Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the T10 kyphoplasty and associated services provided on 
March 27, 2023. 
 
You asked the Plan to pay for the T10 kyphoplasty and associated services. You say that this procedure is 
medically necessary and was planned urgently following a phone visit. You also say that the updated imaging 
demonstrates acute compression fracture that is symptomatic and decreasing your capacity to perform activities 
of daily living, decreasing your quality of life, and a T10 kyphoplasty is very much clinically appropriate. The 
Plan denied your request. The Plan says this request is not medically necessary. The Plan also says that because 
the procedure is not approved, the services ancillary to it are also not approved. 
 
The Plan follows Medicare rules. Medicare rules say that PVA is covered in patients who meet the criteria 
listed in the Medicare rules section of this letter. 
 
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 T10 kyphoplasty and associated services. 
Our reviewer says that you did not meet the coverage criteria. Our physician reviewer found the records did not 
demonstrate an acute/subacute compression fracture by advanced imaging. You had a conventional computed 
tomography scan which did not describe the fracture as acute of subacute. Our reviewer found that you were 
not hospitalized with the pain. You did not receive optimal non-surgical management. 
 
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 T10 kyphoplasty and associated services have not been met. Therefore, we 
decided that the Plan does not have to pay for the T10 kyphoplasty and associated services provided on March 
27, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One. 
 You asked the Plan to pre-approve the drug. The Plan denied your request. The Plan says that the 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 the drug. Our reviewer says that Gel-
One is not medically necessary. Our physician reviewer found that the enrollee has not tried and failed the 
Plan's required drugs Durolane, Gelsyn-3, Synvisc or Synvisc-One. The documentation does not support that 
the Plan's required drugs would likely be less effective or would 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 the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electronic brachytherapy with field setting. 
 
You asked the Plan to pre-approve electronic brachytherapy. You say that brachytherapy offers excellent cure 
rates and cosmetic outcomes. 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 electronic brachytherapy. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found electronic brachytherapy with field setting is not a standard of care for such tumors. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of electronic brachytherapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve electronic brachytherapy with field setting.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Corflex device (22867).  
 
You asked the Plan to pre-approve a Corflex device. You say that this service is medically necessary. The Plan 
denied your request. The Plan says published studies do not demonstrate any long-term health outcome 
advantage with the use of Coflex as an alternative to standard surgical 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 a Corflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception to guidelines. Therefore, the requested Coflex 
device at L2-3 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 Corflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Corflex device (22867).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Euflexxa. 
 You asked the Plan to pre-approve Euflexxa. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the Plan requires a trial of Monovisc, Orthovisc, Synvisc, or Synvisc One 
before it will approve Euflexxa. 
 
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 Euflexxa. Our reviewer says that the 
enrollee does not meet criteria for a step therapy exception for Euflexxa. Our physician reviewer found the 
enrollee has not tried and failed one of the Plan's preferred drugs of Monovisc, Orthovisc, Synvisc, or Synvisc 
One. The record does not show that these drugs would likely be less effective and/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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Euflexxa.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that this is necessary as the enrollee is at risk for harm 
and death. The Plan denied your request. The Plan says a ventilator is not covered by Medicare for this purpose 
and the enrollee's needs could be met by a bilevel positive airway pressure (BiPAP) device with average 
volume assured pressure support (AVAPS) mode. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide positive 
airway pressure (PAP) therapy, regardless of the underlying medical condition, shall not be covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve use 
of a ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on May 23, 2023, by an OON 
provider.  
  
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services were not authorized. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit provided on May 23, 2023, by an 
OON provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the physical therapy (PT) services. 
 
You asked the Plan to pre-approve the PT services. You say that it would be appropriate for the enrollee to 
continue with skilled PT to improve neurological symptoms, stability, balance and functional endurance. The 
Plan denied your request. The Plan says the scores do not show that the enrollee is making progress in therapy.  
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 the PT services. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has previously been treated with outpatient therapies and 
should be independent with a home exercise program. There is no documentation of a recent injury or decline 
in function. The additional therapy services are not an appropriate duration and frequency for treatment of the 
enrollees medical condition and therefore are not 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 the PT services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the physical therapy (PT) 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 services are medically necessary for the enrollee 
to get strong enough to return home. The Plan denied your request. The Plan says the enrollee does not meet 
the 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 the enrollee does 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that based on the enrollee's current physical and 
occupational deficits, along with their comorbidities, the enrollee would benefit from intensive rehabilitation 
hospitalization with daily physician visits and examinations, continuous rehabilitation nursing care, and 
intensive physical therapy and occupational therapy to optimize mobility and regain the ability to perform 
activities of daily living. The Plan denied your request. The Plan says the enrollee does not meet the 
requirements 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 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 enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. 
 
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. 
 
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 an IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you meet the criteria for admission to an IRF. You 
also say you are in pain from the lack of medical physical therapy, and you do not want to go to a skilled 
nursing facility because you do not believe you would receive the type of care you need.  The Plan denied your 
request. The Plan says admission to an IRF is not medically necessary.  
 
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. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While you may have a need for physical therapy and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. 
 
There is not a reasonable expectation that you 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 an IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulatory surgical services (66984-SG-LT) provided on 
March 21, 2022. 
 
You asked the Plan to pay for ambulatory surgical services. You say that these services were medically 
necessary and are supported in the medical record. The Plan denied your request. The Plan says these services 
were not billed in accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. The rules say that providers must report services correctly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ambulatory surgical services have not been met. Specifically, these services were reported with the 
SG modifier and do not have TOS code F as required in this case. Therefore, we decided that the Plan does not 
have to pay for ambulatory surgical services (66984-SG-LT) provided on March 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services provided on March 18, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the radiology services. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says this service was not authorized. 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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the radiology services provided on March 18, 
2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the services provided from December 2, 2022, to December 30, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the services are 
not payable as billed. 
 
The Plan must follow Medicare rules. The rules 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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Since the laboratory tests in this case were billed by the ESRD facility, they are 
not subject to the rules cited by the Plan which pertain to payment under the Clinical Laboratory Fee Schedule 
(CLFS). Therefore, we decided that the Plan has to pay for the services provided from December 2, 2022, to 
December 30, 2022.  
 
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 pre-approve a high frequency chest wall oscillation (HFCWO) 
device. 
 
You asked the Plan to pre-approve HFCWO. You say that this is needed for ongoing therapy and to prevent 
exacerbations. The Plan denied your request. The Plan says the records do not have documented failure of 
standard therapy or imaging confirmation of bronchiectasis. 
 
The Plan follows Medicare rules. Medicare rules state that HFCWOs are only covered for specified 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 HFCWO. Our reviewer says that the 
enrollee does not meet criteria for an HFCWO. Our physician reviewer found the enrollee has chronic 
obstructive pulmonary disease (COPD). There is no diagnosis of bronchiectasis, cystic fibrosis, or 
neuromuscular disease. There is inadequate evidence that this device is beneficial in the treatment of COPD 
and Medicare does not cover it for that diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HFCWO have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a high frequency chest wall oscillation (HFCWO) device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upright walker (E0143). 
 
You asked the Plan to pre-approve an upright walker. You say that this item is medically necessary. The Plan 
denied your request. The Plan says the upright walker is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that an Upright Walker is covered when 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 an upright walker. Our reviewer says 
that the requested upright walker is not medically necessary. Our physician reviewer found the records show 
that the enrollee is able to complete activities of daily living using a standard 4 wheel walker. The enrollee has 
a standard walker. Records do not detail why the Upright Walker 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 an upright walker have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an upright walker (E0143).