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

 
We decided that the Plan has to pre-approve sacroiliac joint fusion. 
 
You asked the Plan to pre-approve sacroiliac joint fusion. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says that the requested services are 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 sacroiliac joint fusion. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has chronic low back pain and sacroiliitis. The enrollee has tried 
transcutaneous electrical nerve stimulation (TENS), physical Therapy and epidural steroid injections. The 
enrollee takes Gabapentin, Zanaflex and Naproxedn for pain. The progress note of November 8, refers to an 
sacroiliac (SI) joint injection with 80% pain relief. The physical exam notes two provocative sacroiliac joint 
exams. However, the enrollee developed severe pain and was unable to continue the provocative tests. The 
records show to reasonable degree of medical certainity that the SI joint has been confirmed as the primary 
pain generator through physical examination and with a diagnostic block. Therefore, the enrollee does meet 
criteria for the requested 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 sacroiliac joint fusion have been met. Therefore, we decided that the Plan has to 
pre-approve sacroiliac joint fusion.  
 
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 a pneumatic compression device (PCD) coded E0652 
and full leg sleeve. 
 
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 services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a PCD is covered when specific criteria are met. 
 
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 services are not medically necessary. Our physician reviewer found there is no documentation of a trial of 
at least four weeks of regular, daily, multiple-hour home usage of a standard pump after careful in-person 
fitting, training, and supervision by a technician. The criteria for coverage are not met and the E0652 PCD is 
not reasonable or medically necessary at this time. 
 
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 pneumatic compression device (PCD) coded E0652 and full leg sleeve.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diabetic foot orthotics (A5500, A5513) to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve diabetic foot orthotics. You say that the requested items are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for OON care 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 
diabetic foot orthotics (A5500, A5513) to be provided by an OON provider.
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 cannot take care of yourself and need IRF care. 
The Plan denied your request. The Plan says based on Medicare guidelines, the requested IRF services 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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for 
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 
rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided 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: 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 LTACH care is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
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 that the enrollee is receiving appropriate care at the present acute-care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve [Shorter description of ITEM or SERVICE at issue, e.g. "a power 
wheelchair"]. You say that the services are necessary. The Plan denied your request. The Plan says based on the 
documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when specific criteria are met. 
 
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 epidural steroid injection. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the criteria for 
another epidural steroid injection requires 50% pain relief for 3 months. This has not been achieved and 
therefore, the request is deemed as not medically 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 an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence garment, any type, (e.g., brief, diaper) each 
(A4520). 
 
You asked the Plan to pre-approve incontinence supplies. You say that please overturn this denial so the 
enrollee may receive the necessary medical supplies that will greatly help to improve quality of life. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
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 garment, any type, 
(e.g., brief, diaper) each (A4520).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter aortic valve replacement (TAVR/TAVI), 
with prosthetic valve; percutaneous femoral artery approach. 
 
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 records do not show any symptoms related to aortic valve disease. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that at issue is the medical necessity of the requested TAVR in this patient with significant aortic 
stenosis and regurgitation. She is asymptomatic and described as having good exercise tolerance. Guidelines 
would not support aortic valve replacement based on the submitted medical records. As a result, at this time the 
requested TAVR would not be considered medically necessary in this patient's clinical management based on 
the submitted documentation. 
 
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 transcatheter aortic valve replacement (TAVR/TAVI), with prosthetic valve; percutaneous 
femoral artery approach.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Life Alert system. 
 
You asked the Plan to pre-approve a Life Alert system. You say that you feel this service should be covered 
because you are legally blind. The Plan denied your request. The Plan says the requested item is not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a Life Alert system.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computerized tomography (CT) scan of the soft tissue of neck. 
 
You asked the Plan to pre-approve a CT scan. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says that the requested services are not medically necessary. 
 
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 CT scan. Our reviewer says that the 
documentation supports that the requested services are medically reasonable and necessary. Our physician 
reviewer found the enrollee has a smoking history and vocal cord paralysis. A low dose CT scan revealed no 
mass and pulmonary nodules. The enrollee presents with vocal cord paralysis and due to this clinical fact, a CT 
of the neck to look at the larynx and pharynx in light of the stable low dose CT of the chest makes perfect 
sense. The lack of clinically palpable neck nodes does not preclude the possibility of laryngeal and supraglottic 
tumor in this high-risk patient. Therefore, the enrollee meets criteria for the requested 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 a CT scan have been met. Therefore, we decided that the Plan has to pre-
approve a computerized tomography (CT) scan of the soft tissue of neck.  
 
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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a physiologic arterial extremity study. 
 
You asked the Plan to pre-approve a physiologic arterial extremity study. 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 in general, noninvasive studies of the arterial system 
are to be utilized when invasive correction is contemplated, or severity of findings dictates noninvasive study 
follow up. 
 
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 physiologic arterial extremity study. 
Our reviewer says that the services are medically necessary. Our physician reviewer found while you have 
normal pulses on physical exam, the lower extremity edema is of concern and due to your comorbidities 
associated with peripheral vascular disease ankle brachial index (ABI) makes perfect sense in order to evaluate 
for possible arterial insufficiency despite normal pulses.  The exam is non invasive and is medically reasonable. 
 
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 physiologic arterial extremity study have been met. Therefore, we decided that 
the Plan has to pre-approve a physiologic arterial extremity study.  
 
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 a non-corrosive finish and adjustment knob (L2780, 
L2425) for an approved orthosis. 
 
You asked the Plan to pre-approve the non-corrosive finish and adjustment knob. You say that these items are 
medically necessary. The Plan denied your request. The Plan says these features are included in the base 
orthosis and are not eligible for unbundled payment. 
 
The Plan must follow Medicare rules. Medicare rules say that rules list addition codes which describe 
components or features that can be physically incorporated in the specified prefabricated bases orthosis but are 
considered to be included in the allowance for the orthosis. 
 
We looked at the file and Medicare rules. Codes L2780 and L2425 are included on the list of codes which 
cannot be unbundled from the base orthosis. Based on this information, we decided that Medicare rules for 
coverage of the non-corrosive finish and adjustment knob have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a non-corrosive finish and adjustment knob (L2780, L2425) for an approved 
orthosis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
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 criteria are not 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 treat with 
insulin three or more times per day or use an insulin pump. 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 continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MedTronic Infuse BMP-2 Allograft. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical studies have not proven that the application of this product is helpful for 
treatment of the enrollee's spinal condition when the spinal surgery is being done from a posterior approach. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no high risk for non-union. There is no failure of fusion documented. This request for 
routine posterior surgery is not Food and Drug Administration (FDA) approved and would be considered 
experimental. 
 
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 MedTronic Infuse BMP-2 Allograft.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a receiver (Monitor), dedicated, for use with therapeutic 
continuous glucose monitor (CGM) system (K0554) and supply allowance used with a therapeutic CGM 
device (K0553) 
 
You asked the Plan to pre-approve the Freestyle Libre 2 and supplies. You say that the enrollee wants to switch 
from the Dexcom G6 to the Freestyle Libre 2. The Plan denied your request. The Plan says the enrollee was 
previously approved for a Dexcom G6 CGM system and supplies for dates of service August 22, 2022, to 
August 21, 2023. Only 1 CGM system and standard monthly supply allowance can be approved each year. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee has Dexcom G6 receiver and supplies. Dexcom G6 receiver and supplies 
serves the same purpose as the Freestyle Libre 2 and supplies. Therefore, we decided that the Plan does not 
have to pre-approve a receiver (Monitor), dedicated, for use with therapeutic continuous glucose monitor 
(CGM) system (K0554) and supply allowance used with a therapeutic CGM device (K0553)
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Actemra (J3262). 
 
You asked the Plan to pre-approve Actemra. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the requested drug is prescribed for an off-label, not 
medically accepted use. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Actemra. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that 
Actemra is not FDA-approved for treatment of papillary craniopharyngioma. Furthermore, the use of Actemra for treatment of papillary craniopharyngioma is not supported by one of the major drug compendia or by 
clinical research that appears in a Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Actemra have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Actemra (J3262).