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

 
We decided that the Plan does not have to pre-approve a Superion (Vertiflex) device (22869, 22870). 
 
You asked the Plan to pre-approve a Vertiflex device. You say that you missed surgery last month. You also 
say you are in a lot of pain and have limited movement. You need this treatment plan. The Plan denied your 
request. The Plan says unproven and not medically necessary procedures are not covered by Medicare. 
 
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 Vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is experimental and investigational. There is more research 
needed due to insufficient evidence of 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 a Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Superion (Vertiflex) device (22869, 22870).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Bone Marrow Aspirate (20939).  
 
You asked the Plan to pre-approve the Bone Marrow Aspirate. You say that the service is medically necessary. 
The Plan denied your request. The Plan says this is considered experimental. 
 
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 Bone Marrow Aspirate. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is considered 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 the Bone Marrow Aspirate have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Bone Marrow Aspirate (20939).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergency transport from skilled nursing facility to 
dialysis back to skilled nursing facility provided on September 22, 2022. 
 
You asked the Plan to pay for the non-emergency transport services. You say that the services were a medical 
emergency and should be paid. The Plan denied your request. The Plan says the enrollee did not meet the 
criteria for ambulance transport. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
 
 
 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 pay for the non-emergency transport services. Our 
reviewer says that the non-emergency transport services were not medically necessary. Our physician reviewer 
found the enrollee was not bedbound, as evidenced by their ability to sit in a wheelchair and dialysis chair. The 
enrollee did not require the expertise of trained personnel or the equipment available only on an ambulance in 
order to effectuate a safe transport. Transportation could have been provided by other means without 
endangering the enrollees condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the non-emergency transport services have not been met. Therefore, we decided 
that the Plan does not have to pay for non-emergency transport from skilled nursing facility to dialysis back to 
skilled nursing facility provided on September 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal elements allograft. 
 
You asked the Plan to pre-approve spinal elements allograft. You say that the enrollee would benefit from this 
procedure.  The Plan denied your request. The Plan says this surgery has been correctly denied. 
 
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 spinal elements allograft. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found spinal elements allograft is experimental, and more research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of spinal elements allograft have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a spinal elements allograft.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat sleep study. 
 
You asked the Plan to pre-approve a repeat sleep study. You say that your doctor wants you to have a sleep 
study again because they feel your continuous positive airway pressure (CPAP) machine may not be working 
properly or well for you.  The Plan denied your request. The Plan says you do not met criteria for repeat sleep 
study. 
 
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 repeat sleep study. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a diagnosis and is compliant with therapy with good response. A repeat study is 
not indicated per the documentation provided. 
 
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 repeat sleep study have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a repeat sleep study.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the hearing aid billed with procedure code V5260 for date of service 
July 31, 2023. 
 
You asked the Plan to pay for hearing aids. You say that these hearing aids were necessary and are supported in 
the medical record. The Plan denied your request. The Plan says that this service is not supported, as there is no 
evidence that hearing aids were prescribed for this enrollee. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. The rules also say that 
Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information 
regarding its decision to deny coverage or payment. 
 
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 pay for hearing aids. Our reviewer says that these 
hearing aids are necessary and are supported in the medical record. Our physician reviewer found the enrollee 
had audiometric testing for hearing loss and was referred for hearing aids. Documentation supports that these 
hearing aids were prescribed. 
 
We looked at this physician's review, the file, and the Plan's rules. Based on this information, we decided that 
the Plan's rules for coverage of hearing aids have been met. The Plan has provided no other reason or 
explanation for the denial of these services. Therefore, we decided that the Plan has to pay for the hearing aid 
billed with procedure code V5260 for date of service July 31, 2023.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 12, 2023 to 
February 10, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that the Notice of Admission (NOA) 
was billed in a timely manner. The Plan denied your request. The Plan says the claim has not been billed with 
the correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 12, 2023 to 
February 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy. 
 
You asked the Plan to pre-approve proton beam therapy. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says guidelines do not indicate that proton therapy is preferred 
over standard radiation therapy. 
 
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 proton beam therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is being offered palliative radiation in the setting of widely metastatic 
disease and the records do not address the need for proton therapy in this context. There are no consensus 
guidelines or published literature that support proton therapy in this clinical situation. The enrollee can readily be treated with non-proton based 3-dimensional radiotherapy. In fact, it appears that the treating radiation 
oncologist agrees that proton therapy is not 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 proton beam therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam therapy.
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 the enrollee needs SNF care in order to have a safe 
discharge. The Plan denied your request. The Plan says the enrollee's condition does not meet the criteria for 
coverage of SNF care. 
 
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 the enrollee has Multiple Sclerosis and recently had cervical decompression and 
fusion services. The enrollee is currently in an inpatient rehabilitation facility (IRF). The enrollee received oral 
medications and had stable vital signs. The enrollee received physical therapy and occupational therapy. The 
enrollee was at a supervision to contact guard/minimal assist level with functional mobility. The enrollee ad 
varying assist with activities of daily living (ADLs). There are no identifiable skilled nursing service needs. 
While there are identifiable skilled therapy service needs, they are not required on a daily basis. The enrollee 
does not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the VIA disc allograft intervertebral disc augmentation 
procedure (0627T). 
 
You asked the Plan to pre-approve the VIA disc allograft intervertebral disc augmentation procedure. You say 
that the service is medically necessary. The Plan denied your request. The Plan says this procedure is 
considered experimental. 
 
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 VIA disc allograft intervertebral 
disc augmentation procedure. Our reviewer says that the requested service is not considered medically 
reasonable and necessary in this case. Our physician reviewer found this procedure is considered 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 the VIA disc allograft intervertebral disc augmentation procedure have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the VIA disc allograft intervertebral disc 
augmentation procedure (0627T).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Cala device. 
 
You asked the Plan to pre-approve Cala device. You say that this is effective and medically necessary. The 
Plan denied your request. The Plan says this is not considered standard medical treatment. 
 
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 Cala device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found current peer-reviewed medical literature do not show that use of the Cala device has been 
shown in controlled studies in a Medicare-approved journal to result in sustained long-term health benefits in 
patients with essential tremor. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Cala device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Cala device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bupivacaine billed with code J3490 for date of service June 
21, 2023. 
 
You asked the Plan to pay for bupivacaine. You say that this service was necessary and can be paid separately. 
The Plan denied your request. The Plan says this service is not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that certain services and items are not separately 
billable when they are performed to facilitate an infusion or injection or hydration.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of bupivacaine have not been met. Specifically, bupivacaine is a local anesthetic which was used to 
facilitate the infusion or injection or hydration. This means this service is not separately payable. Therefore, we 
decided that the Plan does not have to pay for bupivacaine billed with code J3490 for date of service June 21, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says an epidural 
steroid injection 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 injection. Our reviewer says that an 
epidural steroid injection is not medically necessary. Our physician reviewer found that the LCD requires at 
least three months of 50% pain relief, however that time has not passed. Therefore, the request is not 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an epidural steroid injection.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ultrasound of the spinal canal and contents (76800) 
provided on July 7, 2023.  
 
You asked the Plan to pay for the ultrasound. You say that the services were not experimental or 
investigational. You also say that the enrollee meets the Plan's criteria for trigger point injections and both 
current procedural terminology codes are covered.  The Plan denied your request. The Plan says the clinical 
value and effectiveness of spinal canal ultrasound guidance in the setting of trigger point injections of the lower 
back have not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the ultrasound. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has myofascial pain syndrome, myalgia/myositis, and low back pain. An ultrasound of the 
spinal canal and contents (76800) was provided on July 7, 2023, to guide trigger point injections. However, the 
findings on the ultrasound did not mention views of the spinal canal or contents. There was no described 
explanation as to why an ultrasound was needed for trigger points that are typically performed without 
ultrasound guidance. There is insufficient evidence to support this use of ultrasound. 
 
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 ultrasound have not been met. Therefore, we decided that the Plan does not 
have to pay for an ultrasound of the spinal canal and contents (76800) provided on July 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a occupied transit securement kit package, and privacy 
flap. 
 
You asked the Plan to pre-approve the transit option and privacy flap. You say that you are requesting a formal 
mixed decision to pursue other funding resources for these items. The Plan denied your request. The Plan says 
these items to do not serve a medical purpose and cannot be covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.    

The items at issue in this appeal do not serve a purpose that is primarily medical in nature. These items are 
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 a occupied transit securement kit package, and privacy flap.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block injection. 
 
You asked the Plan to pre-approve a genicular nerve block injection. You say that the enrollee says that they 
have too much pain and can't take it anymore. The Plan denied your request. The Plan says the applicable 
guidelines do not support the use of this procedure for short-term relief of knee pain. 
 
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 injection. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found genicular nerve block is considered experimental for knee pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a genicular nerve block injection have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a genicular nerve block injection.