy.  The 
enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does 
not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that this 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of the Minuteman G3R interspinous device. 
 
You asked the Plan to pre-approve the Minuteman G3R procedure. You say that this is a medically necessary 
procedure which should be approved. The Plan denied your request. The Plan says this procedure remains 
experimental at this time. 
 
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 Minuteman G3R procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this 76-year-old male was being treated for spinal stenosis of the lumbar 
region with neurogenic claudication. He presented with exacerbated low back pain and bilateral lumbar 
radiculopathy. However, current evidence-based medical guidelines and peer-reviewed literature do not fully 
support the interspinous fusion device procedure over the gold standard of lumbar fusion. There is a lack of 
large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees 
medical condition. 
 Food and Drug Administration (FDA) indications for this device include moderate spinal stenosis at no more 
than one level. This enrollee has multiple degrees of spinal stenosis, many not at FDA indicated levels of 
moderate spinal stenosis (including the planned level of implantation L4-L5). FDA contraindications include 
spinal instability, scoliosis, obesity, and osteoporosis (and which have not been adequately addressed in the 
medical records).   
 
There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception to guidelines. Therefore, the requested placement of the Minuteman G3R 
interspinous device at L4-5, in this case, is 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 Minuteman G3R procedure have not been met. Therefore, we decided that 
the Plan does not have to pre-approve placement of the Minuteman G3R interspinous device.
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 your health is only getting worse, and you do not 
want to end up in the hospital again. You say you have been to the emergency room three times since being 
sent home. The Plan denied your request. The Plan says authorization denied because the IRF care is not 
medically necessary, and your needs can be met at a lower level of care such as a skilled nursing facility (SNF). 
 
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 you were admitted for wound infection after spinal surgery and living at home with 
ongoing pain and weakness. Your medical problems are stable, and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical and/or occupational therapy, there 
is no documented need for intensive rehabilitation services. This means that medically necessary care can be 
provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (ESI) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the procedure was denied since the notes do not state that there 
was 50% improvement. 
 
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 requested services are not considered medically reasonable and necessary in this case. The documentation 
does not reveal the evidence of cervical radiculopathy on a physical exam in the proposed area of injection. The 
documentation notes that the patient had an IL CESI for date of service 2/2/22 and there is no evidence of at 
least 50% sustained improvement in pain relief and/or improvement in function measured from baseline using 
the same scale for 3 months. Our physician reviewer found that the enrollee's condition does not meet criteria 
for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an epidural steroid injection (ESI) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve immunoassay for tumor antigen, quantitative; CA 125 
(86304) immunoassay for tumor antigen, quantitative; CA 19-9 (86301) carcinoembryonic antigen (CEA) 
(82378) alpha-fetoprotein (AFP); serum (82105). 
 
You asked the Plan to pre-approve the laboratory services. You say that the requested items/services are not 
considered medically reasonable and necessary in this case. The Plan denied your request. The Plan says the 
requested labs 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 the laboratory services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found These services are not covered for the evaluation of patients with signs or symptoms 
suggestive of malignancy. The service may be ordered at times necessary to assess either the presence of 
recurrent disease or the patient's response to treatment with subsequent treatment cycles. 
 
The review indicates that the enrollee requested testing for cancer during the initial visit with a new provider. 
At that visit, she was noted to have an abnormal skin lesion which was later found to be skin cancer (basal cell 
carcinoma). She has no reported personal or family history of disease associated with the requested testing. Her 
provider noted her "concern for asymptomatic cancer" and stated that she "requested labs for cancer screening." 
The provider informed her that "they are likely NOT covered by Medicare". The review has determined that the 
records do not show that the enrollee meets the medically necessary criteria 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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve immunoassay for tumor antigen, quantitative; CA 125 (86304) immunoassay for 
tumor antigen, quantitative; CA 19-9 (86301) carcinoembryonic antigen (CEA) (82378) alpha-fetoprotein 
(AFP); serum (82105).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve open implantation of a cranial nerve neurostimulator electrode 
array and pulse generator. 
 
You asked the Plan to pre-approve open implantation of a cranial nerve neurostimulator electrode array and 
pulse generator. You say that the services are necessary. The Plan denied your request. The Plan says that 
medical necessity has not been established. Therefore, coverage criteria have not been met. 
 
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 open implantation of a cranial nerve 
neurostimulator electrode array and pulse generator. Our reviewer says that the services are not medically 
necessary. Our physician reviewer found three randomized controlled trials suggest that the vagal nerve 
neurostimulator system is safe and, when paired with rehabilitation therapy, improves upper limb function 
more than rehabilitation alone in most patients with upper-extremity deficits due to stroke. Published results 
suggest that the addition of the vagal nerve neurostimulator system enhances the effect of best practice stroke 
rehabilitation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of open implantation of a cranial nerve neurostimulator electrode array and pulse 
generator have been met. Therefore, we decided that the Plan has to pre-approve open implantation of a cranial 
nerve neurostimulator electrode array and pulse generator.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transthoracic echocardiography (TTE), test, real-time 
with image documentation (2D), includes M-mode recording (93351). 
 
You asked the Plan to pre-approve a stress TTE complete test. You say that the requested stress test is 
medically necessary. The Plan denied your request. The Plan says the requested stress test does not meet 
criteria. 
 
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 stress TTE complete test. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no documentation that the ECG shows an uninterpretable pattern. 
There is no evidence provided that would support the need for stress echocardiography. In summary, there is 
insufficient documentation to support the medical necessity for the requested stress echocardiography in this 
enrollees 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 stress TTE complete test have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a transthoracic echocardiography (TTE), test, real-time with image 
documentation (2D), includes M-mode recording (93351).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT 
code(s): 22869 and 22870). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says a review of the applicable guidelines does not support the use of this device for long 
term relief of back and leg pain. The Plan states there are currently no clinical indications for this technology. 
 
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 services. 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 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex superion device placement surgery (CPT code(s): 22869 and 22870).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Stelara. 
 
You asked the Plan to pre-approve Stelara. You say that, due to concern of possible primary non-responder, it 
would be best to switch to another mechanism of action medication post operatively. You say that the 
requested drug is needed to help prevent recurrence of inflammation, need for steroids, hospitalization or repeat 
surgery. You say that, given the enrollee's advanced age, an IL-12/23 medication is much safer than an anti-
TNF. The Plan denied your request. The Plan says the records do not show that the enrollee has had a trial of one of the preferred drugs, that it hasn't worked, or that there are medical reasons that prevent the enrollee from 
using one of them. 
 
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 Stelara. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the Plan requires a trial of drugs Avsola, 
Entyvio or Remicade before they will approve the requested drug. In this case, the enrollee has not tried and 
failed the required drugs. There is no documentation provided indicating that the Plans required drugs would 
likely be less effective and/or likely have adverse effects for 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 Stelara have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Stelara.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging. 
 
You asked the Plan to pre-approve myocardial perfusion imaging. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve myocardial perfusion imaging. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the record indicates that the enrollee is experiencing anginal equivalents 
and that a nuclear stress test has been ordered. The record indicates that a echocardiogram was performed but 
does not indicate that an exercise stress test was attempted or is contraindicated. The record provided does not 
establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service at 
this time. The elements of the coverage criteria are not satisfied. The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of myocardial perfusion imaging have not been met. Therefore, we decided that 
the Plan does not have to pre-approve myocardial perfusion imaging.