Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four home health skilled nursing visits. 
 You asked the Plan to pre-approve home health services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the gastrointestinal (GI) infection has been treated, and education has been 
received. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
enrollee has a chronic stable medical condition, and has received education and observation. There is no 
indication for continued skilled nursing 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve four home health skilled nursing visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
array; peripheral nerve (excludes sacral nerve) (a Nalu peripheral nerve stimulator) (64555). 
 
You asked the Plan to pre-approve the service. You say that clinical evidence validates that peripheral nervous 
system (PNS) improves new health outcomes in chronic pain patients. You state that important outcomes in the 
successful treatment of chronic pain includes but are not limited to pain relief, increased pain interference and 
function. You state that this procedure may be the enrollee's last resort to treat their chronic intractable nerve 
pain that the enrollee's been suffering from for years. The Plan denied your request. The Plan says a review of 
the current medical literature does not support this service to be reasonable and necessary. The Plan states there 
is insufficient evidence to support the use of peripheral nerve stimulation in the treatment of chronic back pain. 
The Plan states there is insufficient evidence supporting the use of the Nalu system for chronic pain and more 
medical research is needed to support this is safe and effective for the enrollee's condition. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the literature indicates that there is evidence that lumbar level peripheral nerve stimulation may 
be an efficacious treatment for chronic low back pain that is refractory to conservative measures. Large studies 
are needed to assess the outcomes and duration of improvement associated with this treatment. There is 
insufficient evidence to support the use of peripheral nerve stimulation in the treatment of chronic back pain. 
There is insufficient evidence supporting the use of the Nalu system for chronic pain. The review has 
determined that the items/services at issue in this case are 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes 
sacral nerve) (a Nalu peripheral nerve stimulator) (64555).
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 can benefit from acute rehab to optimize 
their level of functioning prior to returning home. The Plan denied your request. The Plan says an IRF 
admission 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 the enrollee's nursing, medical and rehabilitation can be 
provided in a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation 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 percutaneous laminotomy/laminectomy. 
 
You asked the Plan to pre-approve the surgery. You say that medical records were included to prove medical 
necessity. The Plan denied your request. The Plan says this procedure is not approved outside of a supported 
clinical 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 the surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this request is experimental for spinal surgery. Open is the gold standard. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous laminotomy/laminectomy.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 85025, 82607, 84439, 
80053, and 80061. We decided that the Plan does not have to pay for the services described by procedure 
code(s) 83540, 83550, 82728, and 83735.  
 
You asked the Plan to pay for procedure codes 85025, 82607, 84439, 80053, 80061, 83540, 83550, 82728, and 
83735 provided on June 28, 2023. You say that you would like the Plan to reconsider their denial of payment. 
The Plan says that the services are not covered as billed. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 85025, 82607, 84439, 
80053, and 80061.  
 
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. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 85025, 82607, 84439, 80053, 
and 80061.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
83540, 83550, 82728, and 83735. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure codes 83540, 83550, 82728, and 83735 have not been met. Specifically, this claim was 
billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory 
setting. Therefore, we decided that the Plan does not have to pay for the services described by procedure 
code(s) 83540, 83550, 82728, and 83735. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve geniculate artery embolization. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this does not meet the requirements 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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the provided medical records and review of the current peer-reviewed medical literature do not 
document that genicular artery embolization has been shown in controlled studies in a Medicare-approved 
journal to result in sustained long term health benefits in patients with pain related to osteoarthritis of the knee. 
 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve geniculate artery embolization.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
You asked the Plan to pre-approve a home ventilator system. You say that the enrollee requires the device to 
help prevent continued pulmonary exacerbations and hospitalizations.  The Plan denied your request. The Plan 
says a home ventilator is not medically necessary for this patient because their needs can be met with an 
alternative device such as a BiPAP device with average volume-assured pressure support (AVAPS).  
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 home ventilator system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that the enrollee 
has fibrosis and chronic respiratory failure. However, the enrollee does not have documented failure of a 
BiPAP or supporting data failure. The enrollee is being prescribed an unproven ventilator modality for therapy. 
Although, there is no dispute of disease severity, the enrollee does not meet the criteria for a home ventilator. 
 
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 home ventilator system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames, the progressive lens, and the vision supply 
service provided on August 24, 2023. 
 
You asked the Plan to pay for the frames, the progressive lens, and the vision supply service. You say that you 
were not told that your Plan did not cover services at this provider. The Plan denied your request. The Plan says 
the services are not covered because the provider is out-of-network. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when received by network providers. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the frames, the progressive lens, and the vision 
supply service have not been met. Therefore, we decided that the Plan does not have to pay for the frames, the 
progressive lens, and the vision supply service provided on August 24, 2023. 
  
Your complaint about the governments healthcare is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) 
sensor. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the criteria for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not treat with 
insulin or have a documented history of problematic hypoglycemic events. Based on this information, we 
decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) sensor.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stab phlebectomy. 
 You asked the Plan to pre-approve stab phlebectomy. You say that stab phlebectomy is medically necessary. 
The Plan denied your request. The Plan says stab phlebectomy is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that stab phlebectomy is covered when the criteria listed 
in the Medicare rules section of this decision are met. 
 
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 stab phlebectomy. Our reviewer says 
that the requested stab phlebectomy is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that for tributary treatment such as stab phlebectomy to be considered medically 
necessary per Medicare coverage criteria, there needs to be persistent significant symptoms following 
successful treatment of truncal (saphenous) reflux with these symptoms existing more than 6 weeks after the 
reflux was treated and despite conservative efforts. Additionally, the veins to be treated need to be at least 
4 mm in diameter. As you have not yet undergone saphenous vein reflux treatment, the above criteria have not 
been met. The Plan does not provide for simultaneous saphenous reflux treatment and tributary treatment.  A 
rationale for this is that many patients experience satisfactory relief with the truncal intervention alone. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of stab phlebectomy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve stab phlebectomy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0656, 
E0657, E0668). 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show a failure to improve with conservative 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 the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that as records do not document a four-week trial and failure of a standard pneumatic compression pump, 
then it cannot be said that the enrollee has unique characteristics that would indicate a segmented pump over a 
standard pump. The records do not document at least four weeks of regular, daily, multiple-hour home usage of 
a standard pump (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 as is required. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device (E0652, E0656, E0657, E0668).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0856) and related 
accessories (E1028, E1002, E2607, E0955, E2615, E1012, E2310, E2363). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the requested power 
wheelchair and accessories are medically necessary for the enrollee. The Plan denied your request. The Plan 
says the coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair and accessories. 
Our reviewer says that the requested items are not medically necessary. Our physician reviewer found the 
enrollee does not have high risk for skin breakdown, does not use a catheter intermittently, does not have 
spasticity, and does not require an alternative means of managing power drive. As the power wheelchair base is 
not medically necessary, the requested accessories are not covered. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Group 3 power wheelchair (K0856) and related accessories 
(E1028, E1002, E2607, E0955, E2615, E1012, E2310, E2363).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets LTACH admission 
criteria, and their ongoing medical care warrants an LTACH level of care to achieve a safe and sustainable 
discharge. The Plan denied your request. The Plan says the LTACH services requested do not meet the 
requirements for approval. 
 
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 patient does not require ventilator weaning, does not have complex wound care, 
and does not need more than six and a half hours of nursing care per day. 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 LTACH services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc One (J7325). 
 You asked the Plan to pre-approve Synvisc One. You say that you want Synvisc because one injection will last 
you longer than an alternative medication. The Plan denied your request. The Plan says you must try and fail, 
or have a contraindication to, the Plan's preferred drug Euflexxa before this drug can be approved. 
 
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 Synvisc One. Our reviewer says that the 
Plan's coverage criteria are not met in this case. Our physician reviewer found that the Plan requires a trial of 
Euflexxa before they will approve the requested drug. In this case, you have not tried and failed the required 
drug(s). There is no documentation provided indicating that the plans required drug(s) would likely be less 
effective and/or likely have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc One have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc One (J7325).