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

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says the requested procedure is considered 
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 the Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review indicates that the Intracept procedure targets the basivertebral nerve for 
the relief of chronic vertebrogenic low back pain. Medicare guidelines consider this type of system unproven 
and not medically necessary. Large well-designed studies in the peer review scientific literature comparing 
stand-alone use of Intracept device to established surgical decompression are needed. Published studies do not 
demonstrate any long-term health outcome advantage with the use of Intracept as an alternative to standard 
surgical treatment. In this case, the review has determined that the requested Intracept procedure is not 
medically reasonable or necessary for the enrollee as the efficacy of the procedure is not demonstrated at this time. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says there are no daily skilled needs. 
 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 the admission. Our reviewer says that 
the requested admission is not medically reasonable or necessary. Our physician reviewer found there are no 
identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a 
daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in 
a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a whirlpool bathtub (K1003). 
 
You asked the Plan to pre-approve a whirlpool bathtub. You say that this is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a whirlpool bathtub is covered if the patient is 
homebound and has a (standard) condition for which the whirlpool bath can be expected to provide substantial 
therapeutic benefit justifying its cost. 
 
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 whirlpool bathtub. Our reviewer says 
that the documentation does not support the coverage criteria for the whirlpool bathtub. Our physician reviewer 
found the enrollee does not have a medical condition for which a whirlpool bath can be expected to provide 
substantial therapeutic benefit. The requested equipment does not serve a purpose that is primarily medical in 
nature. 
 
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 whirlpool bathtub have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a whirlpool bathtub (K1003).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 documents do not support the medical necessity for admission to an IRF. While 
the enrollee may benefit from physical therapy (PT) and occupational therapy (OT), the enrollee's rehabilitation 
needs can be met safely and provided at a lower intensity and alternate setting such as in a skilled nursing 
facility (SNF). 
 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 receiver device (K0554). 
 
You asked the Plan to pre-approve a Dexcom G6 receiver. You say that the requested device is medically 
necessary. The Plan denied your request. The Plan says you do not meet prior authorization criteria. 
 
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 perform blood 
glucose testing at least four times per day or use insulin with at least three daily injections. Based on this 
information, we decided that Medicare rules for coverage of a Dexcom G6 receiver have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 receiver device (K0554).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the consultation visit to be provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the services are necessary. The 
Plan denied your request. The Plan says the enrollee's needs can be met in-network; therefore, going out-of-
network is not medically necessary at this time. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the consultation visit to be provided by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you shattered your humerus bone in the right arm 
and fractured vertebrae in your back. You state that you are not able to feed yourself or use your arm for 
anything. You state that go to the gym and are very active, but you are not able to due to your condition. The 
Plan denied your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical 
and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that you 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says physical therapy is needed, and this can be provided at home by home health. 
 
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 do not require the intensity of services provided at an IRF. Specifically, you are 
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.  
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom power wheelchair. 
 
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 covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that these services is being requested for use in a SNF or hospital. Therefore, we decided that the 
Plan does not have to pre-approve a custom power wheelchair.
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 have been in the hospital multiple times over the 
last 3 months, and the pattern will continue if you do not get rehabilitation services. The Plan denied your 
request. The Plan says the IRF services you are requesting 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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that 
you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational 
therapy, there is no documentation of a need for an intensive rehabilitation program. Our physician reviewer 
also found that there is not a reasonable expectation that you 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the home ventilator is necessary. The Plan 
denied your request. The Plan says the request for a home mechanical ventilator set in volume-assured pressure 
support (VAPS) mode with Auto-EPAP (AE) that could be delivered by bilevel positive airway pressure 
(BiPAP) is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our physician 
reviewer found a home ventilator is not medically necessary. You have diagnoses of chronic obstructive 
pulmonary disease (COPD) and pulmonary fibrosis. You were admitted on May 29, 2022, with acute hypoxic 
respiratory failure that appears to be due to exacerbation of COPD and new heart failure. The initial PaCO2 
was normal.  
 Subsequent arterial blood gas (ABGs) shows mild carbon dioxide (CO2) retention that may be compensatory 
because of metabolic alkalosis. There is no ABG done as an outpatient when stable to demonstrate chronic 
CO2 retention. Therefore, you do not meet criteria for respiratory support during sleep. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 power wheelchair with single power option 
and accessories. 
 
You asked the Plan to pre-approve a group 2 power wheelchair with single power option. You say that this 
power wheelchair is medically necessary. The Plan denied your request. The Plan says the criteria for coverage 
for the requested group 2 power wheelchair have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a group 2 power wheelchair with single power option 
is subject to the criteria listed 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 a group 2 power wheelchair with single 
power option. Our reviewer says that the requested group 2 power wheelchair with single power option is not 
medically reasonable and necessary. Our physician reviewer found based on the medical records provided there 
is no documentation that the enrollee satisfies the coverage criteria for the power tilt seating system. Provided 
records do not support that the enrollee is high risk for development of pressure ulcers and is unable to perform 
a functional weight shift, requires intermittent bladder catheterization or has increased muscle tone or 
spasticity. An office visit on April 7 reports normal gait and normal strength and normal sensory exam. As the 
enrollee does not meet criteria for the power tilt or power recline seating system, she does not meet criteria for 
the single power option. Therefore, the base wheelchair and the associated accessories will not be covered at 
this time. 
 
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 group 2 power wheelchair with single power option have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a group 2 power wheelchair with single 
power option and accessories.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve single photon emission computed tomography (SPECT) 
(78803). 
 
You asked the Plan to pre-approve SPECT. You say that the enrollee needs this service. The Plan denied your 
request. The Plan says the requested service 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 SPECT. Our reviewer says that the 
requested SPECT is not medically necessary. Our physician reviewer found provider has not ordered a SPECT 
scan for an indication for which the applicable NCD supports provision of this service. The reviewer found that 
the enrollees diagnosis is a diagnosis largely (if not exclusively) made on the basis of clinical findings/factors.  
A DaT Scan is only generally utilized to differentiated between Parkinsons disease (PD) and essential tremor. 
Since a diagnosis of PD has already been made, there is not a need to perform any further testing at this time. 
As such the request would not be reasonable and 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 SPECT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve single photon emission computed tomography (SPECT) (78803).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hyaluronan or derivative, Synvisc or Synvisc-One, for 
intra-articular injection, 1 mg (CPT J7325). 
 
You asked the Plan to pre-approve a hyaluronan or derivative, Synvisc or Synvisc-One, for intra-articular 
injection, 1 mg. The Plan denied your request. The Plan says the injection does not meet the Medicare LCD 
coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 hyaluronan or derivative, Synvisc or 
Synvisc-One, for intra-articular injection, 1 mg. Our reviewer says that a hyaluronan or derivative, Synvisc or 
Synvisc-One, for intra-articular injection, 1 mg is not medically necessary. Our physician reviewer found that 
there is no documentation of conservative therapy. The request 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 a hyaluronan or derivative, Synvisc or Synvisc-One, for intra-articular injection, 
1 mg have not been met. Therefore, we decided that the Plan does not have to pre-approve a hyaluronan or 
derivative, Synvisc or Synvisc-One, for intra-articular injection, 1 mg (CPT J7325).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve ablation of malignant prostate tissue with high-intensity focused 
ultrasound (HIFU) for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the Gleason grade is not more than 4. 
 
The Plan must follow Medicare rules. Medicare rules say that high intensity focused ultrasound (HIFU) is 
covered when all of the applicable coverage 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 the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found ablation of malignant prostate tissue with high-intensity focused ultrasound (HIFU) is medically 
necessary. All of the coverage criteria have been met. The enrollee has prostate cancer and was treated with 
radiation therapy in 2017. The prostate specific antigen (PSA) was elevated recently at 7.86 ng/ml. The 
prostate-specific membrane antigen (PSMA) scan shows uptake in the entire prostate gland but no metastasis. 
The biopsy shows Gleason's grade 4+4 adenocarcinoma (grade group 4). 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve ablation of malignant prostate tissue with high-intensity focused ultrasound (HIFU) for the enrollee.  
 
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.