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

 
We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there appears to be some concern that the devices are not as effective as surgical 
decompression and may lead to higher rates of reoperation. 
 
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 device. Our reviewer says that  Our 
physician reviewer found current evidence based medical guideline and peer reviewed literature do not fully 
support the spinal decompression device procedure over the gold standard of lumbar laminectomy. There is a 
lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this 
enrollees medical condition as discussed above. FDA indications include implantation of the Superion device 
at one or two adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is 
indicated at no more than two levels, from L1 to L5.  
 This enrollee has multiple degrees of spinal stenosis, many not at FDA indicated levels of moderate spinal 
stenosis (including the planned level of implantation at L4-5.). FDA contraindications include spinal instability, 
scoliosis, obesity, and osteoporosis, and have not been adequately addressed in the medical records. There is 
imaging evidence of 9mm anterolisthesis of L4 on L5. There is no documentation of the enrollees height, 
weight or body mass index. There is imaging evidence of mild levoscoliosis of the lumbar spine, with no 
documentation of the Cobb angle. The 10/16/20 bone density report has impression of osteopenia; scan of left 
femoral neck indicates osteopenia; left total hip indicates osteopenia; AP total spine is within normal levels; 
she is at medium risk for fracture. There is no compelling rationale presented or extenuating circumstances 
noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for 
Vertiflex Superion interspinous device at L4-5 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prostate Artery Embolization (PAE) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied 
your request. The Plan says that the clinical value and effectiveness of PAE in the setting of lower urinary tract 
symptoms (LUTS) secondary to BPH have not been demonstrated in the peer-reviewed literature. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Prostatic arterial 
embolization (PAE) is considered an experimental technique to treat symptomatic benign prostatic hyperplasia 
(BPH). Very limited studies have demonstrated possible short-term safety and efficacy. The most recent 
American Urological Association (AUA) guidelines do not recommend this procedure outside of a clinical trial 
setting. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prostate Artery Embolization (PAE) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on June 23, 2021. You asked the Plan to pay for the testing services. You say that the documents support the necessity of 
services. The Plan denied your request. The Plan says the billed code cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. The claim lists a place of service as an independent laboratory. The records 
do not show that the specimen was obtained at the independent laboratory. Based on this information, we 
decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that 
the Plan does not have to pay for the drug testing services provided on June 23, 2021.
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 enrollee will benefit from IRF care to optimize 
her level of functioning prior to returning home. You say that the enrollee requires interdisciplinary therapy 
care and daily oversight of care by a physician in an inpatient setting along with specialized physiatry care. 
You say that the enrollee's chance of returning home safely and maintaining life at home will be significantly 
reduced if her opportunity to participate in an acute rehabilitation program is denied. The Plan denied your 
request. The Plan says the need for IRF is not supported based on the records provided. The Plan says that the 
enrollee's needs can be safely met in a less intensive setting. 
 
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 the enrollee's nursing, medical, and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
documentation does not support that the enrollee requires at least 3 hours a day/5 days a week, or 15 hours over 
7 consecutive days of therapy services. The documentation supports therapy services may be provided at a 
lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. The Plan states the 
enrollee could receive care in another setting and the Plan could review alternate settings if requested, such as 
skilled nursing facility, outpatient setting or home health care. 
 
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 enrollee is medically stable and does not need physical medicine and 
rehabilitation (PM&R) physician supervision three (3) times per week (at a minimum) for the ongoing 
management of any active or acute exacerbations of chronic medical conditions. At the enrollee's low activity tolerance and cognitive deficits, the enrollee does not need intensive therapies, consisting of at least 3 hours of 
therapy per day at least five (5) days per week with multidisciplinary approach to daily therapy in an IRF. The 
enrollee will not tolerate and benefit from IRF admission. IRF admission is not medically necessary based on 
lack of medical complexity and lack of acute rehabilitation nursing needs. Document does not support the 
necessity for admission to an IRF. The enrollee's rehabilitation needs can be met safely at a lower intensity and 
alternate setting such as in an SNF. 
 
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 pay for foot orthotics purchased on September 9, 2021. 
 
You asked the Plan to pay for foot orthotics. You say that orthotics were medically necessary. The Plan denied 
your request. The Plan says Medicare coverage criteria were not met. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. The records show 
that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although orthotics may be 
appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, 
we decided that the Plan does not have to pay for foot orthotics purchased on September 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection service coded 64486 provided on July 19, 2021. 
 
You asked the Plan to pay for the injection service. You say that this claim is supported by the medical 
documentation submitted. The Plan denied your request. The Plan says the documentation does not support the 
services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 64486 is Transversus abdominis plane (TAP) block 
(abdominal plane block, rectus sheath block) unilateral; by injection(s) (includes imaging guidance, when 
performed). 
 
We asked our coder 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 the injection service. Our reviewer says that the 
documentation does not support the code as billed. Our reviewer found the documentation submitted was reviewed, and the criteria for coverage have not been met. Anesthesia report documents an injection was given, 
however, does not document the type of injection performed. Therefore, this procedure cannot be confirmed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injection service have not been met. Therefore, we decided that the Plan 
does not have to pay for the injection service coded 64486 provided on July 19, 2021.
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 the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. The Plan states the 
enrollee could receive care in another setting and the Plan could review alternate settings if requested, such as 
skilled nursing facility, outpatient setting or home health care. 
 
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 do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does 
not require intensive physician and nursing oversight in an IRF. While you may benefit from additional multiple therapies, including physical and occupational therapy, the documentation does not reveal that your 
high functional level requires 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary visit provided on October 26, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the domiciliary visit. You say that you were unaware that the facility failed to get 
pre-authorization. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a domiciliary visit provided on October 26, 2021, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom REVO volume management system (L5999) 
for the enrollee. 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says since this component is experimental and not found to be safe and effective, it is not 
reasonable and necessary for this enrollee's condition. 
 
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 system. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found Medicare does not pay for any items or services that are not reasonable and necessary for the diagnosis 
or treatment of illness or injury or to improve the functioning of a malformed body member. The requested 
item is not FDA approved and therefore not proven safe and effective for the enrollee's 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 system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a custom REVO volume management system (L5999) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous passive motion device. 
 
You asked the Plan to pre-approve a CPM device. You say that this is medically necessary. The Plan denied 
your request. The Plan says that this is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have 
received total knee replacement surgery. 
 
You have not had total knee replacement surgery. Therefore, we decided that the Plan does not have to pre-
approve a continuous passive motion device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Duloxetine 30mg capsule. 
 
You asked the Plan to pre-approve Duloxetine. You say that the enrollee has been on this medication since 
2014. You also say that it has been very effective for the enrollee. The Plan denied your request. The Plan says 
the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a 
Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare 
Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Duloxetine 30mg capsule.  
 Benefits for Duloxetine 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 pay for Prodigy-brand diabetic supplies provided on March 20, 
2020. 
 
You asked the Plan to pay for diabetic supplies. You say that the items at issue were a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MA Plans may specify brands and manufacturers 
as preferred and charge lower cost-sharing for the preferred brands or may limit DME to only those preferred 
brands and manufacturers. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of diabetic supplies have not been met. Specifically, the requested items are a non-preferred brand. 
The case record does not contain medical documentation that supports the medical necessity of the requested 
items. Therefore, we decided that the Plan does not have to pay for Prodigy-brand diabetic supplies provided 
on March 20, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chemotherapy administration (96413) provided on August 
31, 2021, by an out-of-network provider. 
 
You asked the Plan to pay for chemotherapy administration. You say that the service at issue was a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for out-of-network 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for chemotherapy administration (96413) provided on 
August 31, 2021, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied 
your request. The Plan says the clinical documentation submitted does not indicate a covered condition for this 
service. 
 
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 injections. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found facet joint injections are considered medically necessary in the absence of untreated 
radiculopathy or neurogenic claudication (except for radiculopathy caused by facet joint synovial cyst). In this 
case, the enrollee has documented radiculopathy. The facet joint is not the main source of pain. 
 
 
 
 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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint injections.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on December 15, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing 
rendered on December 15, 2020.