Persius/hicric huggingface dataset:
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 currently meets full IRF criteria. The 
Plan denied your request. The Plan says the enrollee does not meet the Medicare 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 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 treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. Our reviewer found that 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. Our physician reviewer also found that 
there is not a reasonable expectation that this 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.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation (PVA) for the T8 
spinal level.  
 
You asked the Plan to pre-approve the PVA. You say that the enrollee was seen recently due to back pain after 
lifting injury. Advanced imaging was obtained and showed T8 fracture was acute due to the presence of 
marrow edema and resulted in 60% reduction in vertebral height. You state that this is evidence that the new 
pain complaints is very likely due to the acute compression fracture and not the other older fractures.  The Plan 
denied your request. The Plan says there are multiple potential etiologies of the enrollee's symptoms. As such, 
PVA of T8 cannot be approved.  
 
The Plan follows Medicare rules. Medicare rules say that PVA may only be covered when current back pain is 
primarily due to the acute or subacute fracture identified on advanced imaging.  
 
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 PVA. Our reviewer says that the 
LCD criteria for this surgical intervention are not met.  Our physician reviewer found the record indicates that 
the enrollee has back pain and compression fractures of thoracic and lumbar vertebra. The record provided is insufficient to establish the etiology of the enrollee's pain and indicates the presence of both acute and 
indeterminate age fractures. The elements of the coverage criteria are not satisfied.  
 
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 PVA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve percutaneous vertebral augmentation (PVA) for the T8 spinal level.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you are requesting reconsideration based on the 
medical records submitted. The Plan denied your request. The Plan says that SNF care is no longer medically 
necessary. 
 
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 that you do not require daily skilled nursing or therapy services. You do not meet the 
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility. 
 
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 SNF care.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synojoynt (J7331).  
You asked the Plan to pre-approve Synojoynt. You say that the specialty pharmacy will not fill the request for 
the preferred drug because the secondary insurance cannot be billed. You also say that there are no 
contraindications to using one of the preferred agents, however, they are financially prohibitive. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, Durolane, Euflexxa, 
Supartz, and GelSYN-3. 
 
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 Synojoynt. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has tried and failed the preferred drugs, Durolane, Euflexxa, Supartz, and GelSYN-3. 
The reviewer also found that 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. Therefore, the reviewer found 
that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synojoynt have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Synojoynt (J7331).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a flex-walk system or equal (L5981) and multi-axial 
rotation unit (L5986). 
 
  You asked the Plan to pre-approve a flex-walk system or equal and multi-axial rotation unit. You say that you 
need the advanced foot system for walking long distances, driving, umpiring, and walking up and down stairs.  
The Plan denied your request. The Plan says the request for a K3 foot exceeds your need and cannot be 
covered. 
 
The Plan follows Medicare rules. Medicare rules say that the records must document the beneficiarys current 
functional capabilities and his/her expected functional potential, including an explanation for the difference, if 
that is the case. 
 
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 flex-walk system or equal and multi-
axial rotation unit. Our reviewer says that a flex-walk system or equal (L5981) and multi-axial rotation unit 
(L5986) exceeds your medical needs and is not medically necessary. Our physician reviewer found the treating 
medical physician documentation does not support that you are a K3 ambulator or will participate in K3 level 
activities. 
 
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 flex-walk system or equal and multi-axial rotation unit have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a flex-walk system or equal (L5981) and 
multi-axial rotation unit (L5986).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
  You asked the Plan to pre-approve SNF care. You say that you are not getting the care you need and want to be 
moved to a different facility.  The Plan denied your request. The Plan says SNF care is not medically 
necessary, and your needs can be met at a lower level of 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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an external insulin pump. 
 
You asked the Plan to pre-approve the external insulin pump. You say that this is a medical necessity for better 
control for the enrollee who would benefit from the Omnipod 5 pump and pods.  The Plan denied your request. 
The Plan says that the enrollee does not meet criteria for the insulin pump.  
The Plan follows Medicare rules. Medicare rules say that the external infusion pumps may be covered for 
enrollees who meet coverage indications within certain categories. 
 
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 external insulin pump. Our reviewer 
says that the external insulin pump is a medical necessity. Our physician reviewer found the enrollee's 
glomerular filtration rate is less than 50 cc/min. The cutoff for c-peptide is 200% of the lower limit of normal 
which is 1.56 and 1.57 is very close given the prescriber's recommendation for the Omnipod 5. This meets 
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 external insulin pump have been met. Therefore, we decided that the Plan 
has to pre-approve an external insulin pump.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 1, 2022, to June 
30, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the required NOA was 
submitted. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from June 1, 2022, to June 30, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant surgery services provided on December 2, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this type of provider is 
not payable for these services. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the assistant surgery services 
provided on December 2, 2022.
Appeal type: Home Health
Decision: Unfavorable

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

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee has failed conservative 
treatment and the Intracept procedure is medically necessary. The Plan denied your request. The Plan says the 
requested procedure cannot be approved because medical studies do not show this procedure works better than 
others. 
 
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 that the cause of back pain is not clear and there is no imaging showing Modic 
changes. There is also no foraminal stenosis or facet degenerative joint disease.  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.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the vertiflex device placement surgery (22869, 22870). 
 
You asked the Plan to pre-approve the vertiflex device placement surgery. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the vertiflex device 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 vertiflex device placement surgery. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the vertiflex device is considered experimental. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the vertiflex device placement surgery have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the vertiflex device placement surgery (22869, 22870).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity (romososumab-aqqg) treatments.  
 You asked the Plan to pre-approve the requested treatment with Evenity. You say that Evenity should be 
approved as the enrollee has severe osteoporosis, and Evenity is proven to accelerate bone density gains 
compared to the preferred drugs Reclast and Prolia. The Plan denied your request. The Plan says the 
documentation does not support that a trial of the preferred drugs would have less effectiveness or potential 
adverse effect compared to the requested drug. 
 
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 requested treatment with Evenity. 
Our reviewer says that the requested treatment with Evenity is not shown to be reasonable and necessary based 
on step therapy criteria.  Our physician reviewer found the Plan requires a trial of Prolia or Reclast prior to 
approval of Evenity. There is no evidence that such a trial has been completed. Based on the medical records 
provided and the Medicare-approved major drug compendia, there is no indication that the preferred drug(s) 
would likely be less effective and/or likely have adverse effects for the enrollee. While the Medicare-approved 
major drug compendia do indicate an increase in bone density compared to Prolia, they show no fracture 
reduction in patients treated with Evenity as opposed to treatment with Reclast or Prolia.  
 
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 requested treatment with Evenity have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Evenity (romososumab-aqqg) treatments.
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 necessary for the enrollee to return to 
their prior level of independence. The Plan denied your request. The Plan says ongoing skilled care can be 
provided in an alternative 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve 
branches including imaging guidance, when performed (64624). 
 
You asked the Plan to pre-approve genicular radiofrequency ablation. You say that the enrollee wishes to 
proceed with RFA to provide increased level of function. The Plan denied your request. The Plan says 
peripheral nerve destruction using cryoablation or laser, electrical, chemical or radiofrequency ablation is 
considered experimental, investigational, or unproven for treatment of knee pain. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve genicular radiofrequency ablation. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found genicular nerve radiofrequency ablation is experimental for knee pain. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular radiofrequency ablation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve branches including 
imaging guidance, when performed (64624).