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

 
We decided that the Plan does not have to pre-approve genicular radiofrequency ablation. 
 
You asked the Plan to pre-approve genicular radiofrequency ablation. You say that the requested genicular 
radiofrequency ablation is medically necessary. The Plan denied your request. The Plan says the requested 
genicular radiofrequency ablation 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 genicular radiofrequency ablation. Our 
reviewer says that the requested genicular radiofrequency ablation is not medically necessary. Our physician 
reviewer found the role of blocking and destroying the genicular nerves  in osteoarthritis of the knee is still 
being evaluated and is considered investigational. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular radiofrequency ablation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve genicular radiofrequency ablation.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 7 additional hours of psychological testing. 
 
You asked the Plan to pre-approve 7 additional hours of psychological testing. You say that the requested 7 
additional hours of psychological testing is medically necessary. The Plan denied your request. The Plan says 
the requested 7 additional hours of psychological testing 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 7 additional hours of psychological 
testing. Our reviewer says that the requested 7 additional hours of psychological testing is not medically 
necessary. Our physician reviewer found the documentation does not meet the criteria from LCD L33632 as the 
enrollee is not showing severity of symptoms that would warrant this type of diagnostic treatment and does 
therefore not appear medically necessary or reasonable. The neuropsychological testing as outlined does not 
show extenuating circumstances which would require an extended length of time for the testing beyond what 
the Plan has already approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 7 additional hours of psychological testing have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 7 additional hours of psychological testing.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you have been at a skilled nursing facility and you 
did not make enough progress to be safe at home. The Plan denied your request. The Plan says admission to the 
IRF was denied as not meeting criteria, is not medically necessary, and a lower level of care might be 
appropriate. Skilled nursing facility level of care was offered. 
 
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 were 
admitted for weakness, chronic obstructive pulmonary disease exacerbation, and hyponatremia. Medical 
problems are stable. There are no complex or nursing rehabilitation needs. While you have a need for physical 
or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. Medically 
necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that the requested bed is necessary 
because you cannot use a manual bed. You say that you and your caretaker are not able to crank it up. The Plan 
denied your request. The Plan says a total electric hospital bed is not covered by Medicare or under this 
contract. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested lumbar laminectomy and fusion with 
instrumentation at L4-5 and L5-S1. 
 
You asked the Plan to pre-approve the lumbar laminectomy and fusion services. You say that this procedure is 
medically reasonable and necessary for your condition. The Plan denied your request. The Plan says the 
requested procedure 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 the lumbar laminectomy and fusion 
services. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the imaging studies do not show severe stenosis or spinal 
instability as required 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 the lumbar laminectomy and fusion services have not been met. Therefore, we decided that the Plan does not have to pre-approve the requested lumbar laminectomy and fusion with 
instrumentation at L4-5 and L5-S1.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets the criteria for 
admission to a LTACH. The Plan denied your request. The Plan says that the coverage criteria has 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 requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. All medically necessary care is being provided in the current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the 
records do not show that it is medically necessary for the enrollee to be in an LTACH in place of an acute care 
hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted to the acute care hospital with diverticulitis, intra-
abdominal abscess and required exploratory laparotomy, resection, perforated colon, colostomy, drain 
placement, antibiotics, and wound care. Recent notes describe the enrollee as now tolerating low dose oxygen 
via nasal cannula, still with 2 JP drains, requiring basic wound and tolerating a liquid diet. The enrollee is still 
on intravenous antibiotics and fluconazole and with pleural effusions and mucus plugging. The enrollee 
appears to be more stable and improving and should only require short term additional acute care services that 
can safely be provided at the current facility until more stable and appropriate for a lower level of care.  The enrollee does not require services at the LTACH that are not already available at the current 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has 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 that the requested admission to a SNF 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 SNF care. Our reviewer says that the 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does have 
documented skilled therapy needs. The enrollee needs transfer training and strength training. The enrollee, who 
is noted to have dementia, may perform better in an out-of-hospital environment. The family needs training to 
assist the enrollee. Daily skilled services are reasonably required to establish a maintenance program and/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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 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: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) scan of the lower 
extremity without contrast. 
 
You asked the Plan to pre-approve MRI scan services. You say that this imaging service is medically necessary 
for the enrollee's condition. The Plan denied your request. The Plan says there is no medical need for the 
requested MRI. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI scan services. Our reviewer says 
that the requested MRI is not medically reasonable and necessary. Our physician reviewer found that the record 
indicates that the enrollee has non-painful swelling in the foot with examination consistent with a simple 
ganglion cyst. The record indicates that plain films are normal and no documentation of failed conservative 
therapy. The record provided does not indicate the presence of any red flag symptoms or diagnostic 
uncertainty. The record provided is insufficient to establish the medical necessity of the requested service. The 
requested service is not medically necessary and reasonable for the diagnosis and treatment for the enrollee's 
clinical condition 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 MRI scan services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a magnetic resonance imaging (MRI) scan of the lower extremity without contrast.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the right knee. 
 
You asked the Plan to pre-approve MRI of the right knee. You say that the medical records support the need for 
this MRI. The Plan denied your request. The Plan says MRI of the right knee is not medically necessary. Plain 
x-rays are the initial imaging study for osteoarthritis. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI of the right knee. Our reviewer 
says that an MRI is not medically necessary. Our physician reviewer found the patient is a 68-year-old female 
with knee swelling related to severe osteoarthritis. MRI right knee was requested. However, current guidelines 
recommend x-ray imaging for evaluating severity of osteoarthritis which were not provided for review. There 
was no indication from examination findings or history warranting advanced imaging such as MRI at this time. 
The patient did not exhibit any instability or report of any pain in the right 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 MRI of the right knee have not been met. Therefore, we decided that the Plan 
does not have to pre-approve magnetic resonance imaging (MRI) of the right knee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(Intracept procedure) (64628). 
 
You asked the Plan to pre-approve Intracept procedure. You say that the enrollee has tried and failed 
conservative therapy with no relief. You say that the requested procedure received clearance from the Food and 
Drug Administration (FDA) in 2016. You also say that the procedure is medically necessary. The Plan denied 
your request. The Plan says the requested procedure 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 Intracept procedure. Our reviewer says 
that the requested Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is considered experimental. The reviewer found that more 
research is necessary. Therefore, the reviewer found that the requested Intracept procedure 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 Intracept procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve thermal destruction of intraosseous basivertebral nerve (Intracept procedure) (64628).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for magnetic resonance imaging (MRI) provided on April 5, 
2022. 
 
You asked the Plan to pay for MRI. You say that this was medically necessary. The Plan denied your request. 
The Plan says this test was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 pay for MRI. Our reviewer says that this MRI does 
not meet criteria for payment. Our physician reviewer found the records provided are insufficient to establish 
the medical necessity of this scan. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MRI have not been met. Therefore, we decided that the Plan does not have to 
pay for magnetic resonance imaging (MRI) provided on April 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested device can be provided by a network 
provider. 
 
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 item at issue in this appeal. We found no exception that would require the Plan 
to pre-approve this items. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen 
concentrator 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 additional acupuncture services. 
 
You asked the Plan to pre-approve the requested services. You say that you need these services in order to 
thrive and manage throughout the day. The Plan denied your request. The Plan says you do not meet the criteria 
to qualify for coverage. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services for acupuncture treatments for 
CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per 
year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plans rules 
apply in this case.  
 
We looked at the file and Medicare rules. In this case, there are no medical records regarding your acupuncture 
care to show that additional visits are necessary. Based on this information, we decided that the rules for 
coverage of acupuncture services have not been met. Therefore, we decided that the Plan does not have to pre-
approve additional acupuncture services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the outpatient psychotherapy services coded as 90834, 
90791 and 90837 to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the outpatient services. You say that the medical records provided support 
the necessity of the requested services. The Plan denied your request. The Plan says enrollees must receive 
their medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered. 
 
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 
the outpatient psychotherapy services coded as 90834, 90791 and 90837 to be provided by an out-of-network 
(OON) provider.