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

 
We decided that the Plan does not have to pre-approve Endovenous ablation therapy of incompetent vein, 
extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated 
(L36475). 
 
You asked the Plan to pre-approve these services. You say that you have tried everything and need to have this 
procedure done. The Plan denied your request. The Plan says that this procedure is covered only for 
symptomatic saphenous veins and their tributaries. 
 
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 case file does 
not contain documentation of a 3-month trial of conservative therapy such as exercise, periodic leg elevation, 
weight loss, compressive therapy, and avoidance of prolonged immobility where appropriate. There is 
insufficient documentation to support these services as medically reasonable and necessary. Our physician 
reviewer found that your 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 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging 
guidance and monitoring, percutaneous, radiofrequency; first vein treated (L36475).
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 member chose to go home with home health, but 
now states he is unable to get around his house safely. You also say that the member wishes to pursue inpatient 
rehabilitation again. The Plan denied your request. The Plan says based on Medicare guidelines, the IRF 
services being requested 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 the member's nursing, medical and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
Our physician reviewer also found that the member does not require treatment by multiple therapies, including 
either physical therapy or occupational therapy, at an intensive rehabilitation therapy program. Our physician 
reviewer also found that the member can receive further services at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the remaining additional hours per day of home health 
aide services 7 days a week. 
 
You asked the Plan to pre-approve the remaining additional hours per day of home health aide services 7 days a 
week. You say that the remaining additional hours per day of home health aide services 7 days a week is 
medically necessary. The Plan denied your request. The Plan says the remaining additional hours per day of 
home health aide services 7 days a week is not medically necessary. The Plan has approved 3 hours a day, 5 
days a week, of home health aide services. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the remaining additional hours per day of home health aide services 7 days a week. Our reviewer says that the remaining additional hours per day of 
home health aide services 7 days a week is not medically necessary. Our physician reviewer found based on the 
documentation provided, the enrollee does not have documented skilled nursing needs. The enrollee does not 
have documented skilled therapy needs. There is no documentation showing that HHA services are required to 
assist in the treatment of illness or injury. The services are being requested on a daily, not intermittent, basis. 
As such, the requested HHA services are not medically necessary, reasonable or coverable. 
 
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 remaining additional hours per day of home health aide services 7 days a 
week have not been met. Therefore, we decided that the Plan does not have to pre-approve the remaining 
additional hours per day of home health aide services 7 days a week.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous spacer placement (22869, 22870). 
 
You asked the Plan to pre-approve the procedure. You say that this procedure is medically necessary. The Plan 
denied your request. The Plan says this procedure is considered investigational and is non-covered. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found interspinous spacer devices are considered experimental. More research is needed to show 
safety and efficacy of this 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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an interspinous spacer placement (22869, 22870).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has been deaf since birth and will have 
full access to interpreters at the IRF to guarantee communication. You also say that the enrollee will have three 
hours plus scheduled therapy to get her back to her baseline. The Plan denied your request. The Plan says based 
on Medicare guidelines, the IRF services being requested 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 the member's nursing, medical and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
Our physician reviewer also found that the member does not require treatment by multiple therapies, including 
either physical therapy or occupational therapy, at an intensive rehabilitation therapy program. Our physician 
reviewer also found that the member can receive further services at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the member has complete the acute care 
course of treatment and is ready for transfer to LTACH, which is the most appropriate level of care for this 
member. The Plan denied your request. The Plan says based on Medicare guidelines, the LTACH services 
being requested do not meet the requirements for approval. 
 
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 member does not require services at the LTACH that are not available at the 
acute care hospital or the skilled nursing facility. Our physician also found that the member continues to 
require care in an acute inpatient setting. Our physician reviewer also found that the enrollee can receive further 
care at the current acute care hospital or a lower level of care when deemed appropriate. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar arthrodesis procedure at L3-L5. 
 
You asked the Plan to pre-approve the spinal surgery. You say that it is felt that this surgical intervention is 
medically indicated at this time. The Plan denied your request. The Plan says the documentation does not 
support the need for 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 spinal surgery. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee suffers from moderate low back pain for which she has received physical therapy. 
The exam reveals hip flexion strength is 4/5 right and 3+/5 left; hip internal rotation and hip external rotation 
4/5 bilaterally; ankle dorsiflexion 4/5 on the left. She is status post lumbar fusion at L3-4 and L4-5 on 10/27/21. 
 
However, dynamic flexion/extension films are not provided in order to potentially assess the amount of 
movement (instability) at the requested surgical level. Detailed documentation is not evident regarding 
potential impending/inevitable temporary intra-operative instability. Additionally, the CT scan dated 4/13/22 demonstrated no evidence of hardware failure and/or pseudoarthrosis. There are limited large-scale, long-term 
references showing the safety and efficacy of the requested surgery in this clinical setting. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested lumbar arthrodesis at L3-4 and 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 spinal surgery have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a lumbar arthrodesis procedure at L3-L5.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve dynamic pituitary testing (80400) to be provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve out-of-network care. You say that these services are medically necessary 
and should be performed by the provider the enrollee already knows well. The Plan denied your request. The 
Plan says that there are in-network providers who are able to provide the necessary care, and it is not medically 
necessary to go out-of-network at this time. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 out-of-network care. Our reviewer says that it is reasonable and necessary for the requested services to be performed by the requested provider. Our 
physician reviewer found that the enrollee has a medical history which includes traumatic brain injury resulting 
in hypopituitarism with central hypothyroidism, secondary hypogonadism, and growth hormone deficiency, as 
well as right hemiparesis, normal pressure hydrocephalus, and a ventriculoperitoneal shunt. The enrollee was 
seen by the out-of-network endocrinologist on August 5, 2022. At that time, it was determined that the enrollee 
will require dynamic pituitary testing. Either a Cortrosyn stimulation test or a glucagon stimulation test were to 
be scheduled after baseline levels were reviewed. The documentation shows that the enrollees provider has a 
detailed comprehensive protocol at the requested facilitys endocrine testing unit which is necessary for the 
enrollees complex condition. Although the Plan notes that there are two in-network providers within a 20-mile 
radius of the enrollees zip code, the Plan has not provided sufficient documentation to support that equivalent 
testing with a detailed comprehensive endocrine protocol can be safely provided in-network at this time. 
Therefore, the requested services with the out-of-network provider are 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 out-of-network care have been met. Therefore, we decided that the Plan has to 
pre-approve dynamic pituitary testing (80400) to be provided by an out-of-network provider.  
 
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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of a neurostimulator 
electrode array for the sacral nerve. 
 
 
 You asked the Plan to pre-approve percutaneous implantation of a neurostimulator electrode array for the sacral 
nerve. You say that the requested procedure is medically necessary for the treatment of incontinence and is 
supported by the records provided. The Plan denied your request. The Plan says the requested procedure is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that before a patient is eligible for permanent 
implantation, he/she must demonstrate a 50% or greater improvement through test stimulation. 
 
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 percutaneous implantation of a 
neurostimulator electrode array for the sacral nerve. Our reviewer says that the criteria for coverage have not 
been met. Our physician reviewer found a successful percutaneous test stimulation, defined as at least 50% 
sustained (more than one week) improvement in symptoms has not been demonstrated. The records show that 
the enrollee did not have any improvement with Interstim in 2015. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous implantation of a neurostimulator electrode array for the sacral 
nerve have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous 
implantation of a neurostimulator electrode array for the sacral nerve.
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 provider says a skilled nursing facility (SNF) is 
not the correct care and you could get an infection. You also say that you are on dialysis and SNF cannot care 
for this. The Plan denied your request. The Plan says based on Medicare guidelines, the IRF services being 
requested 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 the member's nursing, medical and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
Our physician reviewer also found that the member does not require treatment by multiple therapies, including 
either physical therapy or occupational therapy, at an intensive rehabilitation therapy program. Our physician 
reviewer also found that the member can receive further services at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 Baroreflex stimulation device. 
 
You asked the Plan to pre-approve the Baroreflex stimulation device. You say that this service is medically 
necessary. The Plan denied your request. The Plan says this procedure is experimental and is non-covered 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 Baroreflex stimulation device. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found there remains an absence of randomized, blinded clinical studies examining 
long-term clinical outcomes establishing the value of Barostim Neo in patient 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 the Baroreflex stimulation device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Baroreflex stimulation 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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical status does not require intensive physician and nursing oversight in an IRF. The documentation 
indicates the enrollee still requires acute care medical management as he had hypotension on 9/21/22 in therapy 
and is not ready for transfer to a rehabilitation program. While he may benefit from additional multiple 
therapies, including physical and occupational therapy, the documentation does not reveal that he requires or 
can tolerate this therapy on an intensive IRF level. 
 
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.