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

 
We decided that the Plan does not have to pre-approve the injection of an anesthetic or steroid into the 
genicular nerve (64454).  
 
You asked the Plan to pre-approve a genicular nerve block. You say that the enrollee is in severe pain, cannot 
walk and keeps falling. You say the injection will give the enrollee back mobility for walking and standing.  
The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a genicular nerve block. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. 
 
 Our physician reviewer found genicular nerve blocks and genicular nerve radiofrequency ablation are 
considered investigational and not medically necessary for the treatment of chronic knee pain, including, but 
not limited to any of the following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to 
knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not 
candidates for knee replacement surgery. The review has determined that the requested genicular nerve block 
of the left knee 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 a genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the injection of an anesthetic or steroid into the genicular nerve (64454).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(Intracept procedure). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee has failed conservative 
treatment without relief. You also say that the science supporting the safety and effectiveness of the procedure 
is robust. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found there is no magnetic resonance imaging (MRI) showing only Modic changes 
without facet degenerative joint disease. The reviewer found that the documentation does not show a clear cause for the enrollee's pain. Therefore, the reviewer found that the requested Intracept procedure is not 
medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve thermal destruction of intraosseous basivertebral nerve (Intracept procedure).
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 medically necessary. The Plan 
denied your request. The Plan says your records do not show that your rehab needs are complex.  
 
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 you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cardiac ablation procedure (93653, 93656). 
 
You asked the Plan to pre-approve a cardiac ablation procedure. You say that this is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the medical records indicate the enrollee is currently 
asymptomatic and therefore the requested procedure is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a cardiac ablation procedure. Our 
reviewer says that the requested cardiac ablation procedure is not considered medically reasonable and 
necessary in this case. Our physician reviewer found the provided records indicate the enrollee has been in 
atrial fibrillation without symptoms and with a normal ejection fraction of 55%. Therefore, the reviewer found 
that the requested cardiac ablation procedure is not medically reasonable or necessary.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a cardiac ablation procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a cardiac ablation procedure (93653, 93656).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sclerotherapy. 
 
You asked the Plan to pre-approve sclerotherapy. You say that this is necessary for the enrollee. The Plan 
denied your request. The Plan says the saphenous reflux is present and therefore is not medically reasonable or 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the treatments of the tributary veins will be 
considered medically necessary if saphenous reflux is not present or already successfully eliminated, the veins 
are greater than 4 millimeters (mm) in diameter and if the patient remains symptomatic after a six-week trial of 
conservative 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 sclerotherapy. Our reviewer says that 
the requested sclerotherapy is not medically necessary. Our physician reviewer found the record indicates that 
the enrollee has persistent tributary varicose veins after saphenous ablation. The record provided does not 
document the failure of a six-week trial of conservative therapy after ablation. Therefore, the reviewer found 
that the requested sclerotherapy 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 sclerotherapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sclerotherapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested item is not medically necessary. 
 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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a ventilator. Our reviewer says that the 
documentation does not support that the requested ventilator is medically reasonable or necessary. Our 
physician reviewer found the enrollee has COPD and obstructive sleep apnea, noncompliant with BiPAP-ST. 
There is no diagnosis of thoracic restrictive disease or neuromuscular disease. Pulmonary function testing 
results in the record are not legible. There is no arterial blood gas, done while stable, to document chronic CO2 
retention. If that is present, the enrollee may benefit from BiPAP with AVAPS during sleep as an outpatient, if 
compliance can be achieved. Medicare does not cover a home ventilator when used at settings that can be 
provided with BiPAP. Therefore, the enrollee does not meet criteria for the requested device. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oxygen machine and supplies provided on August 08, 2023. 
 
You asked the Plan to pay for oxygen machine and supplies. You say that this was medically necessary and 
should be covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for oxygen machine and 
supplies provided on August 08, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy. 
 
You asked the Plan to pre-approve HBO therapy. You say that you may lose a leg if treatment is not started. 
The Plan denied your request. The Plan says you do not meet criteria for HBO therapy. 
 
The Plan follows Medicare rules. Medicare rules state that HBO therapy may be covered for certain 
indications. 
 
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 HBO therapy. Our reviewer says that 
you do not meet criteria for HBO therapy. Our physician reviewer found you have a diabetic foot ulcer and 
osteomyelitis having been treated with antibiotics and superficial wound debridement and wound vacuum, but 
not debridement of the bone. There is insufficient evidence showing normal blood circulation via arteriogram 
to the area or report of having tried and failed debridement of infected bone as 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 HBO therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve hyperbaric oxygen (HBO) therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the injection of an anesthetic or steroid into the 
genicular nerve (64454). 
 
You asked the Plan to pre-approve a genicular nerve block. You say that the right genicular nerve block would 
offer the enrollee a great deal of relief in regard to their knee pain and ability to function, and is therefore 
medically necessary. The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a genicular nerve block. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found a genicular nerve block for knee pain is experimental. 
 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 genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the injection of an anesthetic or steroid into the genicular nerve (64454).
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 services are medically necessary for 
the enrollee's complex medical needs. The Plan denied your request. The Plan says when the enrollee is ready 
to leave the hospital, they can receive this care in another setting. 
 
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 indicates that the enrollee has ongoing acute medical issues and still 
requires acute care services before transitioning to a lower level of care. The enrollee continues to receive acute 
care services, and these have not been denied. The medical record does not indicate that the enrollee requires 
services that they are not currently receiving but that would be available at the LTACH facility. The elements 
of the coverage rules 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 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 needs IRF services. The Plan denied 
your request. The Plan says the enrollee does not meet the requirements for an IRF admission.  
 
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 enrollees nursing, medical, and rehabilitation needs does not 
require an acute 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, and 
an intensive rehabilitation therapy program. 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 the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Medically necessary care can be provided at different level 
of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the record indicates that the enrollee has 
short term memory loss. The record provided does not establish that the enrollee meets the diagnostic criteria 
of both Alzheimer's disease and frontotemporal dementia or that the examination is being requested in the 
context of a clinical trial. The elements of the coverage criteria are not satisfied. The requested service is not 
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 the PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
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 admission is medically necessary for the 
enrollee.  The Plan denied your request. The Plan says the enrollee's care can continue to be provided in the 
current inpatient hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care in current acute care setting as provided by 
the Plan. Documentation does not support that LTACH services are medically appropriate currently. The 
enrollee's records do not support the need to transfer from one acute hospital to another.  
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the CT scan. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are available in network. 
 
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 computed tomography (CT) scan of the chest to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve budesonide capsule, a self-administered drug. 
 
You asked the Plan to pre-approve the medication. You say that the requested drug is medically necessary for 
the enrollee's treatment. The Plan denied your request. The Plan says the medication is not covered as a 
medical benefit under the Plan. 
 
 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 budesonide capsule, a self-
administered drug.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.