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

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee is unable to care for herself and requires 
a SNF admission. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 
admission. 
 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 SNF 
care is not medically necessary. Our physician reviewer found that the enrollee does not have daily skilled 
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The 
enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on 
an inpatient basis in a skilled nursing facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is medically reasonable 
and necessary. The Plan denied your request. The Plan says this 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 Vertiflex procedure. 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. More research is needed before coverage can be 
approved. 
 
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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on February 10, 2022. 
 
You asked the Plan to pay for the office visit. You say that this doctor has provided answers to my back issues 
7 other medical doctors were not able to address. You say that it would make sense to pay this claim as it will 
correct the issue and not be a condition that will cause you to see multiple medical doctors. The Plan denied 
your request. The Plan says Medicare doesnt cover visits to naturopathic doctors. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services.  
 
The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have 
to pay for the office visit provided on February 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you have flat feet, fallen arches, and tendinitis. 
The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the neuroablation procedure (64640) 
 
You asked the Plan to pre-approve the neuroablation procedure. You say that you had a total knee replacement 
in 2007 and you found out your knee was put in the right of your leg instead of the middle. The knee is still 
causing you pain and an enormous amount of scar tissue has formed. The Plan denied your request. The Plan 
says medical studies do not show that this procedure works better than others. 
 
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 this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the neuroablation procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the neuroablation procedure (64640)
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ophthalmic biometry (75619) provided on June 24, 2021. 
 
You asked the Plan to pay for the ophthalmic biometry (75619). You say that this service was billed 
appropriately and is supported in the medical record. The Plan denied your request. The Plan says the medical 
records do not support this service as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 75619 is ophthalmic biometry by ultrasound echography, 
A-scan; with intraocular lens power calculation. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the ophthalmic biometry (75619). Our reviewer says that the 
documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found the 
procedure report does not include documentation of ophthalmic biometry report intraocular lens power 
calculation. Therefore, this procedure cannot be verified. 
  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the ophthalmic biometry (75619) have not been met. Therefore, we decided that 
the Plan does not have to pay for the ophthalmic biometry (75619) provided on June 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve knee arthroplasty for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this si medically necessary. The Plan denied your 
request. The Plan says there is no record of physical therapy, severe knee arthritis on imaging, or conservative 
treatment. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that more conservative measures are needed for knee pain. There is no recent trial and failure of physical 
therapy. 
 
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 knee arthroplasty for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LINX Reflux Management System. 
 
You asked the Plan to pre-approve the LINX device. You say that this device is medically necessary. The Plan 
denied your request. The Plan says a review of the current medical literature does not support the long-term 
efficacy and long-term safety of this procedure. 
 
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 LINX device. 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 a 77-year-old woman with a diagnosis of Gastro-esophageal reflux 
disease without esophagitis, as well as a hiatal hernia without obstruction or gangrene. In this case, the long-
term efficacy and safety of the LINX procedure have not been sufficiently established. Further study with 
longer follow-up is needed before coverage can be approved. 
 
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 LINX device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the LINX Reflux Management System.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the incontinence garments (A4520) shower/bath chair 
(E0240) and toilet seat lift (E0172) 
 
You asked the Plan to pre-approve the incontinence garments, shower chair and toilet seat lift. You say that due 
to your weight you need a commode that can carry 450 lbs due to weight and amputation of the leg. Even if it 
is non-covered medical equipment, would like for the Plan to reconsider the decision of denial. The Plan denied 
your request. The Plan says that shower chairs and raised toilet seats are considered hygienic equipment that is 
not primarily medical in nature. Incontinence supplies are not covered because they are hygienic items that are 
non-reusable. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve the incontinence garments (A4520) shower/bath chair 
(E0240) and toilet seat lift (E0172)
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous laminotomy/laminectomy. 
 
You asked the Plan to pre-approve a percutaneous laminotomy/laminectomy. The Plan denied your request. 
The Plan says the requested 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 a percutaneous 
laminotomy/laminectomy. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found that a percutaneous laminectomy 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 a percutaneous laminotomy/laminectomy have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a percutaneous laminotomy/laminectomy.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says IRF care is not medically necessary and the enrollee's care can be provided at at 
alternate 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 while the complexity of the enrollee's nursing, medical and rehabilitation needs may well require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care, the 
documentation notes that the enrollee continues on IV antibiotics, and the repeat blood culture has not been 
addressed. 
 
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you keep going back and forth to the hospital and 
need IRF care for a better quality of life. The Plan denied your request. The Plan says you do not meet criteria 
for IRF 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 your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does 
not require intensive physician and nursing oversight in an IRF. While you may benefit from additional 
multiple therapies, including physical and occupational therapy, the documentation does not reveal that you 
require this therapy on an intensive IRF level or can fully tolerate an intensive level therapy program. 
 
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 a Vertiflex procedure (22869, 22870). 
 
You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met 
because 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 a Vertiflex procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that current evidence-based medical guidelines and peer-reviewed literature do not 
fully support the spinal decompression device procedure over the gold standard of lumbar laminectomy. 
There is a lack of large-volume, long-term, peer-reviewed outcome studies to support the use of the requested 
device for the enrollees medical condition. 
 
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 procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Vertiflex procedure (22869, 22870).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stab phlebectomy services (37765). 
 
You asked the Plan to pre-approve stab phlebectomy services. You say that this procedure is medically 
reasonable and necessary. 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 stab phlebectomy services are subject to the coverage 
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 stab phlebectomy services. Our 
reviewer says that the requested stab phlebectomy services are not medically reasonable and necessary. Our 
physician reviewer found that eh enrollee has a diagnosis of Varicose veins of bilateral lower extremities with 
other complications. Treatment has included previous endovenous laser ablation and compression hose for 6+ 
months. The enrollee now has worsening bulging veins with pain and swelling of both lower extremities. The 
documentation does not support that the enrollee has pain, aching, cramping, burning, itching, and/or swelling 
during activity or after prolonged standing severe enough to impair mobility, recurrent episodes of superficial 
phlebitis, non-healing skin ulceration, bleeding from a varicosity, stasis dermatitis, and/or refractory dependent 
edema. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of stab phlebectomy services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve stab phlebectomy services (37765).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 Power wheelchair with multiple power 
options. 
 
You asked the Plan to pre-approve a Group 3 Power wheelchair with multiple power options. You say that this 
specific chair is medically necessary due to the patient's multiple sclerosis. The Plan denied your request. The 
Plan says the requested chair is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with multiple power 
options is covered if all coverage criteria for a power wheelchair are met and the patient's mobility limitation is 
due to a neurological condition, myopathy, or congenital skeletal deformity. In addition, the patient must either 
require a drive control interface other than a hand or chin-operated joystick, the patient needs a power tilt or 
power recline system for the wheelchair, or the patient uses a ventilator that is attached to the wheelchair. 
 
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 3 Power wheelchair with 
multiple power options. Our reviewer says that the requested chair is not medically necessary. Our physician 
reviewer found the patient does have a Group 3 qualifying diagnosis. The documentation indicates the patient 
has a mobility deficit. For dressing, eating  the patient is independent without mobility assistive equipment 
(MAE). The patient's caregiver cooks meals and the patient reheats meals. For grooming/hygiene, toileting, 
bathing, etc., the patient is independent with current MAE. The patient uses an external catheter in a recliner, 
has a walk-in shower, grab bars, and shower bench. The patient is slow with ambulation with falls and therefore unable to use a cane/walker. He cannot use a manual wheelchair due to poor trunk control, 
weakness. The documentation does not reveal that the patient uses a ventilator attached to a wheelchair. The 
patient is not at high risk for pressure ulcer. The patient uses an external catheter. The patient does not have 
spasticity that needs a special seating system. The  tilt and recline exceeds the patient's medical needs. The 
patient has 5/5 upper extremity strength and does not require the E2311, E2313, and E2377 to control any 
power options on the wheelchair. The requested  Group 3 power wheelchair with multiple power options 
exceeds the patient's medical needs.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Group 3 Power wheelchair with multiple power options have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Group 3 Power wheelchair with multiple 
power options.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture treatment. 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage of the 
requested service. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the requested service have not been met.  
 Specifically, you have not requested the acupuncture treatment for chronic low back pain. Therefore, we 
decided that the Plan does not have to pre-approve acupuncture treatment.