Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
pneumatic appliance (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that you request 
reconsideration of the decision for authorization of the pneumatic compression device (E0652) and right arm 
sleeve (E0667) to treat the unresolved lymphedema. The Plan denied your request. The Plan says there is no 
evidence that swelling extends beyond your legs and into your chest, trunk or abdomen. A PCD coded as 
E0652 used to treat lymphedema not extending onto the chest, trunk and/or abdomen or CVI is not eligible for 
reimbursement. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. A PCD coded as E0652 is not covered for the 
treatment of lymphedema of the extremities alone even if the criteria in this section are met. Claims will be 
denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that swelling extends beyond 
the enrollees legs and into their chest, trunk or abdomen.  Therefore, we decided that the Plan does not have to 
pre-approve a pneumatic compression device (E0652) and segmental pneumatic appliance (E0667).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) scan of the heart, without 
contrast material, with quantitative evaluation of coronary calcium. 
 
You asked the Plan to pre-approve CT scan services with quantitative evaluation of coronary calcium. You say 
that this imaging is medically necessary for your condition. The Plan denied your request. The Plan says this 
imaging with quantitative evaluation of coronary calcium is not covered for screening purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve CT scan services with quantitative 
evaluation of coronary calcium. Our reviewer says that the requested CT scan with quantitative evaluation of 
coronary calcium is not medically reasonable and necessary. Our physician reviewer found that at issue is 
whether the requested CT imaging is appropriate and medically necessary in your care management program. 
You are asymptomatic from a cardiovascular standpoint. Numerous studies have demonstrated that coronary 
artery calcium (CAC) scoring using ultrafast cardiac CT adds predictive value in assessing risk of coronary 
heart disease (CHD). Clinical studies have not, however, shown that CAC scoring adds value in clinical 
management of asymptomatic patients in whom risk factors are targeted. In summary, current evidence 
showing that the use of CAC scores in clinical management of asymptomatic individuals leads to changes in 
patient management or in individual risk behaviors that improve cardiac outputs outcomes is limited and 
inconclusive.   Overall, there is insufficient support in the peer-reviewed literature demonstrating a significant benefit of CT 
imaging of the heart with quantitative evaluation of coronary calcium in guiding optimal management. As such, 
CT imaging of the heart without contrast material with quantitative evaluation of coronary calcium is 
considered experimental/investigational for the evaluation and management of your amedical 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 CT scan services with quantitative evaluation of coronary calcium have not 
been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) scan 
of the heart, without contrast material, with quantitative evaluation of coronary calcium.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair lift. 
 
You asked the Plan to pre-approve a stair lift. You say that the requested item is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair lift.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of a cardiac rhythm monitor (33285). 
 
You asked the Plan to pre-approve a cardiac rhythm monitor. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says medical-necessity rules for coverage of 
the requested item have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that an ILR is used when syncope is thought to be 
cardiac-related but is too infrequent to be detected by either a Holter monitor or a traditional pre-symptom 
MLR. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a cardiac rhythm monitor. Our reviewer 
says that the requested item is not medically reasonable and necessary in this case. Our physician reviewer 
found that while the enrollee has a history of bradycardia, there is no documentation provided to suggest a 
history of unexplained syncope or any other apparent indication for an ILR. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a cardiac rhythm monitor have not been met. Therefore, we decided that the 
Plan does not have to pre-approve insertion of a cardiac rhythm monitor (33285).
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 need this level of care. The Plan denied your 
request. The Plan says you do not meet criteria for admission to an IRF. 
 
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 your nursing, medical and rehabilitation needs do not require an acute rehab 
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You can receive further services 
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 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 the LTACH services are medically 
necessary. The Plan denied your request. The Plan says 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 the enrollee's needs are being met in the current acute care setting. The LTACH does 
not provide any services that are unavailable in the current 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is medically ready and stable for transfer 
to rehabilitation. You say that without acute rehabilitation services, the enrollee's ability to regain maximum 
function is in jeopardy due to their medical condition. The Plan denied your request. The Plan says the IRF care 
is not medically necessary, and the enrollee's needs can be met at a lower level of care, such as a skilled nursing 
facility (SNF). 
 
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 members nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement; however, the documentation 
does not support that she would meet criteria for admission to an acute inpatient rehabilitation facility. There is 
no indication that the enrollee would require skilled rehabilitation in an IRF, participating in rehab services 15 
hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain her 
functional status. The enrollee can receive further services 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a travel model of a continuous positive airway pressure 
(CPAP) device. 
 
You asked the Plan to pre-approve a travel CPAP. You say that the requested item is a medical necessity for 
you. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a travel model of a continuous positive airway pressure (CPAP) device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diagnostic facet injections. 
 You asked the Plan to pre-approve the injections. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that diagnostic facet injections are covered for the 
indications established in the applicable LCD. 
 
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 injections are not medically necessary. Our physician reviewer found that the MRI revealed a 
mild disc bulge and moderate facet arthritic changes L4-L5 and L5-S1. The enrollee is status post right L3-4, 
L4-5, L5-S1 diagnostic medial branch block (MBB) on May 4, 2022, with only 60% relief of pain for 2 weeks. 
A 2nd diagnostic MBB has been requested. The review has determined that the enrollee does not meet the 
coverage criteria detailed in the LCD. 
 
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 diagnostic facet injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that the requested incontinence supplies are 
getting very expensive for you. The Plan denied your request. The Plan says the requested items are not a 
covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections/medial branch blocks. 
 
You asked the Plan to pre-approve medial branch blocks. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that medial branch blocks are covered when all of the 
following criteria are met: 
1. Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit 
measured on pain or disability scale 
2. Pain present for minimum of 3 months with documented failure to respond to noninvasive conservative 
management (as tolerated) 3. Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by 
facet joint synovial cyst) 
4. There is no non-facet pathology per clinical assessment or radiology studies that could explain the 
source of the patients pain, including but not limited to fracture, tumor, infection, or significant 
deformity.  
 
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 medial branch blocks. Our reviewer 
says that the documentation does not support that the requested services are medically reasonable or necessary. 
Our physician reviewer found the enrollee has a history of low back pain due to lumbar spondylosis, 
degeneration of lumbar intervertebral disc, lumbar post laminectomy syndrome, and a history of old lumbar 
compression fractures. The enrollee is status post lumbar fusion. The enrollee's exam shows some lumbar pain 
with extension and facet loading and lumbar tenderness, and right leg weakness when standing on your heel. X-
ray shows old compression fractures and degenerative arthritis of the facet joints. Magnetic resonance imaging 
is said to show degeneration of discs and facets throughout the lumbar spine. The enrollee has been treated with 
Diclofenac gel, Gabapentin, and Acetaminophen/Hydrocodone and physical therapy. The documentation does 
not support that the enrollee meets LCD criteria 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 medial branch blocks have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections/medial branch blocks.
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 it is felt that LTACH care would be most 
appropriate for this enrollee. The Plan denied your request. The Plan says the enrollee is receiving adequate 
care and is not stable to be transferred at this time. 
 
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 is currently undergoing treatment at an ACH for CoViD-19. The enrollee 
is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently 
available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in 
transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute 
services are required.  
 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you feel that this level of care is necessary for you. 
The Plan denied your request. The Plan says your condition does not require complex rehabilitation or close 
supervision and active management by a rehabilitation physician. 
 
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 members nursing, medical and rehabilitation needs do not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
member does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. There is not a reasonable expectation that this 
individual will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an inpatient rehabilitation facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ESI) (CPT code 62321). 
 
You asked the Plan to pre-approve the epidural steroid injection. You say that the enrollee had the first of two 
diagnostic injections on July 28, 2022. You state the enrollee initially had 50% relief of the first injection. You 
state with the second injection, it gives the steroid a change to build to get longer relief. The Plan denied your 
request. The Plan says the notes do not show that the enrollee's pain decreased by half and the notes also do not 
show they were able to perform their normal activities for at least three months. 
 
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 epidural steroid injection. Our 
physician reviewer found the review has determined that the requested ESI is not medically reasonable or 
necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the epidural steroid injection have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the ESI) (CPT code 62321).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rocklatan drops. 
 
You asked the Plan to pre-approve Rocklatan drops. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested drug is not a covered benefit. 
 
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 Rocklatan drops.  
 
 
 
 Benefits for Rocklatan drops may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.