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

 
We decided that the Plan does not have to pre-approve a basivertebral nerve ablation (BVN)/Intracept 
intraosseous nerve ablation system (64628). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that it is medically necessary. The Plan 
denied your request. The Plan says records do not show that your pain is compatible with vertebrogenic pain. 
The enrollee does not meet criteria for approval. 
 
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 Intracept procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review indicates that the Intracept procedure targets the basi-vertebral nerve for 
the relief of chronic vertebrogenic low back pain. Medicare guidelines consider this type of system unproven 
and not medically necessary. Large well-designed studies in the peer review scientific literature comparing 
stand-alone use of the Intracept device to established surgical decompression are needed.  Published studies do 
not demonstrate any long-term health outcome advantage with the use of Intracept as an alternative to standard 
surgical treatment. The review has determined 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 an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a basivertebral nerve ablation (BVN)/Intracept intraosseous nerve ablation system 
(64628).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the item is medically 
necessary. The Plan denied your request. The Plan says your medical record shows that you have not had a 
four-week trial of an E0650 or E0651. 
 
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. 
 
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 the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652).
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 the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that 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. 
 
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 
services are not medically necessary. Our physician reviewer found the provided primary source documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. You could be treated with a bilevel positive airway pressure (BiPAP) machine with average volume-
assured pressure support (AVAPS) capability to achieve the ordered settings and failure of such a device has 
not been documented. The plan has indicated coverage for such a device is available upon request. The 
elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron. 
 
You asked the Plan to pre-approve Ondansetron. You say that the enrollee has the diagnosis of nausea and 
vomiting associated with cancer chemotherapy The Plan denied your request. The Plan says coverage criteria 
has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that oral anti-emetic drugs that are used as full 
replacement for intravenous dosage forms of a cancer regimen are covered under specific circumstances.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Ondansetron have not been met. Therefore, we decided that the Plan does not have to pre-approve 
Ondansetron.  
 
Benefits for Ondansetron may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor (E0651) and a segmental 
pneumatic appliance for use with pneumatic compressor, full leg (E0667) to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve a pneumatic compressor and an appliance. You say that the enrollee has a 
history of chronic lymphedema of the lower extremities and needs this equipment. There is no other supplier 
that can provide the enrollee with the dual wave mode found in the requested equipment. The Plan denied your 
request. The Plan says the enrollee must receive care and services from a network provider. The supplies are 
available with an in-network provider. 
 
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 pneumatic compressor (E0651) and a segmental pneumatic appliance for use with pneumatic compressor, full 
leg (E0667) to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the supporting information 
demonstrates that the enrollee clearly meets FDA indications for use. 
 The Plan denied your request. The Plan says this procedure is considered experimental/investigative. 
 
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 items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the magnetic resonance imaging (MRI) shows degenrative facet joints and the cause 
of pain is unclear. 
 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 the Intracept procedure (64628, 64629).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Sprint PNS System (64555). 
 
You asked the Plan to pre-approve the Sprint PNS System. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service 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 Sprint PNS System. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Sprint PNS system is experimental for back 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 the Sprint PNS System have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Sprint PNS System (64555).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intracept procedure. 
 
You asked the Plan to pre-approve Intracept procedure. 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 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 Intracept procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a five to six month history of back pain in addition to a long-standing 
history of chronic low back pain in the setting of spondylolisthesis and spinal stenosis. The magnetic resonance 
imaging shows multiple levels of facet degenerative joint disease. The cause of back pain is unclear. Therefore, 
the enrollee does not meet 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 Intracept procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Intracept procedure.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 12, 2022, to 
August 9, 2022. 
 You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says the NOA was not received timely. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
We looked at the file and the rules. A valid NOA was not received timely. Based on this information, we 
decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not 
have to pay for the home health services provided from July 12, 2022, to August 9, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the requested Prolia is medically necessary. The Plan 
denied your request. The Plan says the enrollee must try and fail an injectable bisphosphonate first. 
 
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 Prolia. Our reviewer says that the Plan's 
step therapy criteria have not been met. Our physician reviewer found the Plan requires a trial of an injectable 
bisphosphonate (e.g. Pamidronate, Zoledronic Acid, Ibandronate) before they will approve the requested drug. 
In this case, the enrollee has not tried and failed a required drug. There is no documentation provided indicating 
that the Plans required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
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 is ready for discharge to the skilled 
nursing facility. The Plan denied your request. The Plan says the SNF services you are requesting do not meet 
the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (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: 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 are appealing the denial of IRF admission. The 
Plan denied your request. The Plan says that the enrollee does not meet the Medicare criteria for admission to 
an Inpatient Rehabilitation Facility. 
 
  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 enrollee's 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 intensive rehabilitation physician or nursing oversight in an IRF. The enrollee's 
functional level does not require treatment by multiple therapies, including physical or occupational therapy, in 
an intensive rehabilitation program in an IRF. The documentation does not support that the enrollee can fully 
tolerate 3 hours of therapy, given the enrollee's pain levels limiting activity. Therefore, this enrollee does not 
need an intensive IRF 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 wheelchair components to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve wheelchair components. You say that the requested provider is the only one 
in the area able to provide the required parts. The Plan denied your request. The Plan says the requested items 
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 
wheelchair components to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the culture, bacterial; quantitative colony count, urine 
(87086) provided October 11, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that the test was ordered by a treating physician 
who makes the professional determination of diagnosis and medical necessity to successfully treat their 
patients. The Plan denied your request. The Plan says the diagnosis is inconsistent with the procedure. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 87086 is Culture, bacterial; quantitative colony count, 
urine. 
 
We asked our coder 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 laboratory service. Our reviewer says that the Medicare 
criteria for coverage were not met. Our reviewer found upon review of the included Diagnostic Laboratory 
Tests Guidance Publication 100-3, Manual Section Number 190.12, Manual Section Title Urine Culture, 
Bacterial, diagnosis N32.81 is not an acceptable diagnosis code to be billed with procedure 87086 in order to 
receive reimbursement consideration, therefore, no payment is allowed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the culture, bacterial; quantitative colony count, urine (87086) provided October 11, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve home health physical therapy to be provided by an OON provider. You say 
that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the 
requested services are neither emergent nor urgent to seek out-of-network care. The Plan says there are equally 
qualified in-network providers that can provide the services being requested. 
 
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 home health physical therapy to be provided by an OON provider. Therefore, we 
decided that the Plan does not have to pre-approve home health physical therapy to be provided by an out-of-
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says compression stockings described by code 
A6549 are noncovered. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6549.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat. 
 
You asked the Plan to pre-approve a raised toilet seat. You say that you had surgery on your lower back. You 
say that you also have neck problems, and your feet fall asleep. You also say that you have been close to falling 
on several occasions due to not having handrails or a means to hold on. The Plan denied your request. The Plan 
says a raised toilet seat is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat 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 raised toilet seat.