Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued physical therapy (PT) services 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 the enrollee does not meet the medical necessity criteria for the requested physical 
therapy continuation. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 services. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the additional requested therapy generally is not accepted as 
specific and effective therapy for the patients condition beyond what was approved by the health plan. The 
patient has had prior therapy and the documentation does not reveal that the patient requires the ongoing unique 
skills of a professional therapist to safely and effectively provide treatment, that the services can be safely and 
effectively performed only by a therapist, or, by or under the supervision of a therapist. The requested services 
are not part of a maintenance program, and  the specialized skill, knowledge and judgment of a qualified 
therapist is not required to establish, design and/or deliver a program to maintain the patient's current condition 
or to prevent or slow further deterioration. There has been instruction in an independent home program. 
Ongoing skilled therapy 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued physical therapy (PT) services for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a single-photon emission computerized tomography 
(SPECT) scan (78830). 
 
You asked the Plan to pre-approve a SPECT scan. You say that the SPECT is needed to properly diagnose and 
treat the enrollee. The Plan denied your request. The Plan says the requested SPECT test would not otherwise 
be expected to be beneficial in the evaluation of the enrollee's cognitive issues. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 a SPECT scan. Our reviewer says that a 
SPECT scan is not reasonable and necessary. Our physician reviewer found functional radionuclide imaging, 
such as a SPECT computed tomography (CT), may be complementary to structural imaging, and can be 
considered when structural imaging is inconclusive. Inconclusive structural imaging has not been documented 
for this enrollee. Our reviewer also found that it has not been demonstrated that SPECT imaging is reasonably 
expected to impact the management and outcome of the enrollee in this case. 
 
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 SPECT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a single-photon emission computerized tomography (SPECT) scan (78830).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar medial branch block. 
 
You asked the Plan to pre-approve a lumbar medial branch block. You say that the requested lumbar medial 
branch block is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for the requested lumbar medial branch block. 
 
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 lumbar medial branch block. Our reviewer says that the enrollee does not meet criteria for the requested lumbar medial branch block. Our 
physician reviewer found the records do not show that there have been 3 months of conservative care, with 
documented failure to respond to non-invasive conservative care management (including physical therapy 
and/or an exercise program).  In addition, there is evidence of spinal stenosis changes on the MRI that are 
suggestive of another cause for the enrollee's pain.  The review has determined that the enrollee does not meet 
the coverage criteria detailed in the LCD. 
 
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 lumbar medial branch block have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a lumbar medial branch block.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint arthrodesis. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee does not meet the criteria. 
 
The Plan follows Medicare rules. Medicare rules say that percutaneous stabilization of the sacroiliac joint is 
only covered under certain medical 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 the requested services. Our physician 
reviewer found that documentation does not support that the enrollee has undergone and failed a minimum of 
six months of intensive non-operative treatment, has had imaging studies, has had a positive response to either 
Gaenslen's test or distraction test, or that the enrollee has had at least 75% reduction after 2 separate sacroiliac 
joint injections. In this case, the review has determined that the requested arthrodesis is not medically 
reasonable or necessary 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve sacroiliac joint arthrodesis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device. 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that the requested device is not medically 
reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says this 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 CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that at issue is the medical appropriateness and necessity of implantation of the 
wireless pulmonary artery pressure monitoring system (CardioMEMS) for management of congestive heart 
failure (CHF) in this enrollee. The CardioMEMS device was approved by the Food and Drug Administration in 
2014 and consists of a sensor device placed in the pulmonary artery to allow measurement of pulmonary artery 
pressure in the management of patients with CHF. The clinical study on which Food and Drug Administration 
approval was based showed improved clinical outcomes and decreased hospitalizations in enrollee in whom the 
CardioMEMS system was implanted, reflecting a patient population with preserved ejection fraction and was somewhat limited in scope. Subsequent follow-up studies remain encouraging and suggest an improvement in 
heart failure symptoms with the use of the device. In addition, published expert opinion in the cardiology 
literature is supportive of the clinical usefulness of CardioMEMS. Nonetheless, there remains a dearth of 
randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of 
CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not be 
considered medically appropriate and necessary in this patient's clinical 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 CardioMEMS device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the CardioMEMS device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 4, 2021. 
 
You asked the Plan to pay for the lab services. You say that this was medically necessary drug testing. The 
Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on October 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Reactiv8 peripheral nerve stimulator (PNS) device. 
 
You asked the Plan to pre-approve a Reactiv8 PNS device. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
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 Reactiv8 PNS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found overall, there is lack of evidence to support PNS over traditional treatment of chronic 
low back pain. There is a lack of literature evaluating long-term efficacy and adverse events associated with 
implantable PNS devices. Long-term data are especially important for these technologies due to the invasive 
(and in some cases, permanent) nature of theses devices. Therefore, the request is considered 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 Reactiv8 PNS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Reactiv8 peripheral nerve stimulator (PNS) device.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder. 
 
You asked the Plan to pre-approve an implantable loop recorder. You say that the requested implantable loop 
recorder is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria 
for the requested implantable loop recorder. 
 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 an implantable loop recorder. Our 
reviewer says that the enrollee does not meet criteria for the requested implantable loop recorder. Our physician 
reviewer found the enrollee has a history of atrial fibrillation and placed on anticoagulation. There is no 
documentation provided to suggest a history of unexplained syncope, cryptogenic stroke or any other apparent 
indication for an implantable loop recorder (ILR). In summary, there is insufficient documentation to support 
the medical necessity for insertion of an ILR in this enrollees clinical 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 an implantable loop recorder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an implantable loop recorder.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you have a lot of medical issues and have to have 
rehabilitation to get better. The Plan denied your request. The Plan says the denial of authorization for IRF care 
is correct. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 
 Our physician reviewer found the complexity of your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including physical or occupational therapy, in an intensive 
rehabilitation therapy program. There is no indication that you would require skilled rehabilitation in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Opdivo, Fluorouracil, Leucovorin, Oxaliplatin, Aloxi and 
Decadron. 
 
You asked the Plan to pre-approve Opdivo, Fluorouracil, Leucovorin, Oxaliplatin, Aloxi and Decadron. You 
say that the services are necessary. The Plan denied your request. The Plan says that based on the 
documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Opdivo, Fluorouracil, Leucovorin, 
Oxaliplatin, Aloxi and Decadron. Our reviewer says that the services are medically necessary. Our physician 
reviewer found folfox already approved for neoadjuvant treatment rectal cancer. The enrollee also has 
metastatic non-small cell lung cancer (nsclc), PDL1+. As such, first line opdivo is approvable for PDL1+ nsclc 
per micromedex opdivo. There are no safety concerns for FOLFOX+opdivo as it is approved for metastatic 
gastric 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 Opdivo, Fluorouracil, Leucovorin, Oxaliplatin, Aloxi and Decadron have been 
met. Therefore, we decided that the Plan has to pre-approve Opdivo, Fluorouracil, Leucovorin, Oxaliplatin, 
Aloxi and Decadron.  
 
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 Myopro Motion G Orthotic Device. 
 
You asked the Plan to pre-approve Myopro. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested item 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 Myopro. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a past medical history of a stroke with left upper extremity weakness.  
Although records from the device manufacturer/vendor argue medical necessity of the requested device, no 
records from the enrollee's actual treating provider clarify why the requested device is the most appropriate 
treatment for the enrollee's condition. In addition, provided records report left shoulder subluxation and left 
upper extremity spasticity which may be a contraindication to use of the device. Therefore, the enrollee does 
not meet criteria for the requested item. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Myopro have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Myopro Motion G Orthotic 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 IRF care is medically reasonable and necessary. The 
Plan denied your request. The Plan says the rules for IRF care have not been met. 
 
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 that the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care in an IRF at this time. 
As of August 11, 2022, you were transferred to a telemetry unit. The documentation does not reveal that you 
are currently medically ready for discharge. The chest X-ray revealed bilateral perihilar infiltrates concerning 
for multifocal pneumonia or aspiration changes vs atypical viral process. Background pulmonary congestion 
and edema could not be excluded. You have also had an episode of atrial fibrillation after albuterol. Your 
medical status still has acute medical issues and needs management and monitoring in the acute hospital prior 
to transfer to a rehabilitation program. While you may benefit from additional multiple therapies, including 
physical and occupational therapy, the documentation does not reveal that you currently require 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.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an additional knee-shin stance flexion feature (L5845). 
 
You asked the Plan to pre-approve an additional knee-shin stance flexion feature. You say that the services are 
necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage 
criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a determination of the type of knee for the prosthesis 
will be made by the treating practitioner and/or the prosthetist based upon the functional needs of the 
beneficiary. 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 an additional knee-shin stance flexion 
feature. Our reviewer says that the services are medically necessary. Our physician reviewer found clinical 
documentation by the provider is very specific regarding your functional level, including the ability to perform 
variable cadences and traverse different kinds of environments beyond recreation. Thus, the request meets the 
criteria for a K3 level prosthetic with microprocessor knee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an additional knee-shin stance flexion feature have been met. Therefore, we 
decided that the Plan has to pre-approve an additional knee-shin stance flexion feature (L5845).  
 
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.