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

 
We decided that the Plan does not have to pre-approve low dose radiation therapy for plantar fasciitis. 
 
You asked the Plan to pre-approve low dose radiation therapy for plantar fasciitis. You say that low dose 
radiation therapy for plantar fasciitis is medically necessary. The Plan denied your request. The Plan says low 
dose radiation therapy for plantar fasciitis is considered investigational. 
 
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 low dose radiation therapy for plantar 
fasciitis. Our reviewer says that the requested low dose radiation therapy for plantar fasciitis is not considered 
medically reasonable and necessary. Our physician reviewer found that the provided medical records and 
review of the current peer-reviewed medical literature do not document that use of radiation therapy has been 
shown in controlled studies in a CMS-approved journal to result in sustained long term health benefits in patients with plantar fasciitis. As summarized in Up to Date. Plantar Fasciitis: Ineffective and experimental 
treatments. Patients have access to multiple approaches to plantar fasciitis that are not supported by high-
certainty evidence or are experimental. We discourage patients from using any of the following treatment 
strategies...Radiation therapy  Radiation of the plantar fascia is sometimes used in Europe to treat chronic 
plantar fasciitis that is unresponsive to more conservative approaches. Because of concern about the 
possibility of late-onset hematopoietic malignancy, radiation therapy is seldom used to treat plantar fasciitis in 
other parts of the world. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of low dose radiation therapy for plantar fasciitis have not been met. Therefore, we 
decided that the Plan does not have to pre-approve low dose radiation therapy for plantar fasciitis.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LinQ device (0775T). 
 
You asked the Plan to pre-approve the LinQ device. You say that this service is medically necessary. The Plan 
denied your request. The Plan says there is insufficient evidence in the published medical literature to fully 
assess the safety and efficacy of the device 
 
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 LinQ device. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that this is considered an experimental/ investigational procedure. Therefore, the request is 
deemed 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 LinQ device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the LinQ device (0775T).
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 in need of continued skilled nursing 
services. The Plan denied your request. The Plan says the records indicate the enrollee is stable and daily 
physical and occupational therapy is not medically necessary to establish a maintenance program. The Plan 
says the enrollee's needs can be met with custodial 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 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that you would like to request reconsideration of the 
denied PET scan and that the services requested are medically necessary. The Plan denied your request. The 
Plan says that the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the PET scan. Our reviewer says that 
the service is medically necessary. Our physician reviewer found the enrollee has multiple symptoms of 
memory loss, tremors, and walking difficulty. Neurodegenerative disease has been a concern with multiple 
work-up including MRI of brain (unremarkable), DaT scan showing abnormal findings raising potential of 
Parkinson Plus syndrome. The enrollee has clinical symptoms and signs of dementia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the PET scan have been met. Therefore, we decided that the Plan has to pre-
approve a positron emission tomography (PET) scan.   
 
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: 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 inpatient rehabilitation facility are medically 
necessary. The Plan denied your request. The Plan says the inpatient rehabilitation facility are 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 the enrollee's medical problems are stable and there are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies and an intensive 
rehabilitation therapy program. 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the out-of-network skilled nursing facility (SNF) care 
provided from February 18, 2023, to March 31, 2023. 
 You asked the Plan to pay for the out-of-network SNF care. You say that you should be reimbursed for the 
SNF care. The Plan denied your request. The Plan says you did not meet the criteria for the out of network SNF 
stay. 
 
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 pay for the out-of-network 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 you did not have daily skilled nursing needs that require the 
specialized skill, knowledge, and judgment of a skilled professional nurse. You did not have daily skilled 
therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. 
You did 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 the out-of-network SNF care have not been met. Therefore, we decided that the 
Plan does not have to pay for the out-of-network skilled nursing facility (SNF) care provided from February 18, 
2023, to March 31, 2023.
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 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 Prolia 
is not medically necessary. Our physician reviewer found that the enrollee has not tried and failed the Plan's 
required drugs ibandronate, pamidronate, zoledronic acid. Also, there is no indication that the Plan's required 
drugs would likely be less effective 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 the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular nerve block. 
 
You asked the Plan to pre-approve the genicular nerve block. You say that you suffer from arthritis and have 
anxiety from living in constant pain in your knee. The Plan denied your request. The Plan says the genicular 
nerve block 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 genicular nerve block. Our reviewer 
says that the genicular nerve block is not medically necessary. Our physician reviewer found that you have 
chronic bilateral knee pain due to osteoarthritis of the knee. However, genicular nerve blocs and genicular 
nerve ablations are considered investigational and not medically necessary for the treatment of chronic 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 the genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the genicular nerve block.
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 believe the denial is unjustified based on the 
member's clinical condition and the criteria established by the Centers for Medicare and Medicaid Services 
(CMS) for acute rehabilitation. The Plan denied your request. The Plan says based on Medicare guidelines, the 
IRF services being requested do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the member's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our physician 
reviewer also found that while the medical records support a need for physicial and/or occupational therapy, 
there is no documented need for intensive rehabilitation services. Our physician reviewer also found that 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Corlanor. 
 
You asked the Plan to pre-approve Corlanor. The Plan denied your request. The Plan says that self-
administered drugs do not fall under Medicare Part B coverage. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Corlanor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that the enrollee has a history of severe and problematic 
hypoglycemia following surgery. The Plan denied your request. The Plan says the Medicare criteria was not 
met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM. Our reviewer says that the 
CGM coverage criteria was not met. Our physician reviewer found that the record provided does not indicate 
that the enrollee is being treated with insulin or has problematic hypoglycemia as defined by the Medicare 
rules. The elements of the coverage criteria are not satisfied. The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
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 these services are medically necessary for the 
enrollee. The Plan denied your request. The Plan says these services can be provided in an alternate setting.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollees nursing medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollees 
medical conditions are currently being managed on an outpatient basis. The enrollee's medical and 
rehabilitation needs do not require the intensive interdisciplinary approach provided on acute inpatient 
rehabilitation. Therefore, the acute inpatient rehabilitation admission is 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 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 the Sprint peripheral nerve stimulator (PNS) (64555, 
C1778). 
 
You asked the Plan to pre-approve the Sprint PNS. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Sprint PNS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered an experimental/investigational procedure. It is the subject of ongoing clinical 
trials. 
 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 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Sprint peripheral nerve stimulator (PNS) (64555, C1778).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
  You asked the Plan to pre-approve the injections. You say that you are having increased limit to mobility due 
to the pain and do not want to take any medications. You say that you have already done physical therapy, 
acupuncture, and massage therapy. The Plan denied your request. The Plan says facet joint injections 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 the injections. Our reviewer says that 
facet joint injections are not medically necessary. Our physician reviewer found that there is documentation of 
radiculopathy and non-facet pathology per radiology studies. Therefore, you do not meet the LCD coverage 
criteria. 
 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint injections.
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 should be covered as the enrollee 
disagrees with the denial. The Plan denied your request. The Plan says the services denied correctly as the 
enrollee does not meet the clinical requirements to be approved.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found The complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for frequent falls and a diabetic foot infection and had amputation of the great toe. Medical 
problems are stable. There are no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. 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 acute inpatient rehabilitation facility (IRF) admission and services.