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

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the neck. 
 
You asked the Plan to pre-approve a CT scan of the neck. 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 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 of the neck. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the provided records do not 
indicate the medical necessity or reasonableness, as defined by Medicare rules, of the requested service at this 
time. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CT scan of the neck have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a computed tomography (CT) scan of the neck.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 
admission. 
 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 admission to a SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee is with failure to thrive, 
traumatic brain injury (TBI), chronic obstructive pulmonary disease (COPD) and falls. From a nursing 
perspective, the enrollee received oral and inhaled medications. The enrollee had stable vital signs. Regarding 
rehabilitation services, the enrollee received physical therapy. The enrollee was at a minimal to contact guard 
assist for functional mobility including gait to 75 feet.  
 
There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The 
enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet 
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of admission to a SNF have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
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 the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the record indicates that 
the enrollee has a diagnosis of osteoarthritis of the knees. The Food and Drug Administration has stated that the 
requested drug is indicated for the enrollee's condition. The record indicates that the enrollee completed a series 
of Euflexxa injections in August 2021. The record does not indicate the effectiveness of these treatments nor is 
there any recent documentation of patient assessment to support the medical necessity, as defined by Medicare 
rules, of the requested service at this time. 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 the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar epidural steroid injection. 
 
You asked the Plan to pre-approve the requested service. You say that the enrollee has mild to moderate 
stenosis. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injections are 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 service. Our physician 
reviewer found that the enrollee has a history of chronic back pain with spinal stenosis of lumbar region. The 
enrollee has had significant low back and bilateral lower extremity pain. The enrollee received a lumbar 
epidural steroid injection on February 10, 2022. She experienced 84% relief for 3 days. A repeat injection is 
covered when there is documentation of at least50% sustained improvement of pain for at least 3 months. The 
review has determined that the requested lumbar ESI 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 requested service have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a lumbar epidural steroid injection.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve OON SNF services. You say that the enrollee requires SNF services. The 
Plan denied your request. The Plan says the enrollee does not have an out-of-network benefit.  The enrollee has 
been approved for SNF care at a network facility. 
 
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 
skilled nursing facility (SNF) services to be provided by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 99 home health visits. 
 
You asked the Plan to pre-approve an additional 99 home health visits. You say that these additional home 
health visits are medically necessary. The Plan denied your request. The Plan says the enrollee requested 147 
home health visits. The Plan approved 18 and denied the remaining 99. The Plan says that the enrollee is not 
homebound and is able to walk 7000 steps a day. The already-approved skilled nursing visits should cover the patient's scheduled catheterizations until other arrangements are made to help drain the patient's bladder. 
Additional visits beyond those already approved are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 99 home health visits. Our 
reviewer says that an additional 99 home health visits are not medically necessary. Our physician reviewer 
found yt appears that previously the health plan has approved once daily home health visits.  Records indicate 
that recently home health visits have been provided at a rate of 1-3 per day.   Currently, thrice-daily home 
health visits are being requested to perform urinary straight catheterization.  It is unclear why the enrollee does 
not have a Foley.  It is unclear who performs the straight catheterizations when only one or two home health 
visits are provided per day.  It is unclear why the patient, facility staff, family, friends or paid caregivers cannot 
perform the catheterizations.  The request for three home health visits per day is not intermittent and by default 
does not meet the criteria for home health 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 an additional 99 home health visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an additional 99 home health visits.
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 you do not need intensive therapies, consisting of at least 3 hours of therapy per day 
at least 5 days per week with multidisciplinary approach to daily therapy in an IRF. Your rehab can be safely 
provided at a lower intensity and alternate setting such as in a skilled nursing facility. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee did not require skilled therapy to 
establish a safe and effective maintenance program. As a practical matter, the enrollee did not require any 
skilled services on an inpatient basis, at a SNF level of care as of 4/4/22. The enrollee did not have any parental 
medications, daily, complex wound care or nutrition given via a feeding tube. The enrollee received skilled 
care and improved; however, her functional improvement had plateaued by 4/4/22 and she did not require any 
further inpatient skilled rehab services. The enrollees function was at or near her new baseline level of 
function and she could be discharged to a lower level of care for further services.  As of 4/4/22 the enrollee 
required custodial 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synthroid tablets. 
 
You asked the Plan to pre-approve Synthroid tablets. You did not provide an argument with your appeal 
request. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical 
benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Synthroid tablets.  
 
Benefits for Synthroid tablets may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 Transmitter and Dexcom G6 Sensor. 
 
You asked the Plan to pre-approve a Dexcom G6 Transmitter and Dexcom G6 Sensor. You say that the items 
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 plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers as long as the enrollee retains access to all medically necessary items (including non-
preferred brands). 
 
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 Dexcom G6 Transmitter and Dexcom 
G6 Sensor. Our reviewer says that the items are not medically necessary. Our physician reviewer found the 
record does not indicate a medical rationale why the available preferred brand products are not appropriate for 
the enrollee. The elements of the coverage criteria are not satisfied. The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Dexcom G6 Transmitter and Dexcom G6 Sensor have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 Transmitter and Dexcom G6 
Sensor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Supply allowance for therapeutic continuous glucose monitor 
(CGM) includes all supplies and accessories, 1 month supply (K0553) provided April 22, 2021. 
 You asked the Plan to pay for supply allowance for CGM. You say that these services have been getting 
approved and paid by the plan since 2020. The Plan denied your request. The Plan says the records do not 
support the service billed and evidence of misrepresented services. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 pay for supply allowance for CGM. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this case the record indicates that the enrollee has diabetes and does not use insulin 
at last thrice daily. The record does not indicate that enrollees insulin treatment regimen requires frequent 
adjustment by the enrollee on the basis of BGM or CGM testing results. 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 supply allowance for CGM have not been met. Therefore, we decided that the 
Plan does not have to pay for Supply allowance for therapeutic continuous glucose monitor (CGM) includes all 
supplies and accessories, 1 month supply (K0553) provided April 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections (64490, 64491). 
 
You asked the Plan to pre-approve facet joint injections. You say that the patient has pain at the back of his 
neck which radiates to his shoulders and has had these symptoms for over a year. You say this patient has 
cervical facet arthropathy cause of this pain, which is progressively getting worse. You say that in the past he 
has diagnostic cervical medial branch blocks at C3, C4 and C5 levels and has reported over 90% relief of his 
neck pain by the procedures for over a week. The Plan denied your request. The Plan says repeat diagnostic 
MBB at B/L C3-C5 are not reasonable or necessary per LCD L35936, as member had only 50% response for 4 
weeks, to initial 2 diagnostic MBB's. 
 
The Plan follows Medicare rules. Medicare rules say that after the first diagnostic facet joint procedure, there 
must be a consistent positive response of at least 80% relief of primary (index) pain (with the duration of relief 
being consistent with the agent used). 
 
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 facet joint injections. Our reviewer says 
that facet joint injections are not medically necessary. Our physician reviewer found that the record indicates 
that the enrollee has neck pain and received a diagnostic facet injection that provided 50% relief as reported at 
the time of the injections in May and August 2021 and at a January 2022 follow up visit.  The elements of the coverage rules are not satisfied.  The requested service cannot be recommended 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections (64490, 64491).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee's needs can be met at a lower level of care such as home with 
supervision. 
 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 the admission. Our reviewer says that 
the requested admission is not medically reasonable or necessary. Our physician reviewer found the enrollee 
does not qualify for SNF coverage. The enrollee does not have documented skilled nursing or skilled therapy 
needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent 
deterioration of the enrollees condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet injections. 
 
You asked the Plan to pre-approve facet injections. 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 Facet Joint Interventions are considered medically 
reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet specific criteria. 
 
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 facet injections. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the record does not indicate that the 
enrollee has failed to respond to noninvasive conservative therapy. The elements of the coverage criteria are 
not satisfied. The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor. 
 
You asked the Plan to pre-approve a Freestyle Libre continuous glucose monitor. You say that this is medically 
necessary. The Plan denied your request. The Plan says the requirements for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
Freestyle Libre continuous glucose monitor have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Freestyle Libre continuous glucose monitor.