Persius/hicric huggingface dataset:
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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 documentation shows that the enrollee has functional impairments however there is 
no documented neurologic weakness or complex functional deficits thus would not require intense therapy or 
interdisciplinary team management. There are no active medical comorbidities or hospital complications 
specified thus the enrollee would not be expected to require inpatient hospitalization with close medical 
monitoring during 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Caris MI Profile. 
 
You asked the Plan to pre-approve the Caris MI Profile. You say that the Caris MI Profile is medically 
necessary. The Plan denied your request. The Plan says the Caris MI Profile 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 the Caris MI Profile. Our reviewer says 
that the Caris MI Profile is not medically necessary. Our physician reviewer found the enrollee has a diagnosis 
of Malignant neoplasm of extrahepatic bile duct, with Secondary malignant neoplasm of large intestine and 
rectum, Secondary malignant neoplasm of liver and intrahepatic bile duct, and Secondary malignant neoplasm 
of other specified sites. The coverage criteria as established by NCD 90.2 have not been met in this case, as the 
laboratory test does not have FDA approval or clearance as a companion in vitro diagnostic, and an FDA-
approved or -cleared indication for use in the enrollee's cancer. 
 
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 Caris MI Profile have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Caris MI Profile.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that if you stay in hospital longer, you won't 
come out, there is a lot of diseases in hospitals, and you need to be in a rehab. You are bed ridden and high risk 
of falls. The Plan denied your request. The Plan says the request is not medically necessary, when you are 
ready to leave the hospital, you can safely receive this care in another setting, such as a Skilled Nursing Facility 
(SNF). 
 
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 There is no evidence that the enrollee requires services that are not currently 
available.  As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in 
transferring the enrollee to the LTACH.  The enrollee can remain at the current ACH until such time no acute 
services are required.  The enrollee can then be transferred/discharged to a lower level of care for any ongoing 
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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Omnipod 5 G6 introductory kit, generation 5, 
(A9274). 
 
You asked the Plan to pre-approve Omnipod delivery system. You say that the enrollee needs this item. The 
Plan denied your request. The Plan says the requested item is not covered under Medicare Part B 
 
The Plan must follow Medicare rules. Medicare rules say that drugs and supplies used with disposable drug 
delivery systems are also non-covered items. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Omnipod delivery system have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an Omnipod 5 G6 introductory kit, generation 5, (A9274).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous radiofrequency ablation (ERFA). 
 
You asked the Plan to pre-approve ERFA treatment. You say that the enrollee needs this procedure. The Plan 
denied your request. The Plan says this request is for treatment of the perforator veins and not for the lesser or 
greater saphenous veins or their tributaries. 
 
The Plan follows Medicare rules. Medicare rules state that ERFA is only covered under certain indications. 
 
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 ERFA treatment. Our reviewer says 
that the enrollee does not meet the Medicare criteria for ERFA. Our physician reviewer found coverage is not 
provided for radiofrequency ablation of perforator veins. There is no documentation of ulcers that would 
warrant consideration of an overturn of this policy based on medical necessity. Apparently, other procedures on 
the same leg have been approved which may provide satisfactory resolution. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ERFA treatment have not been met. Therefore, we decided that the Plan does 
not have to pre-approve endovenous radiofrequency ablation (ERFA).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp (J0881). 
 
You asked the Plan to pre-approve Aranesp. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy requirements have not been met. 
 
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 Aranesp. Our reviewer says that the 
requirements for coverage of Aranesp have not been met. Our physician reviewer found the Plan requires a trial 
of Retacrit or Procrit before they will approve the requested drug. Based on the medical records provided there 
is no indication that the enrollee has tried and failed the required drugs. There is also no indication that the 
required drugs would likely be less effective or 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 Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp (J0881).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with features 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 this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 wheelchair is not medically reasonable or necessary. Our physician reviewer found that this request 
exceeds the enrollee's medical needs. There is no evidence of myopathy, congenital skeletal deformity, or 
neurological condition that would require a group 3 power wheelchair. Ehlers Danlos is a connective tissue 
disorder. The documentation does not reveal that the patient is at high risk for development of a pressure ulcer, utilizes intermittent catheterization for bladder management, or needs a power seating system to manage 
increased tone or spasticity.  
 
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 a group 3 power wheelchair with features for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bioimpedance spectroscopy testing using the 
ImpediMed L-Dex device. 
 
You asked the Plan to pre-approve bioimpedance spectroscopy testing using the ImpediMed L-Dex device. 
You say that the requested bioimpedance spectroscopy testing using the ImpediMed L-Dex device is medically 
necessary. The Plan denied your request. The Plan says the requested bioimpedance spectroscopy testing using 
the ImpediMed L-Dex device 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 bioimpedance spectroscopy testing 
using the ImpediMed L-Dex device. Our reviewer says that the requested bioimpedance spectroscopy testing 
using the ImpediMed L-Dex device is not medically necessary. Our physician reviewer found the record 
indicates that the enrollee has a history of breast cancer and underwent lumpectomy and sentinel node biopsy. 
The record indicates that the enrollee does not have edema. The safety and efficacy of the requested service to 
be used in the enrollee's clinical condition has not been established. The record provided does not establish the 
medical necessity and reasonableness, as defined by Medicare rules, of the requested service. 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 bioimpedance spectroscopy testing using the ImpediMed L-Dex device have 
not been met. Therefore, we decided that the Plan does not have to pre-approve bioimpedance spectroscopy 
testing using the ImpediMed L-Dex device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says your 
request is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that  
 
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 requested services. Our physician 
reviewer found that you have a history of neck pain due to cervical spondylosis. Cervical medial branch blocks 
were performed on two separate occasions, with one day of 50% pain relief following the second injection. In 
this case, the records did not show that you had 80% relief from the previous medial branch blocks. There is no 
documentation provided for the requested 4 levels of ablation. The review has determined that you do not meet 
the criteria for the requested procedure. 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of a spinal distraction device (Vertiflex) 
(22869). 
 
You asked the Plan to pre-approve Vertiflex. You say that the requested service is necessary for the enrollee. 
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 Vertiflex. Our reviewer says that the 
requested Vertiflex procedure not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested procedure is considered experimental. Therefore, the reviewer found that the 
requested Vertiflex procedure is 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 Vertiflex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve insertion of a spinal distraction device (Vertiflex) (22869).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit and treatment to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit and treatment OON provider. You say that the services are 
necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide 
these services. Therefore, coverage criteria have not been met. 
 
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 
an office visit and treatment to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
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 the Intracept procedure is medically 
necessary. The Plan denied your request. The Plan says the Intracept procedure is not medically necessary as it 
is considered 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 Intracept procedure is experimental. More research is needed before this 
procedure can be considered medically necessary and reasonable for the patient's 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 the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553, K0554). 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that the device is medically 
necessary. The Plan denied your request. The Plan says coverage rules have not been met. 
 
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 the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor (K0553, K0554).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve Revita allograft. 
 
You asked the Plan to pre-approve Revita allograft. You say that the requested Revita allograft is medically 
necessary. The Plan denied your request. The Plan says that the requested Revita allograft is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Revita allograft. Our reviewer says that 
the requested Revita allograft is medically necessary. Our physician reviewer found the requested Revita 
allograft is medically necessary to avoid additional surgical procedures. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Revita allograft have been met. Therefore, we decided that the Plan has to pre-
approve Revita allograft.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that there appears to be a medically 
necessary need for the compression socks. The enrollee's legs are swollen and blistering. The Plan denied your 
request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you would like to know if the items can 
be covered. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553). 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose 
monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been 
met. 
 
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 the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor (K0553).