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

 
We decided that the Plan does not have to pre-approve lumbar/sacral facet joint injections. 
 
You asked the Plan to pre-approve lumbar/sacral facet joint injections. You say that lumbar/sacral facet joint 
injections are medically necessary. The Plan denied your request. The Plan says facet joint injections do 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 lumbar/sacral joint injections. Our reviewer says that lumbar/sacral facet joint injections are not medically necessary. Our physician reviewer 
found in this case, there is no documentation of the degree of pain relief and the duration of pain relief from 
previous injections. The review indicates that the requested facet joint injections do not meet the Medicare 
LCD coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lumbar/sacral facet joint injections have not been met. Therefore, we decided 
that the Plan does not have to pre-approve lumbar/sacral facet joint injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal electrical osteogenesis stimulator. 
 
You asked the Plan to pre-approve a spinal electrical osteogenesis stimulator. You say that this item 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 must follow Medicare rules. Medicare rules say that a spinal electrical osteogenesis stimulator 
(E0748) is covered only if any of the following criteria are met: 
 
1. Failed spinal fusion where a minimum of nine months has elapsed since the last surgery, or 
 
2. Following a multilevel spinal fusion surgery (see Appendices section), or 
 
3. Following spinal fusion surgery where there is a history of a previously failed spinal fusion at the same 
site.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a spinal electrical osteogenesis stimulator have not been met. Specifically, nine months have not 
elapsed since the single-level spinal fusion surgery and there is not a history of failed spinal fusion surgery.  
Therefore, we decided that the Plan does not have to pre-approve a spinal electrical osteogenesis stimulator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve a portable ventilator. You say that the enrollee suffers from Chronic 
Respiratory Failure consequent to COPD. The enrollee's condition is life-threatening and would put her at a 
heightened risk of serious harm or morbidity if she does not use a non-invasive ventilator. The Plan denied 
your request. The Plan says the requested ventilator does not meet criteria. 
 
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 a portable ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the record indicates that the enrollee 
has chronic respiratory failure from chronic obstructive pulmonary disease. The provided primary source 
documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. The enrollee could be treated with a BiPAP machine with AVAPS capability. The plan has indicated 
coverage for such a device is available upon request. The elements of the coverage criteria are not satisfied. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dynamic adjustable knee extension / flexion device, 
includes soft interface material (E1810) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a dynamic adjustable knee extension. You say that the enrollee continues to 
have approximately 7-degree flexion contracture and would benefit from an extension. Dynasplint is a 
proprietary brace and is not offered by other companies/orthotist and cant be obtain through an in-network 
option. The enrollee has continued to attend physical therapy and still has some trouble with extension of her 
knee. The Plan denied your request. The Plan says there are other in-network (INN) providers available. The 
expectation is that members exhaust INN resources before seeking OON care. 
 
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 
a dynamic adjustable knee extension / flexion device, includes soft interface material (E1810) to be provided 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bioimpedance spectroscopy (BIS) 
 
You asked the Plan to pre-approve a bioimpedance spectroscopy (BIS). You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the services you are 
requesting do not meet the requirements for approval. 
 
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 bioimpedance spectroscopy (BIS). 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the review has determined that the items/services at issue in this case 
are 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 bioimpedance spectroscopy (BIS) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a bioimpedance spectroscopy (BIS)
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme (Q0138). 
 
You asked the Plan to pre-approve Feraheme. You say that the enrollee has not tried and failed the preferred 
drugs, Infed (iron dextran) and Venofer (iron sucrose). The Plan denied your request. The Plan says the 
preferred drugs are not able to be purchased under buy and bill. You also say that it is not covered under the 
enrollee's pharmacy benefit. 
 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 Feraheme. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has tried and failed the preferred drugs, Infed (iron dextran) and Venofer (iron 
sucrose). The reviewer also found that there is no documentation provided indicating that the plans required 
drugs would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the reviewer 
found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme (Q0138).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued SNF services. 
 
You asked the Plan to pre-approve continued SNF services. You say that you broke your hip and are not able to 
walk on your own yet. You say that you cannot return home. The Plan denied your request. The Plan says the 
enrollee does not meet Medicare criteria for SNF coverage. 
  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 continued SNF services. Our reviewer 
says that you no longer qualify for SNF coverage. Our physician reviewer found that you do not have 
documented skilled nursing needs or skilled therapy needs. Your care needs can be provided 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 continued SNF services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued SNF services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom silicone high-definition passive hand 
prosthesis. 
 
You asked the Plan to pre-approve the requested custom hand prosthesis. You say that you believe that this 
prosthesis is medically necessary for you. The Plan denied your request. The Plan says though the enrollee may 
meet criteria for a functional hand prosthesis, the type of prosthesis requested exceeds the medical need. 
 
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 requested custom hand prosthesis. 
Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the requested prosthesis exceeds the patient's medical need. The documentation 
does not reveal an objective evaluation of the patient's amputated extremity. There is no objective physical 
evaluation of the patient's function with the current prosthesis. The prosthetic evaluation was via telemedicine. 
It appears the prescription for the requested prosthesis was provided 2 months before the actual telemedicine 
consultation. The telemedicine visit does not appear to be video in nature. The medical progress notes by the 
physician do not appear to discuss the need for the specific prosthesis. Furthermore, the appeal letter from July 13 is signed by a nurse but not the patient's treating medical physician provider. The practice manager for the 
prosthetic company writes the appeal on August 25, 2022, which notes that "The justification for the device is 
to create a realistic appearance that will match the patient's own physical characteristics and will allow (her) to 
perform static grasping activities." The documentation does not support a need for the requested device. 
The requested device with features of a realistic appearance exceeds the patient's medical and functional need 
over a standard prosthesis.  
 
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 custom hand prosthesis have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a custom silicone high-definition passive hand prosthesis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prosthetic equipment to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve prosthetic equipment. You say that this equipment is medically necessary. 
The Plan denied your request. The Plan says there are in-network providers available to provide the prosthetic 
equipment you need. 
 
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 prosthetic equipment to be provided by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral radiofrequency ablation for SI joint. 
 
You asked the Plan to pre-approve bilateral radiofrequency ablation for SI joint. You say that bilateral 
radiofrequency ablation for SI joint is medically necessary. The Plan denied your request. The Plan says 
bilateral radiofrequency ablation for SI joint 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 bilateral radiofrequency ablation for SI 
joint. Our reviewer says that bilateral radiofrequency ablation for sacroiliac joint is not considered medically 
reasonable and necessary. Our physician reviewer found that according to the literature, sacral lateral nerve 
branch blocks and/or ablations/neurotomies for the diagnosis and/or treatment of sacroiliac joint mediated pain 
is considered experimental and investigational.  Per CMS NCD, surgically induced lesions of nerve tracts 
which involve destruction of nerve tissue are primarily indicated for controlling the chronic or acute pain 
arising from conditions such as terminal cancer or lumbar degenerative arthritis. Radiofrequency ablation for 
denervation, whether performed using traditional, cooled, or pulsed radiofrequency, is considered 
investigational and therefore, 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 bilateral radiofrequency ablation for SI joint have not been met. Therefore, we 
decided that the Plan does not have to pre-approve bilateral radiofrequency ablation for SI joint.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99212) provided November 29, 2021. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99212 is not supported in the medical record. Specifically, this procedure is included in 
procedure code  96372. Based on this information, we decided that Medicare rules for coverage of the 
physician services have not been met. Therefore, we decided that the Plan does not have to pay for physician 
services (99212) provided November 29, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
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 admission is not medically necessary. 
 
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 these services. Our reviewer says that 
the admission is not medically necessary. Our physician reviewer found you underwent carpal tunnel surgery 
and were discharged to a SNF on August 22, 2022. The physical therapy evaluation dated August 23, 2022 
states you are independent with rolling and standing up and need assistance with ambulation, standing up, and 
bed/chair transfers. You have no skilled nursing needs. You are mobilized at a household level and do not 
require skilled therapy on a daily basis. As a practical matter, you do not require the necessary services on an 
inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a penile prosthesis implant (54405). 
 
You asked the Plan to pre-approve a penile prosthesis implant. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says medical-necessity rules for the 
requested service have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a penile prosthesis implant. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found Medicare says the requested procedure can be approved when it is considered 
medically needed. Before a penile prosthesis implant can be covered, the enrollee must have tried and failed 
other treatments, such as intracavernosal injections, intra-urethral medications by mouth, or vacuum 
constriction device and oral medications. The medical records received do not show that the enrollee has tried 
and failed other treatments. 
 
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 penile prosthesis implant have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a penile prosthesis implant (54405).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided on March 16, 2022. 
 
You asked the Plan to pay for the psychotherapy services. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says the criteria for coverage of the 
psychotherapy services have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy services have not been met. Specifically, the record does not include 
documentation of a consultation or an attempt to consult the enrollee's primary/attending physician as required 
by Medicare rules. Therefore, we decided that the Plan does not have to pay for the psychotherapy services 
provided on March 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a foley catheter with monthly in-home skilled nursing 
for catheter changes (A4344). 
 
You asked the Plan to pre-approve a foley catheter. You say that the catheter is medically necessary due to an 
overactive bladder, urge incontinence and severe stress incontinence. The Plan denied your request. The Plan 
says the requested item does not meet Medicare criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a foley catheter. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee must have acute retention or bladder outlet obstruction, perioperative catheter 
needs for selected surgical procedures, to assist with the healing of sacral or perineal wounds, prolonged 
immobilization, or to provide comfort for end-of-life care. The records do not show that these requirements 
have been met. 
 
 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 foley catheter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a foley catheter with monthly in-home skilled nursing for catheter changes (A4344).