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

 
We decided that the Plan does not have to pre-approve a Sprint Peripheral Nerve Stimulator (PNS). 
 
You asked the Plan to pre-approve the Peripheral Nerve Stimulator. You say that this service is medically 
necessary. The Plan denied your request. The Plan says this treatment is experimental and non-covered. 
 
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 Peripheral Nerve Stimulator. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found there are limited published studies that show this request to be an effective 
and/or safe treatment for the noted pathology. Further research is needed to show safety and efficacy. 
 
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 Peripheral Nerve Stimulator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Sprint Peripheral Nerve Stimulator (PNS).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that the requested Botox to treat gastroparesis is medically 
necessary. The Plan denied your request. The Plan says the requested Botox to treat gastroparesis is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Botox. Our reviewer says that the 
requested Botox to treat gastroparesis is not medically necessary. Our physician reviewer found the record 
indicates that the enrollee has a diagnosis of gastroparesis. The Food and Drug Administration has not stated 
that the requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia do not 
contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. 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 Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Via Disc Allograft (0627T). 
 
You asked the Plan to pre-approve the Allograft procedure. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says this service is experimental and is non-covered. 
 
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 Allograft procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is only limited published, large-scale, long-term peer-reviewed literature that 
shows this request to be an effective and/or safe treatment for the noted pathology. Further studies are needed 
to demonstrate this request has beneficial outcomes compared with conventional treatment. 
 
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 Allograft procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Via Disc Allograft (0627T).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve the SNF care. You say that you need to be at a SNF to get the physical 
therapy and the personal care that you need. The Plan denied your request. The Plan says there is no order for 
an admission to a SNF. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the SNF care have been met. 
Specifically, an order and records for the SNF were not sent. Therefore, we decided that the Plan does not have 
to pre-approve the skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on August 2, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that there is no contractual 
agreement in place at this time which indicates that these services are included in the dialysis rate. The Plan 
denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on August 
2, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve infliximab-abda (renflexis). 
 
You asked the Plan to pre-approve infliximab-abda (renflexis). You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 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 infliximab-abda (renflexis). Our 
reviewer says that the documentation does not support that the requested drug meets step therapy criteria. Our 
physician reviewer found the enrollee has rheumatoid arthritis. The documentation does not support that the 
enrollee has tried and failed Inflectra (infliximabdyyb) or Avsola (infliximab-axxq). The documentation does 
not support that Inflectra (infliximabdyyb) or Avsola (infliximab-axxq) would likely be less effective and/or 
likely 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 infliximab-abda (renflexis) have not been met. Therefore, we decided that the 
Plan does not have to pre-approve infliximab-abda (renflexis).
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 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. 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 clinical documentation shows that you have skilled therapy and nursing needs but 
does not specify any complex functional deficits or acute medical issues. Thus, the complexity of your documented nursing, medical and rehabilitation needs would not be expected to require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. Additionally, therapy notes do not show 
you would be able to tolerate 15hrs of therapy per week. 
 
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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says based on Medicare guidelines, the IRF services you are requesting do not 
meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 
 
 Our physician reviewer found the enrollee is medically stable and the clinical documentation does not show 
any complex functional deficits. The complexity of the enrollee's documented nursing, medical and 
rehabilitation needs would not be expected to require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation 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: 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 you are requesting additional therapy because you 
are unable to walk on your own and do not have anyone at home to care for you. The Plan denied your request. 
The Plan says the Skilled Nursing Facility (SNF) services you are requesting do not meet the requirements for 
approval. 
 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. Based on 
the documentation provided, you no longer qualify for SNF coverage after 2/3/2023.   
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an attended polysomnography (PSG) (95811). 
 
You asked the Plan to pre-approve an attended PSG. The Plan denied your request. The Plan says this PSG is 
needed for enrollees with symptoms of obstructive sleep apnea (OSA) and other severe health conditions, 
which could include lung failure, heart failure, seizures, or other health problems. The Plan also says that your 
doctor did not say that you have any of these health problems. 
 
The Plan follows Medicare rules. Medicare rules say that a Type I PSG is covered when used to aid the 
diagnosis of obstructive sleep apnea (OSA) in beneficiaries who have clinical signs and symptoms indicative of 
OSA if performed attended in a sleep lab facility. 
 
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 attended PSG. Our reviewer says 
that an attended PSG is not medically necessary. Our physician reviewer found you have a high suspicion for 
OSA, but do not have any conditions that would preclude a home sleep study, such as very severe obesity or 
severe heart or lung disease. If OSA is confirmed on the home sleep test, auto-titrating continuous positive 
airway pressure (CPAP) could be initiated. 
 
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 attended PSG have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an attended polysomnography (PSG) (95811).
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 IRF care is not medically necessary, and your 
needs can be met at a lower level of care such as a skilled nursing facility, on an intermittent basis at home with 
home health care, or in a long-term care setting. The Plan denied your request. The Plan says you need the 
rehabilitation to regain your strength, balance, and mobility. 
 
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 clinical documentation does not show any complex functional deficits (single 
joint arthroplasty is not an IRF compliant rehabilitation diagnosis) or any acute medical issues. This means the 
complexity of your documented nursing, medical and rehabilitation needs would not be expected to require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH is the right level of care for the 
enrollee. The Plan denied your request. The Plan says the denial of LTACH care is correct. 
 
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 record does not show that the enrollee requires services that are not currently 
being received but would be available at the LTACH. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a K3 foot for a lower limb prosthesis. 
 
You asked the Plan to pre-approve K3 foot. You say that the enrollee is functioning at a K3 level. The Plan 
denied your request. The Plan says a K3 foot is not necessary. 
 The Plan follows Medicare rules. Medicare rules state that coverage of lower limb prosthetic components is 
based on an assessment of the enrollees functional level. 
 
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 K3 foot. Our reviewer says that the 
enrollee does not meet criteria for the requested K3 foot. Our physician reviewer found the documentation does 
not support that the enrollee's functional level is K3. The enrollee has significant comorbidities and 
documentation does not support that the enrollee's needs are unable to be met with a lower level foot. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of K3 foot have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a K3 foot for a lower limb prosthesis.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve repeat epidural steroid injections (ESIs) (64483, 64484). 
 
You asked the Plan to pre-approve the repeat ESIs. You say that the enrollee needs these services. The Plan 
denied your request. The Plan says that the requested injections are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat ESI after 14 days can be performed, using a 
different approach, level and/or medication if appropriate, with the rationale and medical necessity for the 
second ESI documented in the medical record. 
 
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 repeat ESIs. Our reviewer says that 
the requested ESIs are medically necessary. Our physician reviewer found the provided documentation 
indicates only 20% pain relief for four weeks. The reviewer found that coverage guidelines allow for a different 
approach if an ESI does not provide adequate pain relief. Therefore, the reviewer found that epidural steroid 
injections using a different approach would be medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the repeat ESIs have been met. Therefore, we decided that the Plan has to pre-
approve repeat epidural steroid injections (ESIs) (64483, 64484).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for in-line cartridge containing digestive enzyme(s) for enteral 
feeding, each (CPT code B4105) provided on May 17, 2022. 
 
You asked the Plan to pay for the item. You say that the claim should be paid. The Plan denied your request. 
The Plan says the item is not supported by the records provided. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The documentation submitted did not include an itemized shipping/billing invoice to indicate the billed 
supplies were delivered. The proof of delivery did not specify what was delivered or the address it was 
delivered to. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for in-line cartridge containing 
digestive enzyme(s) for enteral feeding, each (CPT code B4105) provided on May 17, 2022.