Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve home health services. You say that the requested home health aide visits are 
medically necessary. The Plan denied your request. The Plan says the requested home health aide visits are not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve home health services. Our reviewer 
says that the requested home health aide visits are not medically necessary. Our physician reviewer found 
based on the documentation provided, the enrollee does not have documented skilled nursing needs. The 
enrollee does not have documented skilled therapy needs. The enrollee does not appear to be homebound.   
 As such, home health services, including home health aide services, are not medically necessary, reasonable or 
coverable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation, nerves innervating the 
sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography) (64625). 
 
You asked the Plan to pre-approve the procedure. You say that it does not make sense that suddenly, the 
procedure you have had so many times is not supported by research. Please reconsider the decision and allow 
you to have the procedure again. The Plan denied your request. The Plan says this procedure has not been 
proven to be safe if done in the hip and lower back area. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at this the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or 
computed tomography) (64625).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home mechanical ventilator. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the request for a home mechanical ventilator set in average volume-assured 
pressure support (AVAPS) mode with Auto-EPAP (AE) that could be delivered by bilateral positive airway 
pressure (BiPAP) is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found that the record 
indicates that the enrollee has chronic respiratory failure from chronic obstructive pulmonary disease. The 
provided primary source documentation does not contain sufficient detailed information in the medical record to justify the treatment selected. The enrollee could be treated with a BiPAP machine with AVAPS 
capability.  The plan has indicated that coverage for such a device is available. 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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home mechanical ventilator.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 20 additional non-emergent transportation trips 
(A0100). 
 
You asked the Plan to pre-approve these services. You say that you are in need of transportation services for 
dialysis treatment. The Plan denied your request. The Plan says the benefit for the requested services has been 
exhausted. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 40 trips per year.   
 
We looked at your request, the records in the case file, and the Plans rules. Based on this information, we 
decided that you have exhausted the Plans maximum benefit for coverage of routine transportation. 
Specifically, the Plan contract says that up to 40 one-way routine transportation trips every year are covered. 
You previously received 41 covered routine transportation trips this calendar year; therefore, you have 
exhausted the allowable benefit for this service. Therefore, we decided that the Plan does not have to pre-
approve 20 additional non-emergent transportation trips (A0100).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve One call Solo telephone alert system (E1399). 
 
You asked the Plan to pre-approve a medical alert device. You say that you believe the medical alert device is 
medically necessary and allows the enrollee to remain independent. The Plan denied your request. The Plan 
says Medicare does not pay for a medical alert button or any other emergency response service. 
 
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 One call Solo telephone alert system (E1399).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation services. 
 You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
request does not meet medical requirements. 
 
The Plan must follow Medicare rules. Medicare rules say that facet joint interventions are only covered under 
certain medical indications.  
 
We looked at the file and Medicare rules. The records show that the enrollee received lumbar radiofrequency 
ablation services on December 15 and 30, 2021. For each covered spinal region, no more than two sessions are 
covered per rolling 12 months. Based on this information, we decided that Medicare rules for coverage of the 
requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve 
radiofrequency ablation services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tennis shoes. 
 
You asked the Plan to pre-approve tennis shoes. You say that you have bilateral plantar fasciitis. The Plan 
denied your request. The Plan says the shoes are not primarily medical in nature. 
 
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 tennis shoes.
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 IRF care is a medical necessity for 
you. The Plan denied your request. The Plan says medical necessity rules for IRF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) scan of the 
cervical spine (72141) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an MRI scan of the cervical spine. You say that the requested service is 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 
an MRI scan of the cervical spine (72141) to be provided by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR). 
 
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 an ILR 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 the records show that you do not have a 
history of irregular heartbeat (atrial fibrillation) or any significant cardiac arrhythmias noted on 
electrocardiogram (EKG) monitoring. A recent randomized clinical trial found that continuous monitoring for 
atrial fibrillation with an ILR was not superior to the usual standard of care. The services are therefore not 
reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an implantable loop recorder (ILR).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing. 
 
You asked the Plan to pre-approve the requested testing. You say that you have a history of breast cancer in 
your family. The Plan denied your request. The Plan says the testing is considered a screening. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing is only covered under certain 
medical indications. 
 
We looked at the file and Medicare rules. The records do not show that you have a personal history, signs or 
symptoms of a covered cancer diagnosis. Based on this information, we decided that Medicare rules for 
coverage of the requested testing have not been met. Therefore, we decided that the Plan does not have to pre-
approve genetic testing.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Optimizer Smart Device. 
 
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 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 services are not medically necessary. Our physician reviewer found the enrollee has left ventricular 
dysfunction and continued symptoms, though to reflect congestive heart failure, despite medical treatment. 
While the Optimizer Smart Device received Food and Drug Administration (FDA) approval in 2019, it remains 
the subject of multiple studies examining long-term efficacy, as well as randomized, controlled, double-blinded 
trials to quantify clinical efficacy. Until such statistically rigorous studies are completed, it is premature to 
presume clinical outcomes and benefit. At this time, the services are not reasonable or medically necessary. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Optimizer Smart Device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Orthovisc (J7324). 
 
You asked the Plan to pre-approve Orthovisc. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage for the requested drug have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that purified natural hyaluronans are indicated for 
treatment of pain associated with osteoarthritis of the knee or osteoarthritis of the shoulder.  
 
We looked at the file and Medicare rules. In this case, the medical records indicate that the requested drug is 
not prescribed for treatment of osteoarthritis of the knee or shoulder. Based on this information, we decided 
that Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not 
have to pre-approve treatment with Orthovisc (J7324).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nurse practitioner services to be provided by the 
requested out-of-network provider.  
 
You asked the Plan to pre-approve nurse practitioner services. You say that this nurse practitioner works under 
your former primary care physician (PCP) who has retired. The Plan denied your request. The Plan says when 
you become a member of our Plan, you must choose a Plan provider to be your PCP. Your PCP is a physician, 
nurse practitioner, or physician's assistant who meets state requirements and is trained to give you general 
medical care. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve nurse 
practitioner services to be provided by the requested out-if-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11103 billed for date of service December 
15, 2021. 
 
You asked the Plan to pay for procedure code 11103. You say that you appended the -59 modifier to this code, 
so it should be paid. The Plan denied your request. The Plan says this is an add-on code and you did not bill the 
appropriate primary code. 
 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, we have confirmed that code 
procedure code 11103 is an add-on code and has not been billed with an appropriate primary procedure code. 
Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 11103 billed for date of service December 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OneTouch Ultra test strips. 
 
You asked the Plan to pre-approve these services. You say that you do not want to switch to the preferred 
brand. The Plan denied your request. The Plan says the services are available from the preferred provider. 
 The Plan must follow Medicare rules. Medicare rules say that Plans may limit enrollees to preferred providers 
for durable medical equipment and supplies.  
 
We looked at the file and Medicare rules. The requested items are from a non-preferred provider. The services 
are available from one of the Plans preferred providers. 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 OneTouch Ultra test strips.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the transurethral waterjet ablation prostate, including 
control post-operative bleeding, including ultrasound guidance, complete (0421T). 
 
You asked the Plan to pre-approve the outpatient procedure. You say that the medical records provided support 
the necessity of the services in dispute. The Plan denied your request. The Plan says the enrollee does not meet 
the Medicare criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Per the LCD, you must be 80 years old and aquablation is not 
covered if there is a known or suspected prostate cancer, or the prostate specific antigen (PSA) greater than 10.  
Based on this information, we decided that Medicare rules for coverage of the outpatient procedure have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the transurethral waterjet ablation 
prostate, including control post-operative bleeding, including ultrasound guidance, complete (0421T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that your foot was damaged after surgery in 2018 
and you are a high fall risk. The Plan denied your request. The Plan says the services are not covered. 
 
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.   
 
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 pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network cardiologist. 
 
You asked the Plan to pre-approve these services. You say that you would like a second opinion. The Plan 
denied your request. The Plan says the services are available from network providers. 
 
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 
a referral to an out-of-network cardiologist.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One (J7326). 
 
You asked the Plan to pre-approve Gel-One. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications.  
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 Gel-One. Our reviewer says that the 
requirements for coverage of Gel-One have not been met. Our physician reviewer found the Plan requires a 
trial of Euflexxa or Synvisc/Synvisc One before they will approve the requested drug. The case file does not 
document that the enrollee has tried and failed these drugs. The documentation also does not support that 
Euflexxa or Synvisc/Synvisc One would likely be less effective or have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One (J7326).